In June 2012 the Ministry of Health convened a Panel of Experts to provide advice after the occurrence of five incidents of serious errors in reporting of anatomical pathology results.
The errors occurred over a two year period:
- four incidents involved breast biopsy tissue and the fifth involved oral tissue,
- the errors occurred in both hospital and community laboratories, and
- each of the errors resulted in the patient undergoing unnecessary surgery.
The Panel had the opportunity to consider reports of the investigations into each of the events and also spoke with several of the patients affected as well as their family members.
Four of the errors resulted from transposition of specimens with those of other patients during the laboratory process. The fifth error resulted from a misinterpretation of the specimen.
The Panel considers that overall quality processes in New Zealand laboratories are of a high standard. Nevertheless international evidence shows that the nature of processing anatomical pathology specimens is vulnerable to errors of the type seen here.
The longer term solution to reducing these errors is to introduce greater use of technology of the laboratory process. The Panel makes recommendations for how processes should be standardised in the meantime to minimise the risk of errors.
The Panel also makes a number of other recommendations including:
- improved reporting of serious and sentinel events,
- improved collaboration between laboratories on quality initiatives, and
- improved and nationally consistent processes for supporting patients affected by serious errors.
Errata November 2012
The last paragraph on page 3 has been revised to correctly identify the affected breast.