At least one woman who was wrongly operated on after a botch-up in reporting pathology results has not received an apology, and others were told of the mistake over the phone "quite some time" later, a panel of experts looking into the mix-ups has found.
In June the Ministry of Health convened a panel of experts to look into five cases where woman had unnecessary surgery because of mistakes in reporting pathology results.
One of the cases involved a woman having part of her jaw cut away after being wrongly diagnosed with cancer of the mouth.
Another woman had a mastectomy by mistake after her breast biopsy was swapped with another.
A Herald on Sunday investigation found six woman had been affected by errors made in pathology laboratories.
The panel of experts yesterday reported back that there was five incidents over a two-year period.
Four incidents involved breast biopsy tissue and the fifth involved oral tissue.
Four of the errors resulted from transposition of specimens with those of other patients during the laboratory process. The fifth error resulted from a misinterpretation of the specimen, it reported.
In compiling the report panel representatives met with four of the woman who reported on their experiences during and after the case.
The response from health providers once the mix-up was realised "generally was short in duration and largely unsatisfactory", it said.
One woman who initially had a false negative result reported the response as being very unsympathetic because they believed her cancer had been caught in time and treatment had not been delayed.
Three of the four woman reported that an apology in some form had been received.
"Other women reported being told of the errors over the phone quite some time after surgery," it said.
One woman waited three months for an apology from the laboratory.
"Another woman was very happy with the response from one laboratory and their follow-up."
In its report the panel suggests a raft of measures to support affected patients, including acknowledgment of the mistake being made promptly, full disclosure of all information provided to the patients and communication should convey empathy and understanding.
The panelists also spoke with groups of doctors and laboratory staff involved with two of the incidents.
It said that where an error had occurred staff were "utterly devastated".
Many of those involved welcomed an approach of immediate and open disclosure.
Three of the four woman spoken to had sought lump sum compensation for treatment injury, but the process for consideration and decision making had been difficult, it found.
The panel recommended that ACC noted the experiences of the women and consider its policies in regards to lump sum compensation for patients affected by biopsy errors.
The panel found that the overall quality of processes in New Zealand laboratories were of a high standard, but international research showed that the nature of processing specimens was vulnerable to errors of these types.
"The longer term solution to reducing these errors is to introduce greater use of technology of the laboratory process," the panel said.
But in the meantime, it made a raft of recommendations to providers, the Ministry of Health and the Laboratory Roundtable.
Included in the recommendations was the suggestions that all laboratories should be required to report sentinel events to the Health Quality and Safety Commission, individuals involved in these cases should be advised of the scope of their entitlements and as technical solutions became economic automation should be pursued for steps involving specimen handling.
"A major part of the report involved interviews with affected people and their families and the panel is very grateful for their input. Their experiences have highlighted that better support is needed for people who are harmed by diagnostic errors," Ministry of Health chief medical officer Don Mackie said.
The Medical Laboratory Workers Union supported the findings.
Tight timeframes, increased demand and a culture that does not support collaboration between laboratories contributed to increased possibility of laboratory error, said Union president Stewart Smith.
"Medical laboratory work has been treated as a commodity by DHB funders of both the hospital and community services. It's an area of healthcare that only draws attention when something goes wrong and these tragic consequences for patients result."
Health providers, including laboratories, and other key organisations had been sent a copy of the report with the expectation that they reviewed their own processes based on the recommendations, Dr Mackie said.
He would write to the sector in November and ask all laboratories to explain how they had assessed their own progress in light of the report.
