Oversight improvements to prevent misreadings

Two doctors must read all significant biopsies

Administrators at Sturdy Memorial Hospital may never know exactly how pathologists misread 19 prostate biopsies between 1995 and 1997, but the risk manager says recent improvements in oversight should practically eliminate the chance of it happening again.

The biopsies clearly were misread, says Sharon Simoneau, ASHRM, CHRM, director of risk management, quality assessment, and medical staff services at Sturdy Memorial Hospital in Attleboro, MA.

Why they were misread is difficult to determine. Prostate biopsies are known to be hard to read, but one of the two pathologists involved was the chief of pathology, and the other also was very experienced.

"We can consider a number of different reasons that they may have misread the biopsies, but we may never know which one it was," Simoneau says. "But whatever it was, we’ve implemented strategies that should address all those possibilities."

The hospital already had begun to upgrade its biopsy oversight a year before the mix-up was discovered, Simoneau says. Additional changes were made in response to the misread biopsies, all consisting of steps to ensure redundancy in the biopsy reading process.

"Now two physicians have to read diagnostically significant biopsies," she explains. "All breast and prostate biopsies now are read by two pathologists, and so is any biopsy that necessitates radical surgery. We’re assuming that there was only one read on the biopsies that were misread."

In addition to the prostate biopsies performed between 1995 and 1997, the hospital is having an outside provider review all diagnostically significant biopsies in the same period, on the theory that patients naturally will wonder about any other biopsy performed at that time. The hospital has sent 15,000 biopsies, expecting that about 6,000 will be diagnostically significant and require close review.