My heart goes out Darrie Eason, the woman who appeared on this morning’s Today Show who was diagnosed with breast cancer, had a double mastectomy, and learned later that they had made a mistake — in fact, she had no cancer at all.
In her case, her biopsy specimen was mixed up with another woman’s — and that woman was told she did not have cancer. Of course, for the woman who does have breast cancer, she has now had a delayed diagnosis, too.
I’ve walked in Darrie’s shoes. I’ve faced a horrible horrible cancer diagnosis, and I’ve faced all those demons about treatment choices and prognoses. Then I learned they were wrong — I didn’t have cancer. I wouldn’t wish that horror on my worst enemy.
I applaud the young woman and her attorney. Instead of filing (what Dr. Nancy Snyderman called) a “blanket of lawsuits,” they have gone back through the process to isolate the lab that made the error, CBL Path(ology) Laboratories. They have sued the lab, and have demanded a review of their processes.
CBL Path says one of their technicians took a shortcut that created the error, and that no systemic problems exist at their lab. Dr. Snyderman explained that the error that took place was a result of “batching” — meaning — instead of reviewing one biopsy specimen for one patient at a time, the tech was processing a number of specimens from a number of patients at the same time. Thus, they got mixed up.
(Pardon my cynicism, but throwing one lab tech under the bus does not fix the problem, nor does it improve the results. In fact, a system problem MUST exist, or the short cut could not and would not have been taken to begin with.)
Have you been diagnosed with cancer? or any other disease that is diagnosed based on lab work? Before you make treatment decisions with your doctor, heed Dr. Snyderman’s excellent advice so you can make sure the same kind of mix up doesn’t happen to you.
The idea always goes back to getting a second opinion. In this case, you need to get a second opinion based on your lab work. But here’s the important part — the second opinion needs to be read from the slides developed from the biopsy and NOT from the paperwork!
Like this: lab #1 creates slides from the specimen, decides what the diagnosis is, and records it on paper.
To get an accurate second opinion, ask lab #2 to read the slides to proffer their second opinion, and not just review the paperwork from lab #1.
Would this have helped me? I’m not sure. I was told two labs had independently confirmed my diagnosis — but — I don’t know whether lab #2 read the slides, or read the paperwork from my biopsy. I didn’t even know to ask the question.
So that’s why I share all this with you…. I hope if you are in a situation where your diagnosis is based on lab work that you will be assertive enough to ask that the slides be reviewed a second time.
It’s something Darrie Eason and I share — the hope that what happened to us will never happen to you.
Thanks for the lesson, Darrie. And bless you for taking your message out to those who may face such difficulty in the future.
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Trisha;
See, I’m still reading! (: Unfortunately, it sounds to me like the technician mislabeled the slides themselves, so re-reading the slides wouldn’t help. This type of mishap actually occurred in our laboratory once, although it was due to the physician’s office reversing the patient labels on 2 breast biopsies done in the office sequentially. There are innumerable protocols to prevent these types of errors, but one has to impress on workers to ALWAYS follow the protocol. This is tough to do. (That said, I entirely agree with you about the lab in question seeming to slough it off as an isolated human error. There are always ways to improve, if one bothers to look!)
Proper protocol should be after specimen are received in the lab each one has a gross examination done by a Pathologist. He/she reads the requisition, picks up the specimen with the original label from the OR visible on the container, reads the label and matches it to the Req. Then he submits the tissue for processing. This is not being done in a lot of labs because they cut corners to save money. Techs are grossing the specimen and when the specimen are given numbers labels are made covering the original label placed on the specimen by the OR. Because we have big central labs instead of individual hospitals doing their own exams hundreds get processed and batched. Bad practice but saves money.
I wrote about this on my blog…. it certainly isn’t going to solve anything by throwing one tech under the bus. I’m not sure if it was even a “shortcut” or if it wasn’t standard practice. Batching specimens happens in EVERY lab, which is setting yourself up for errors. The system has be improved. We can’t just blame individuals.