On May 4 2012 Windsor Regional Hospital announced the occurrence of a sentinel event related to procedures in its pathology department. Windsor regional hospitals have a well documented history of pathology errors in the reading of test result reports leading to unnecessary surgery. After a well publicized incident of unnecessary surgery 3 years ago at Hotel-Dieu Grace Hospital the provincial government ordered a review of the reporting practices at the Windsor hospitals. The review resulted in a recommendation that the pathologist labs of the three Windsor hospitals be centralized so as to minimize pathology errors.
Patient Identification Error
In the latest case a patient identification error led to a lumpectomy being performed on the wrong patient. An unnamed staff pathologist is being blamed for the error. Apparently there were two files open at the same time on the pathologist’s desk. As a result information relating to the two patients were mistakenly transposed when the pathologist was completing a report on tissue extracted by way of biopsy. The pathologist reported that the patient’s biopsy as significant for advanced breast cancer. Unfortunately it was for the wrong patient. The hospital announced that the mistake occurred as a result of a failure to follow its own policies and procedures.
Medical Mistake Led to Unnecessary Surgery
The erroneous report led to the patient being operated on. She had a lump and four lymph nodes were removed. A tissue review of the lump after the surgery found that it was benign. The patient identification error was found when these results were compared to the report of the biopsy that preceded the surgery. There was a clear mismatch. The patient whose tissue was positive for breast cancer has received appropriate medical treatment.