More than 100 patient tissue samples had to be retested at Grand River Hospital’s laboratory due to an issue blamed on human error.
“The processor did not remove all of the water from the specimen, and therefore the quality of the slides was not optimal,” Dr. Dimitrios Divaris, the hospital’s chief of laboratory medicine, said Friday in an interview.
The lab recently replaced one of the alcohol solutions it uses to dehydrate tissue samples with a fluid of a different strength.
That change, Divaris said, necessitated an override to the machine’s programming.
“Unfortunately, when we had to (replace) that fluid … that manual override was not done,” he said.
As a result, when the machine ran on May 24, it didn’t remove all the moisture from the samples.
The error was quickly realized when the process stopped, Divaris said – but by that point, it was too late to properly process all 117 of the samples.
Many were able to go through a reprocessing and come out usable – but some patients will need additional follow-up with their doctors.
“There were 19 where we couldn’t get all the information that we felt we may have been able to get,” Divaris said.
One cancer patient required a second biopsy, which has since been completed.
Hospital officials say they’ve already adjusted their processes to add an extra double-check step, which they say should help prevent similar issues in the future.
“In an organization (with) as many complex processes as happen in this laboratory, what we seek is learning and improvement – not punishment,” hospital president Malcolm Maxwell said.
The hospital’s pathology lab handles approximately 27,000 patient specimens per year.
