Pathologist error: Double standard for docs & lab techs?

Pathologist error happened elsewhere:

• Winnipeg pathologist's work under scrutiny
• Botched breast cancer tests in Newfoundland

And now significant pathologist error has hit my city:

• Edmonton pathologist misread prostate cancer biopsies (2 Dec. 2011)
• Edmonton prostate biopsies prompt review of 1,600 tests (2 Dec. 2011)

Apparently the pathologist was substituting for another doctor over the summer. According to the news item:

"Of the 126 retests completed, 51 had no discrepancies with the pathologist’s initial report, 46 had minor discrepancies and 29 had substantial discrepancies."

If the subset of biopsies already retested is representative of the 159 prostate biopsies (or 1,568 non-prostate specimens), the pathologist made serious errors on 23% of the tests examined.

For interest, in the transfusion service laboratory (TS) when it comes to ABO grouping of patients, where errors can cause serious morbidity and potentially mortality, the margin of error allowed for medical technologists during competency assessment is zero, i.e., all ABO groups must be interpreted correctly.

Anyone hired to work in the TS lab, whether as fulltime, part-time, or casual staff, would undergo orientation during which they would be oriented to the lab's policies and procedures, retrained on basic theory and practice as needed, and undergo comptency assessment before being allowed to work independently with the same arms-lenght supervision as experienced staff.

If the medical laboratory technologist had not worked in the discipline for awhile, it's guaranteed they would be retrained before being 'let loose on patients.'

QUESTIONS

#1. Did the substitute pathologist have current experience reading prostate and other biopsies? If not, was retraining provided?

My guess: No current experience otherwise there would be many tests to re-examine over multiple years. No retraining because physicians, unlike other health professionals, seem to be exempt from re-training unless they emigrate from foreign countries or were discovered - after the fact - to have made major errors.

#2. Were the substitute pathologist's assessments checked by a second pathologist or were they reported "as is"?

My guess: Reports were unchecked and reported 'as is." There are no built-in processes to check physician error, except in retrospect when things go drastically wrong.

#3. What is the root cause of this screw-up?

My guess: Pathologist shortage.  ( Lots of evidence )

Are Edmonton pathologists now so overworked and in such short supply that physicians near retirement, who may not have current experience, are hired as substitutes so others can take much needed vacations?

Contributing factors: Double standard for physicians, who do not have to undergo the competency assessment that lab technologists do AND whose work seldom, if ever, has built-in system checks designed to detect errors.

SUMMARY

1. A substitute pathologist made multiple serious errors that impact patient care.

2. So far, all that happened is that he or she retired.

3. The pathologist's name will likely not be released since quality systems (QS) is now an integral part of health care. QS is a non-punitive system designed to foster staff revealing errors in a safe environment.

4. Alberta's College of Physicians and Surgeons releases names only if the physician is part of a disciplinary hearing open to the public.

5. Alberta's Health Quality Council will investigate. Will it provide a full public report of what happened? Who knows. I hope so, including answers to the 3 questions above.

MUSINGS

As a life-long transfusion science educator, I am often struck by how physicians are not required to meet the same standards of competence as medical laboratory technologists. Fact is, physicians who treat patients (clinicians) can prescribe transfusions in a total state of ignorance. They typically have little education in transfusion medicine.

The blood system relies on lab technologists to monitor inappropriate transfusion orders and draw them to the attention of the physicians (often hematopathologists) who serve as medical directors of transfusion services in Canada's urban centres. In smaller centres that lack technologists who are transfusion specialists, there are no checks on the incompetent ordering practices of clinicians, except in retrospect if things go dramatically wrong.

Tidbit: My experience in tranfusion service laboratories and blood centres is extensive. However, if I wanted to work in one today as a medical laboratory technologist, I would not be allowed to without providing clear evidence of continuing competency to the Alberta College of Medical Laboratory Technologists. And once on the job, I would receive extensive retraining.

