In some fields, five serious errors in two years would be acceptable. But not when the consequence is women being wrongly operated on. This was the traumatic upshot of mistakes in the reporting of pathology results during that period. In New Zealand.
Four women who were told they had cancer and needed to have their breasts removed went ahead with the operation - only to be told later there had been a mix-up with specimens. Another had part of her jaw cut away in error. In response to the focus put on these errors by this newspaper, the Ministry of Health convened a panel of medical experts in June to offer advice.
Some of its findings, released this week, offer little comfort. One verges on being disrespectful to the women affected. The panel concludes, in effect, that the error rate is acceptable. It is excused on the basis that international research shows the nature of processing specimens is vulnerable to errors of this type. Thus, while this country's laboratories compare well with those overseas, nothing different can be expected here.
Any experience like that endured by the five women should never be acceptable. And nor does the picture of high standards painted by the report tally with that of a senior pathologist spoken to by the Herald on Sunday.
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Dr Ian Beer, of PathLab Waikato, said he and his colleagues were under pressure to meet a five-day deadline for breast cancer diagnoses. Biopsies were being processed in batches, and stressed staff were making mistakes. They were, he said, being "set up to fail". And failure was the outcome when four specimens were transposed with those of other patients during the laboratory process and a fifth was misinterpreted.
Beer wanted the deadline for suspected breast cancer specimens to be doubled to 10 days, the turnaround time expected for other cancer diagnoses. His request seemed reasonable. Yet the report concludes the current time-frame is appropriate given the importance for women to have certainty as early as possible. But it is surely better for women to wait a little longer for that certainty, rather than be subject to an approach that, while quicker, has a much higher risk of flawed diagnosis. Further, the panel's recommendations for preventing more faulty results are not utterly compelling. In the long term, it envisages the potential for human error being reduced by automated technology. In the meantime, it suggests that, where possible, only one specimen should be handled at a time. But the effectiveness of this will depend on the pressures on a workforce that may be spread too thinly in too many cases.
The panel also found that most of the women had been treated disrespectfully in the aftermath of their horrific experiences. One had not received an apology and others were told of the mistake over the phone "quite some time later". The report says there should be prompt acknowledgment of an error, full disclosure of all information to the women, and opportunities to discuss this with qualified staff. It is a severe indictment that this even needs to be said. Immediate and full disclosure and appropriate support should have been the automatic response to the women's plight.
Their misfortune did not end there. At least some of the women who sought support from the ACC were treated unsympathetically. "Their experience to date is that the process for consideration and decision-making has been difficult for them," the panel notes. The ACC should, it says, review and improve its policies on lump sum compensation for such patients, as well as its processes for responding to such claims.
Clearly, much work awaits the new board charged with overseeing a culture change at the ACC. Equally, much needs to be done to restore women's faith in the breast cancer screening system. The panel's report takes a relatively benign approach to neutralising the problems. More will be needed if the botch-ups continue.