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Right patient – wrong sample

01 January 2012

Mr Q, a 23-year-old student, was admitted to hospital as a surgical emergency with an acute abdomen. A provisional diagnosis of acute appendicitis was made and Mr S, consultant surgeon, performed a laparoscopic procedure. The findings at the time of surgery revealed a normal appendix, which was removed.

Mr S undertook a thorough inspection of the rest of the abdominal contents and discovered a small perforation of the body of the stomach with thickening of the surrounding tissue and localised contamination. A biopsy of the perforation site was taken and sent to the pathology laboratory for frozen section analysis by consultant pathologist Dr F.

Dr F called the operating theatre a short time later to discuss the biopsy result, which appeared to demonstrate an undifferentiated malignant tumour. Both Mr S and Dr F considered this to be highly unusual, particularly in view of Mr Q’s age. Dr F was confident in the accuracy of his initial assessment of the specimen, but felt that further histopathological analysis and stains together with a second opinion from colleagues in his department would be helpful. Following this discussion, Mr S decided at this point simply to close the perforation with an omental patch, wash out the contaminated fluid and await further assessment of the biopsy.

Postoperatively, Mr Q made a straightforward recovery. Mr S requested a CT scan that did not reveal any other disease and only demonstrated some gastric wall thickening at the site of the perforation. After further histopathology tests, the final opinion of Dr F and his colleagues was that the initial diagnosis of an undifferentiated malignant tumour was correct. Following careful discussion between Mr S and the patient, Mr Q underwent a total gastrectomy three days after the initial biopsy. Again, Mr Q made an uneventful recovery. The final pathology report from the resected specimen proved to be a normal stomach with no features of malignancy.

On the grounds that his major surgery had been unnecessary, Mr Q made a claim against the doctors involved in his care. The hospital initiated an internal investigation and it became apparent that there had been an error in the pathology laboratory. The frozen section sample taken from Mr Q had been mislabelled in the pathology department and actually belonged to another patient who had had surgery some hours earlier. The correct specimen taken from Mr Q was entirely benign.

The case was defended successfully on behalf of the member, Mr S. An investigation by the regulatory body (to whom the clinicians involved had been reported) also exonerated Mr S and Dr F. A separate claim against the hospital did, however, result in a substantial settlement for the claimant on the basis of errors in the pathology labelling processes.

This is a genuine case from outside the UK, and was reported in the media.

Learning points

  • Many doctors will have a claim made against them during their professional lives. Even when some mistakes occur because of system failures, it is the doctors who may initially be investigated. In this situation the clinicians did go to extra lengths to check the veracity of the pathology report before acting upon it, but were ultimately let down by problems with the hospital’s systems for labelling pathology specimens.
  • Misidentification of pathology specimens occurs every year in even the most developed healthcare systems. In the UK, figures obtained via the Freedom of Information Act for the NHS in 2009 revealed almost 12,000 samples were incorrectly labelled by pathology laboratory staff. This can potentially lead to both inappropriate treatment and also delays or false reassurance in the management of unreported conditions. Despite technological advances and improvements in quality control of system processes, clinicians should always be alert to the possibility of a misidentification error when an unexpected result appears.
  • Additional opinions from colleagues and further biopsy material can help confirm or refute an unexpected pathology result and prompt investigation into any mistakes in labelling or specimen identification that may have occurred. In the context of cancer treatment, such processes are facilitated by the multi-disciplinary team approach, which is now standard for the management of gastric cancer in the NHS in England.
  • In the case described, it is likely that a wider group of clinicians would have suggested additional biopsy material from an endoscopy and a laboratory check on the identity of the specimen, prior to proceeding with such radical treatment in a very young man.