Press Releases

July 19, 2010

Critical Incident Review to Examine the Accidental Switch of Biopsy Samples From Two Patients

Routine quality assurance process identified issue; Both patients identified and fully informed

Diagnostic Services Manitoba and the Winnipeg Regional Health Authority are advising the public today that they have launched a Critical Incident Review into the accidental switch of two Breast Health Centre patient biopsies that had been analyzed by DSM.

As a result of the unintentional sample switch, one woman underwent unnecessary surgery (a lumpectomy), while the second experienced a ten-week delay in her diagnosis. She is now being offered treatment on an expedited basis. Both patients and their families have also experienced emotional distress as a result of the mistake.

Discrepant results for Patient A were discovered by a pathologist during DSM's routine quality assurance process which require that patients' initial biopsy results be compared with biopsy results from any surgical tissues that are later removed. In the case of Patient A, her initial biopsy tested positive for cancer while the biopsy of the tissue that was removed from the subsequent surgery tested negative. An investigation was immediately launched.

DNA testing has confirmed that the biopsy results initially given to Patient A belonged to another patient. Patient B has since been identified, given the correct biopsy result and is being offered treatment on an expedited basis.

Both DSM and the WRHA are confident this is an isolated incident, identified by system safeguards and involving only these two patients.

A Critical Incident investigation has been initiated to determine how the mix-up occurred as well as to identify what changes can be made to reduce the possibility of such an incident happening again. DSM and the WRHA have apologized to both patients and have committed to sharing with them the findings of the CI review and any recommendations stemming from it.

Both patients also are aware that because of recent national interest in this issue, DSM and the WRHA are releasing this notification. However, both patients have indicated that they consider this to be a personal health issue and have asked that their privacy be respected.

Any other patient with questions can call the WRHA - DSM designated line (788-8004) and leave a message. Calls will be responded to promptly by the appropriate person.

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