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Oral biopsy swap, leading to unnecessary surgery (11HDC01318)
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(11HDC01318, 7 March
Medical laboratory ~ Biopsy ~ Error ~ Biopsy swap ~
Pathology ~ Specialist laboratory ~ Right 4(1)
A woman had a biopsy taken by an oral surgeon. The biopsy was
sent to a specialist medical testing laboratory. The biopsy was
processed and the report indicated squamous cell carcinoma, a form
The woman was subsequently diagnosed with cancer by clinicians
at a district health board (the DHB) and underwent extensive
surgery. Histology following surgery showed no sign of cancer. The
possibility was therefore raised that the original biopsy results
showing cancer did not in fact belong to the woman.
The DHB alerted the laboratory, which undertook an internal
investigation. The investigation concluded that the woman's tissue
sample had been wrongly labelled with another patient's name when
the biopsies were being processed at the laboratory. Consequently,
the woman was given the wrong biopsy result.
It was held that that, while the cause of the mix-up appeared to
be human error, the laboratory was responsible for ensuring that
its processes were sufficiently robust to prevent such errors from
occurring. This was particularly important for a specialised
laboratory, which only processes oral tissue biopsies and as a
result is less able to rely on commonly used strategies to mitigate
the risk of error, such as separating similar types of specimen
from one another.
By giving the woman biopsy results that did not belong to her,
the laboratory failed to provide services with reasonable care and
skill and therefore breached Right 4(1).
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