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UHNBC Pulls Faulty Piece Of Equipment From Service

By 250 News

Friday, March 25, 2011 11:09 AM

Prince George,B.C. - Northern Health is conducting a review of a piece of diagnostic equipment at UHNBC and how it is operated after a  problem with one run of samples during an automated overnight processing.
 
NH was made aware of the issue last Friday morning when lab technologists and pathologists identified concerns over the quality of a group of tissue samples which had been processed overnight. The processor, which prepares specimens for pathologists to analyze, has been temporarily taken offline while the review is done. From preliminary information it appears that a reagent alcohol mixture was contaminated with water. The problem was discovered immediately and affected only one batch of samples.
 
“This is an isolated incident that our laboratory staff and pathologists picked up on right away, but unfortunately the samples had already been affected,” said Dr. David Butcher, NH’s Vice-President of Medicine. “We are investigating the root of the problem and contacting physicians and their patients, and we are confident the problem was confined to the identified samples.”
 
The processing problem involved samples from 30 patients. The contaminated mixture can distort the samples so that a definitive reading for a diagnosis is not possible. The affected patients and their physicians are being notified by Northern Health and patients should discuss any concerns with their physician directly, as follow up may vary. Any re-testing that is required will be given top priority.
 
“I would like to apologize to any patients this has affected,” said Michael McMillan, Northern Interior Chief Operating Officer for Northern Health. “We have made some immediate changes to how our lab staff prepares the machine to make sure this type of problem won’t happen again.”
 
Northern Health currently processes more than 15,000 specimens annually at UHNBC

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Comments

it happens, humans
Yeah, "it happens" because we are too reliant on technology to do what humans used to have to do manually, exercising their knowledge. Sure, mistakes would be made anyway, but at least the level of complacency (dependence on the machine) would have been less, people would know it is all up to them and their own brain power, no one else, or no machine to blame.
metalman.
Someone used there knowledge to catch the mistake the machine made or this could have gone undetected for more samples.
That particular problem is not as serious as it is being made to appear. All they have to do is heat the specimens to remove the wax, treat with xylene to remove the molten wax. Then they can reprocess the tissues. When complete, they will be the same as if there had been no problem. The extra delay would be 24 hours. Years ago, I dealt with this problem over and over again, when technology was much younger and more inefficient.

Incidentally, doing this process manually would delay cancer diagnosis by at least three days, perhaps more. Thank god for modern technology.
To Jakeadoo, this problem will always be detected because it does not permit the rest of the process to be completed (cutting an extremely thin slice to put on a microscope slide). The tissue itself is not damaged from this error.
good quality assurance in this case. Looks like Northern Health authority has pulled their socks up in patient care. Glad to see that.
There always will be someone who is not going to be happy about something. I think the hospital now is a lot better than it was twenty years ago.

This is only my opinion, and I have been lucky, and have not spent that much time in a hospital, other than to meet with someone. Knock on wood, nearly five decades and have never spent a night in the hospital other than when I was hatched.
Thanks for the clarifications, ammonra.
metalman.