CMS response to cancer misdiagnoses due to lab errors

Swerlick, Robert A rswerli at EMORY.EDU
Wed Mar 21 15:04:17 UTC 2018


The biopsy pathway is incredibly complex with many steps and many potential sources of error. I operate within multiple health systems with different EHR's (EPIC, Cerner, CPRS) and NONE of these electronic records has robust tracking tools for anatomic pathology. I do not know the specifics of the events at Wake, but I would venture to guess that there are system issues here which are likely the major players and these issues are common to almost every health system in the country (world).


I also suspect these types of errors are ongoing everywhere.


Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669
________________________________
From: Jackson, Brian <brian.jackson at ARUPLAB.COM>
Sent: Tuesday, March 20, 2018 2:32:11 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] CMS response to cancer misdiagnoses due to lab errors


Speaking as a pathologist:  There are a number of possible root causes here.  The news story gave very little detail, but did indicate that the hospital is blaming one individual who is no longer part of the lab.  It’s certainly possible that one person’s negligence could have caused these errors in ways that would have been difficult for others to detect.  For example, a pathologist or pathologist’s assistant or pathology resident could switch samples or containers or labels during initial processing of the biopsies.  Or a histotechnologist could do the same thing when making the microscope slides.  It’s also possible that it could have been something that would have been caught by a better quality management system.  But maybe not.  Given such limited info, it’s just really impossible to say.



In an ideal world, the post-investigation details of a case like this would be made public for the rest of us to learn from.  Unfortunately, accreditation agencies (and I’m using the word broadly to include CMS) don’t put enough emphasis on post-problem transparency and education.  We’re often left to rely on whatever local journalists can discover and publish.  Which these days is usually little to none, given the decimation of local investigative journalism thanks to the business dynamics of the internet.



--Brian Jackson



From: Bob Latino [mailto:blatino at RELIABILITY.COM]
Sent: Tuesday, March 20, 2018 10:17 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] CMS response to cancer misdiagnoses due to lab errors



Thanks Peggy.



The hospital corrective action plan is weak (based on the one paragraph explanation they provided).



Where was the management oversight to detect all of those 'now visible' deficiencies in qualifications, equipment deficiencies and less-than-adequate (LTA) quality processes?



Why didn't the staff who worked daily in the presence of these obvious deficiencies, feel comfortable to speak up?  OR, did they speak up and weren't heard (or listened to)?



Their response is the typical 'retrain and revise procedures' approach while overlooking the systemic deficiencies, restraining cultural paradigms and sociotechnical factors, that permitted the 'drift' to occur in the degradation of standards. This is often the case when seeking to be compliant versus safe.



How come most of the ~6000 hospitals in the U.S. are accredited yet the medical error death rate continues to climb (since magnifying glass was focused on the topic of patient safety in the 1999 IOM report)?



Bob



Robert J. Latino, CEO

Reliability Center, Inc.

1.800.457.0645

blatino at reliability.com<mailto:blatino at reliability.com>

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From: Peggy Zuckerman [mailto:peggyzuckerman at GMAIL.COM]
Sent: Tuesday, March 20, 2018 11:07 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] CMS response to cancer misdiagnoses due to lab errors



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