If my assumptions about the substitute pathologist are true (and it's big if), would the harm to patient safety exist if pathologists had to demonstrate the same competency as I would before being let loose on patients?

Reflections of a blood eater

Updated: 16 May 2015 

December 1 is World AIDS Day and every year, despite the advances, HIV and AIDS continue to be major challenges for mankind:

• Number with HIV highest yet

Since its appearance in 1978, AIDS has had a profound effect on the blood industry, requiring screening questions and new expensive tests. Transfusion-associated HIV infection is now rare in the West but continues to occur in developing countries. The aftermath of the so-called "tainted blood scandals" occurred in all countries and continues today in some countries

As a blood banker I worked on the bench ("in the trenches") in the pre-AIDS days when syphilis and hepatitis B were the main concerns. We performed risky practices in those days and never gave safety a thought.
Here's a few memories from my past that I call "Reflections of a Blood Eater."

From the mid-60s to 1977 I worked as a medical laboratory technologist (aka clinical lab scientist) for the Canadian Red Cross in Winnipeg, which was a combination blood center and transfusion service along the lines of Puget Sound Blood Center in Seattle. Yes, mid-60s! We are definitely in the realm of old-geezers here. 

One of my most fond memories from that time was how we used to "shuck" (pour out) blood clots from 100s of donor specimens into kidney dishes before preparing 5% saline suspensions for red cell testing. All the while smoking and drinking coffee, of course. Time was a factor and those clots got tossed with wild abandon - it was the start of what could be a very long day depending on the clinic size. 

We worked until all blood was tested and sorted (put into inventory), no matter how long that took. For the 1000+ donor clinics after New Year's Day that could be from 07:00 to 23:00 hrs. No union to influence working hours in those days, either.

But I digress. To start each day we would shuck like crazy until the kidney dishes were full. Blood would splatter everywhere, including all over us, our smokes and coffee cups. No gloves, of course, only white lab coats that we wore everywhere including into the lunch room.

My most vivid memory from those days is the taste of blood on my cigarette filter. It tasted awful, probably more so as I'm a vegetarian. The second most vivid memory is of bloody finger streaks on the back of everyone's lab coat (after all, techs need to keep their hands clean and the buttocks was as good a wipe as any).

When hepatitis B testing was instituted (during my years there we went through counterimmunoelectropheresis, reverse passive hemagglutination, and radioimmune diffusion, now considered prehistoric), one year all lab staff were tested for both HBsAg and anti-HBs. 

Of the 20 or so technologists none were positive for HBsAg and only one (a good friend of mine still working there) was anti-HBs positive.
So, what does this contribute to the issue, i.e., the risk of disease transmission via drinking, eating, smoking in the lab? Probably not much. 

We were testing healthy blood donors for hepatitis and Canada had a relatively low prevalence rate, even given immigrants from higher prevalence countries. Mind you, some of the specimens tested were positive, and perhaps some of those made their way to my cigarette filters. Also, in the 1960s we bled donors from Manitoba's two penitentiaries. Indeed, once the rate of HBsAg in jails became known, prisoners were dropped as donor sources.

In retrospect, based on my experience working at the Red Cross in the pre-AIDS days, I suppose that I view the risk of contracting hepatitis and other blood-borne agents from activities such as drinking as being quite low. Certainly not zero, however. Consider that there were two technologists in Saskatchewan who contracted hepatitis B and died from mouth pipetting positive controls chemistry lab. We in the blood centres had luck on our side.

Also, Baruch Blumberg, awarded a Nobel Prize in 1976 for his discovery of HBsAg (initially called Australian antigen), tells the story of how his laboratory technologist came down with hepatitis B before they knew what the Australian antigen was (Source: ISI Current Contents).

Personally, I would not want to play Russian roulette with a million-bullet gun cartridge containing only one bullet. Sooner or later, someone gets the bullet. This scenario likely applies to all the rarer risks that we try to prevent by using universal precautions.

Today's students and younger lab professionals are astounded at these practices. In retrospect, even this vegetarian, once blood eater, finds them surreal.