Pathology reports were accidentally switched between patients in two separate incidents earlier this year in Nova Scotia hospitals, according to an article in today’s Huffington Post Canada. The errors, about a month apart, caused one woman to undergo an unnecessary mastectomy and another to have an unneeded biopsy. And of course on the other end of those two incidents were two women who had vital procedures delayed and their peace of mind crushed.
“Mistakes happen and this is one of those very unfortunate, devastating times," said Chris Power, president and CEO of the Capital District Health Authority, responsible for health care in the Halifax, Canada area. The authority apparently waited until this week to announce the errors to the public in order to allow the misdiagnosed women complete their treatments.
Despite these inexcusable mistakes, things actually could have been far worse. The mix-up was caught by the health authority’s quality assurance mechanism, which compares all processed tissue before and after surgery. Had it not been for this oversight system, the errors might never have been discovered and at least one of the women involved might have faced a more advanced cancer. Due to the quality assurance mechanism, officials said they were confident these were the only incidents.
In order to prevent such incidents from reoccurring, the health authority conducted two internal reviews, reviewed standard operating procedures and investigated best practices worldwide, according to the article. Next year bar codes and an automated laboratory system will be added to the diagnosis process. Doctors hope this technology will limit future mix-ups.
COMMENT:
In an unnecessary surgery case, we always ask the doctor why he believed the surgery was needed. In other words, what were the indications for surgery?
- What were the lab results that suggested this patient needed surgery?
- What alternatives were there for the patient.
- What were the risks of not having surgery?
- Did you discuss those alternatives and risks with the patient?
