Earlier this year, the Ministry of Health became aware of five serious errors in reporting of pathology results for breast tissue and oral tissue over a two year period. Of those five errors, four resulted from transposition of specimens with those of other patients during the lab process, and one resulted from misinterpretation of the specimen. The Ministry convened a panel of experts to provide advice regarding the errors. The Panel has now released its report. While the Panel considers that overall quality processes in New Zealand laboratories are of a high standard, vulnerability to error remains. The Panel has made a number of recommendations to minimise such risk to error, and has also suggested improved reporting of serious and sentinel events; improved collaboration between laboratories on quality initiatives; and improved and nationally consistent processes for supporting patients affected by serious errors. The Report is available here.
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Expert panel makes recommendations on pathology laboratory errors
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