Biopsy error leads to unnecessary chemo

A woman received "several months" of unnecessary chemotherapy after a botched tissue biopsy at Whangarei Hospital.

The incident was revealed after the Health Quality and Safety Commission released its annual report of serious adverse events at District Health Boards.

The number of these reported events at Northland DHB was 15 in the 2013/14 financial year, six more than the previous 12 months. Chief medical officer for the DHB, Dr Michael Roberts, said he was "very disappointed" when he learned of the botched biopsy result "There was a lady who received some chemotherapy which she didn't need because when the tissue for her cancer was looked at under the microscope [it was misread]," Dr Roberts said. The mistake was only discovered after the breast cancer patient received "several months" of additional chemotherapy, he said. The doctor treating her thought something was not right and had the biopsy reassessed, which was when the mistake was discovered. The DHB apologised to the patient, who did not make a formal complaint.

"She was very, very keen to make sure that people learnt from it and to make sure that it didn't happen again," Dr Roberts said.

"Our target is zero harm to all patients and we continue to work hard to deliver high-quality, safe healthcare to Northlanders."

Following the incident, the DHB put new policy in place that ensured each biopsy was checked by two pathologists, rather than one. However, according to the New Zealand Breast Cancer Foundation the double reading of biopsies is standard in most labs.

Chief executive of the foundation, Van Henderson, said while it is never good for someone to have unnecessary treatment, it is particularly bad in the case of chemotherapy. "The side effects can vary quite a lot but obviously some people suffer a great deal," Mrs Henderson said.

As far as the foundation was aware there had not been an instance of a misread breast cancer biopsy before. The rise in reported serious adverse events should be attributed to increased reporting, rather than increased events, Dr Roberts said. "I think that some of those we definitely had lessons to learn but the thing I feel content about is that we have learnt the lessons," Dr Roberts said.

In 2013/14, falls were the most frequent cause of harm reported by DHBs, making up 55 per cent of all cases - nine of the 16 Northland DHB serious adverse events reported. "While it is impossible to avoid falls altogether, we continue to introduce interventions that will both reduce the rate of falls and the seriousness of harm to patients from falls," said Dr Roberts.

"We continue to work closely with the "First Do No Harm" regional falls programme and we are engaging with the Aged Care facilities to share our learning and progress the falls prevention message."

The DHB was also happy no serious adverse events (SAEs) resulted in death this year, he said. Last year two of the nine reported events resulted in death. Nationally there was a four per cent increase from the previous year, with 454 being reported throughout all DHBs. The increase in SAEs reported nationally and in Northland reflects the health sector's commitment to improved reporting of cases, he said.

Dr Michael Roberts, Northland DHB chief medical officerReported serious adverse events
in Northland:
• Patient received unnecessary chemotherapy
• A baby's blood transfusion instrument disconnected causing blood loss
• Two patients with eye injuries had treatment delayed
• Patient with cancer had a three-month delay for a second appointment because of lost documents
• Patient required surgery after pressure injury from previous stay in hospital
• A child's small malignant lump was not identified and patient had to be transferred to a tertiary hospital
• Nine elderly patients experienced falls resulting in serious harm