Alies Maybee of Patients Canada thinks the oversight process at Capital District Health Authority played a role in a patient having a breast needlessly removed in late March. The woman had been misdiagnosed with cancer and assigned unnecessary treatment after pathology reports were mistakenly switched between two medical charts.
"Our thought is that (the process) needs to be revised, and it should be revised with the input of patients," said Maybee.
The mistake was detected in laboratories at the Queen Elizabeth II Health Sciences Centre in Halifax, where samples from the entire health authority — which serves the Halifax area and part of a neighbouring county — are collected to be processed and analyzed.
An oversight system — referred to as a quality assurance mechanism — compares all processed tissue from before and after a surgery to ensure they are the same.
"What's supposed to happen is they match," Capital Health CEO Chris Power said on Monday after the mistake was made public. "But in this case they didn't and that's when we were alerted that we have a problem here."
Maybee described the process as "a little like closing the barn door after the horse has left."
Now would be a good opportunity to involve patients in the discussion, she added.
"I think everyone can benefit from the experience and understanding and perspective that patients and their caregivers bring to the system," she said.
In an email, Capital Health said it involves patients and citizens in various aspects of its review processes, including community consultation sessions and patient safety teams. It said recommendations are also vetted by oversight councils made up of members that include citizens and former patients.
Maybee praised the health authority for its transparency, as did Nancy MacCready-Williams, CEO of Doctors Nova Scotia.
"I was very impressed with the sincerity and the candour and the transparency demonstrated by Chris Power in her role as CEO and president of Capital Health by both publicly sharing the issue and, as well, sharing with the public how Capital Health will work to prevent a similar issue from happening in the future," said MacCready-Williams.
Power said the introduction of bar codes and automated laboratory systems later this year and in 2014 will help decrease the likelihood of similar mistakes happening.
Capital Health said this was one of two similar incidents that took place this year as a result of two separate lab mistakes.
It said a biopsy was conducted on the wrong patient in April after slides were mislabelled with incorrect patient identification.
The authority said the errors affected four patients, two who were misdiagnosed with cancer and given needless treatment, and two who were mistakenly told they did not have cancer and did not immediately receive the treatment they required.
Ray Wagner, a lawyer representing women in her 60s who received the unnecessary mastectomy, said she has been experiencing an emotional roller-coaster as a result of the ordeal, including suffering from emotional depression.
"She (went) through the emotions of initially having a diagnosis of cancer, and we all know that everybody in society fears that," Wagner said in an interview Tuesday.
"Then finding out that all this was unnecessary, and then the anger that goes with it. ... That's where she is now."
The woman's identity has not been released.
The health authority apologized Monday for the errors, saying all affected patients have been identified.
"Mistakes happen and this is one of those very unfortunate, devastating times," said Power.