High-tech system will reduce risk of human error in specimen handling, says director.

A pathology service has become the first in New Zealand to use a a high-tech barcode tracking system to help eliminate the risk of laboratory botch-ups.

Mistakes with specimens have had catastrophic consequences and last year health officials ordered an urgent investigation after three women had breasts removed after mistakenly being told they had breast cancer.

In another case, a Nelson woman had her top jaw cut away when she was wrongly diagnosed with cancer of the mouth after a lab worker dropped two samples on the floor and mixed them up.

An expert panel convened by the Ministry of Health found automated, individualised mechanisms for specimen labelling and handling should be the "gold standard" for reducing the risk of sample mix-ups.


Pathology Associates Ltd director Dr Richard Massey said he had found such a mechanism in the state-of-the-art Cerebro specimen tracking system.

Dr Massey said mistakes were rare in New Zealand laboratories, but processing pathology specimens was vulnerable to human error.

"A momentary lapse in concentration can lead to samples being misidentified. And incorrect or insufficient labelling can have devastating consequences for patients."

His labs, which handled around 230 pathology specimens each day, previously used a manual checking system under which surgical pathology specimens were matched up to request forms. Under the new system, each specimen carried a unique barcode to prevent errors associated with transcription and handwritten labels.

They were then electronically monitored as they passed through each histology processing stage.

"Instead of people checking the identity of each specimen is correct, the Cerebro system will now do that throughout the laboratory process."

His company had decided to invest in the technology two years before a series of mistakes at other labs were made public.

"We identified our histology processes as potentially being the most vulnerable and we were aware that there was a new technology was just arriving on the market that could potentially address those issues."


Other labs around the country were now watching the Bay of Plenty and Waikato-based services' progress with interest.

"Some have spoken to us at length, and we're aware that some other labs have gone as far as figuring what it would cost to implement."