Back during Circuit Breaker, everyone’s biggest fear was testing positive for COVID-19, Or, even worse, testing falsely positive for the virus and giving ourselves a mini heart attack.
Imagine that fear, but make it a hundred times worse. That was probably what the 180 Khoo Teck Puat Hospital (KTPH) patients felt when they were misdiagnosed with a more aggressive form of breast cancer.
Hospital To Discipline Staff And Compensate Patients
According to The Straits Times, the hospital has apologised to the affected patients and will offer compensation and counselling services to them.
Associate Professor Pek Wee Yang, chairman of the KTPH Medical Board said, “We have reached out to all affected patients to offer our support, and we give the assurance that we will look into the appropriate compensation for each individual patient.
“We would also like to seek their understanding and patience as this process will take some time to complete. In addition, we will provide psychological counselling to these patients, where needed, during this period.”
Earlier in January, Senior Minister State for Health Koh Poh Koon had told Parliament that the extra costs incurred by patients for their medical expenses will be fully refunded, reported CNA. However, the process will take some time to complete.
Associate Professor Pek emphasised that KTPH views the incident “very seriously”. Five people—staff members and KTPH’s management—have also been disciplined by the hospital.
This comes after a disciplinary committee was convened by the National Health Group (NHG) following the investigations into the misdiagnosis.
The five were given penalties including cessation of employment, financial penalty, and a stern warning. In addition, counselling, retraining and re-education of the staff are being carried out.
Incident Caused By Human Error And Inadequate Quality Control
TODAYonline reports that the investigations began when KTPH revealed in December 2020 that about 180 of their breast cancer patients may have been misdiagnosed with a more aggressive form of breast cancer and half may have received unnecessary treatment.
The error involved a higher positive rate for HER2 than usual, which led to the wrong diagnosis of a more aggressive breast cancer (as compared to HER2-negative cancers).
NHG had set up an independent review committee to carry out an investigation and thorough evaluation after noticing that KTPH had higher than usual positive breast cancer rates in their internal review.
The various healthcare experts in the review committee found that inaccurate HER2 positive rates were caused by a sub-optimal HER2 staining protocol at the department which handled the lab tests.
NHG noted that the “sub-optimal HER2 staining protocol was caused by human error when establishing the protocol” which led to the over-staining of slides, which affected the interpretation of slides, causing the abnormally high HER2 positive rate.
“The calibration error was not discovered due to a failure to conduct rigorous checks at the point when the protocol was established.”
Moreover, the review committee discovered lapses in the department’s quality control.
Though they were aware that the HER2 positive rate of KTPH deviated from international benchmarks, they ultimately “attributed the deviation to differences in patient population, and did not recheck the accuracy of the staining protocol.”
The failure of the staff members to perform quality control checks properly affected the interpretations of the over-stained slides and led to a delay in the detection of the error, NHG said.
In order to prevent similar cases from occurring again, the review committee has proposed new recommendations, including:
- A proper selection of the correct assay optimisation protocol, and improving the checking process to confirm the selected protocol
- Strengthening the Quality Control (QC) and Quality Assurance processes for the HER2 IHC section, and designating staff with the expertise to oversee the programme
- Close monitoring and auditing of processes and results using best industry practices and international benchmarking
- Retraining, re-educating, and upgrading competencies to reinforce professional technical knowledge and skills
NHG has formed an implementation committee to ensure that KTPH implements all the recommendations.
Associate Professor Pek promised to “expeditiously rectify all gaps in our processes in the laboratory” and will “ensure strict adherence to industry’s best practices and international benchmarks.”
“We are determined to set things right to regain the trust and confidence of our patients.”
Feature Image: DerekTeo / Shutterstock.com