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Specimen mix-up

01 November 2005

This case report took place five years ago in a hospital overseas. Dr A, a dermatologist, took a punch biopsy of thick skin plaques on Mr J’s knee to confirm a diagnosis of psoriasis. Mr J had recently retired from his occupation as a carpet fitter. When the laboratory reported ‘a poorly differentiated squamous cell carcinoma’, Dr A discussed the result with his colleague Dr Q – a plastic surgeon – and arranged for Mr J to see him.

Dr Q carried out a wide excision – 2cm to 3cm in diameter – of the lesion on Mr J’s knee. However, this time the histology report showed only a seborrhoeic keratosis with no evidence of malignancy.

Subsequent investigation revealed that the original specimen had been given the same number, in the lab, as a fine-needle aspirate from another patient’s lung. Dr V, the pathologist who had signed Mr J’s report, was at a loss to explain how the error had arisen and why she had not noticed the error before signing the two reports.

Although we felt that the hospital should bear some of the liability on behalf of the unknown laboratory assistant who had mislabelled the specimens, it refused to accept this argument, claiming that Dr V was solely liable because she had signed the histopathology report. The claim was settled for a sum equivalent to £35,000 (US$62,000), with almost the same again in costs.

Learning points

  • A heavy workload – Demand on clinical laboratories is intense, with heavy workloads and often poor staffing levels. But this is mitigation, not a defence. Reliable and frequently reviewed specimen management procedures are therefore essential if errors are to be avoided.
  • Learning from mistakes – The hospital should undertake a root cause analysis of this untoward incident and introduce changes to their procedures to prevent a recurrence.
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