Dutch hospital removes prosate from wrong patient!

I hate reading about medical mix-ups like this with such profound, life-altering results. Many years ago, before computers, I reported a positive syphilis test result for a patient with a common last name. It turned out that two patients being tested had the same first and last name. The physician asked me to retest the blood sample, saying: "I want to be sure that the result is correct before I have to tell an 80-year-old nun that she has syphilis." Indeed, the two patient samples had been reversed. I learned from that mistake, and never to my knowledge made an error like that again in 30 years of lab testing. These kinds of errors happen all too frequently; so often that Atul Gawande wrote a book titled 'The Checklist Manifesto' addressing solutions to the problem of medical mistakes.

My local hospital has become so paranoid about this that every time a new nurse, doctor, etc comes in the room to do a procedure you get the, "What's your name, what are you here for, etc" list of questions. My mother went in for eye surgery they used a marker to put an 'X' over the eye they were going to do.

Sad that this kind of thing still happens.
Andrew

It happens way too often. On my BT procedure the form I had to sign had the right name but a different birthday and different address. I would not let them proceed until I reviewed the exact procedure the doctor would use, i.e. number of seeds and type and reviewed his pre op notes. He was a little upset at having to go through this because he was running late, but it was my ass on the line and I made him go through it.
When I was in the hospital in Japan the helicopter pilot next to me had a fractured upper arm; they removed the cast and recast his lower arm, which he thought was rather strange. Three days later his bone separated and had to undergo major surgery to pin it. Since then I always check before any procedure is done, and question anything I feel is out of place.

One of the reasons that medical residents are limited by law in the U.S. to an 80-hour maximum work week is to prevent medical errors due to lack of sleep. According to the Institute for Safe Medication Practices (www.ismp.org) nearly 100,000 people in the U.S. die each year due to medication errors. I think that all of us, like John T., would be wise to question before proceeding.
(As I wrote earlier, Atul Gawande, a surgeon, has written an excellent book about medical mistakes that I recommend reading. It is written in clear, understandable, non-technical language: 'The Checklist Manifesto')

I ran into another case (not personally involved) where a father and son came into a clinic where I worked. Their names were the same, except for Sr/Jr and their birthdates. Both had the same test, a prothrombin time to monitor their anticoagulation and adjust their warfarin meds. The results were correctly sent for each, but the physician's office staff switched the results and adjusted the dose of medication for each based on the other's result. Thankfully this was caught by the physician in her end-of-the-day review.

Post Edited (Tim G) : 6/13/2013 11:53:05 AM (GMT-6)

I think all the "what's your name?what's your dob etc" stuff was done correctly, but that, then in the absence of the aptients and the docs and the forms a lab tech put two sets of samples on the table at the same time and then muddled the two samples. They have a new protocol that says only work on one set of samples at one time.

Years ago I had a job as Insurance Coordinator for a really large company.

At one building - Jim Williams was the general manager.

The head of the cleaning company's name was Jim Wilson.... I knew them both pretty well.

I received a phone call that Jim Wilson had died on the property the night before.

In my haste - I got the names mixed up.. I called our main office insurance person - the Workers Comp carrier and OHSA...

It was pretty ugly trying to clean that up.

A recent study showed that labs can mix up biopsy slides 1-3% of the time. The suggestion for improvement was DNA matching of samples to a cheek swab from patient. The study came out late 2012/early 2013. I was paranoid that this had happned to me, and I was getting someone else's diagnosis. Fortunately, the endorectal MRI and final pathology during surgery matched up to me.

All the patient questions in the world don't fix this type of problem....

Clocknut - the path report showed a cancer-free prostate.

This was clearly a lab labelling error and not a mistake by the surgeon, and I don't think there is anything a patient can do to make sure the lab doesn't slip up.
It's not really an option for all patients to get two biopsies done in different hospitals and have them tested by two different labs. (Getting a second opinion about your slides isn't going to help if they are not actually your slides)

I know that one of my fears at surgery was that despite the evidence they would remove my prosatte only to find that I did not have cancer. So when I got my pos- op results I was actually slightly relieved.

Alf

As to the meds deaths, been there, nearly done that. My neuro prescribed an SSRI and an MAOI concurrently, which is a big "Duh!" Got Serotonin Syndrome, and eight day coma, and nearly died.
Second, isn't it funny that residents are working ONLY 80 hours. Sure, as a restaurant/hotel manager I worked those kind of hours from time to time, but I sure wouldn't have wanted to be responsible for someone's health.

Tim G said...
One of the reasons that medical residents are limited by law in the U.S. to an 80-hour maximum work week is to prevent medical errors due to lack of sleep. According to the Institute for Safe Medication Practices (www.ismp.org) nearly 100,000 people in the U.S. die each year due to medication errors.