A Perspective

When I go to work and see the same mistakes happen again and again, I get discouraged. I see the way some techs work, their poor skills, their unwillingness to improve. I see supervision addressing the problems of broken equipment, budgets, scheduling, and not work habits that cause delays, errors, and poor results.

I began this blog because I think potential patients need to know the dangers they face when they have a biopsy taken. They need to know how to get justice after a sentinel event and how to protect themselves, how to stop such an event occurring.

You may have never heard the term ‘sentinel event’ before. It is a term used by The Joint Commission, TJC. The following was copied from their site here.

A sentinel event is a Patient Safety Event that reaches a patient and results in any of the following:

  • Death
  • Permanent harm
  • Severe temporary harm and intervention required to sustain life

Such events are called “sentinel” because they signal the need for immediate investigation and response. Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission.

The Joint CommisionIt’s that last part that gets me ‘Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission.’ That means a doctor, hospital, or any other healthcare organization, gets to decide whether they will tell anyone about their mistakes. Most of the institutions in which I have worked did not report.

Given that, and given patients might not even know what happens to their biopsies and surgical specimens, how can a patient know if their specimens were handled correctly? How can they know their diagnosis is accurate?

The above text from the TJC site speaks of one kind of event, a sentinel event. When such an event occurs patients are nearly always aware. They might not be told what happened that made them sicker but they know something happened. In my lab that something could be all the topics I have discussed: processing errors, mix ups, lost specimens, poor cutting, and others I haven’t covered.

Without information and a rudimentary understanding of the process, a patient cannot ask questions and get answers. It’s hard enough to ask questions when you are facing a doctor who would avoid answering them. It is easy for them to avoid giving answers if you don’t ask the right questions.

It doesn’t take an event as serious as a sentinel event to hurt a patient either. Routine lab errors can have consequences that might go unnoticed. Consider the woman with no cancer who is diagnosed with cancer because her biopsy was contaminated. She will ‘recover’. Or how about the 600+ cases ruined due to an untrained lab assistant when he put the wrong chemicals in the processor. All of those people represented in those blocks got diagnoses that were not as clear as they should have been. They were far more likely to be wrong than on a day the processors were correctly maintained.

My blog is meant to inform people about these potential problems so they can recognize when something bad has happened and be armed with the right questions and right responses, in as far as I know them.

I qualified that, in as far as I know them, because I am a lab tech. I am not a lawyer. I am not a doctor. I cannot speak on particular cases. My intention is to uncover the hidden lab and explain what I’ve seen. In so doing, you might be surprised, entertained, or shocked. Mostly, I would have you learn enough to protect yourself and defend yourself from poor practices. I would have you get the quality care you expect to receive when you walk into a health care institution and if the worst happens, I would have you know what to do.

 

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