Pre-laboratory
A urologist had just completed a transurethral resection on a prostate. He dutifully placed about thirty prostate fragments into the correctly labeled specimen jar. He then completed the next case, also a transurethral resection, again dropping the fragments into a specimen jar, which just happened to be the same jar used for the previous patient. Thus, about 60 pieces of tissue from two different individuals got mixed up in one container. In another case, a surgeon who knew that his patient had had a diagnosis of cancer some years before, sent in a specimen labeled “mass” without mentioning the previous history. That patient’s specimen got placed into formalin and was deprived of the benefit of testing that requires fresh, unfixed tissue. In another instance, I saw a requisition form on which critical historical information had been covered by a label affixed by a careless individual in the clinician’s office. One of the most spectacular pre-lab events in my experience was when a surgeon removed a cancerous esophagus, handed it to an assistant, after which the esophagus was “somehow” never seen again.
From time to time, a specimen container arrives at the laboratory, perfectly labeled, yet empty. The jar and the underside of the lid are carefully inspected, but to no avail. I do not know how this occurs, but it occasionally does. A specimen may be mistakenly deposited by an inattentive courier into an obscure fridge in an unrelated laboratory, where it may languish indefinitely. In one instance, a fridge, used for specimen storage in the operating room, was replaced. However, no one had checked the contents of the old fridge, which held two pathology specimens that were banished to the hospital basement where they lay undetected in the discarded fridge for weeks. Placement of a specimen into an inappropriate container may not only cause it to remain unfixed, but may also ensure that it reaches the wrong destination.
Another pre-lab factor involves legibility. The cumulative Time devoted to deciphering illegible handwriting is unacceptably high, and is a problem often compounded by arcane abbreviations understood only by a subset of clinicians. Illegibility contributes towards the high cost of medical care, as when I needlessly caused the additional expenditure of more than $1000 to reach a diagnosis because key information, illegibly scribbled, was overlooked and led me to perform a series of unnecessary tests. Another factor that hinders the pathologist’s interpretation is inadvertent crushing of a small biopsy sample. Tissues are fragile, and must be treated delicately. The electrical knife, when used to obtain biopsies, can impose its own distorting effects, and highly cauterized tissues may not be interpretable at all.
Elaborate systems are in place to maximize pre-lab efficiency, but as long as human beings are involved in specimen gathering and transport, problems in this phase of the biopsy cycle will never be completely eliminated.