"There are some atypical cells probably" said the pathologist.
The doctor was worried, it was his wife's PAP* smear report after all. After a brief discussion they both decided to go for a Human Papilloma Virus detection just to ensure that the picture does not turn out to be bad. He walked to another section and spoke with the Microbiologist regarding the case, the investigation would be outsourced from there to another laboratory which carries out molecular diagnostics.
A couple of minutes later.
"What sample is required for HPV-PCR** pa?" he called the microbiology laboratory and asked.
"EDTA-sample Sir" a technician replied.
The doctor billed for a HPV-PCR test from the billing section and sent the sample from the sample collection centre as told.
The EDTA vacutainer reached the laboratory through the house-keeping. Another technician received it and took a printout of the worksheet and kept everything ready for the test to be outsourced.
Now one may wonder what this is all about and what happened after that.Let me tell you what the final report was:
Hepatitis B Virus- Not Detected
 |
| Human Papilloma Virus |
Eh? B or P, what is in a letter? Definitely a great raise in Blood Pressure! I did fall of the chair when I heard this. Everything is pretty much kicked to Pluto if there is a miss or a change, especially in a health care setting when this happens it is not at all pardonable. I am sharing this because it is a necessary learning, unfortunately I wasn't around when this happened. I heard various versions from the technicians regarding this matter, what I understood was the kind of miscommunication that happen over telephonic conversations. The doctor called asking for HPV, the technician heard it as HBV and advised him to send a EDTA vacutainer, but in reality it is either a cervical swab or cytology fluid that needs to be sent. Well even after that with the mismatch in the bill, nobody really bothered to cross check. The outsourced test was for HBV-PCR since it was an EDTA vacutainer. The realization dawned only when the doctor called asking for the HPV-PCR report after two days. HPV is a virus associated with cervical cancer and HBV is a virus associated with hepatitis and liver cancer, two different clinical presentations and diagnoses. The matter is getting sorted out, and we hope not to have such disastrous events again.
What bothers me is the mechanical nature of work that happens in most of the hospitals. This happened with a hospital staff, a doctor, I cannot imagine the scenario if it was a patient. It does happen nevertheless. Nobody talks about it, the matter is hushed up or sorted out by us doctors or dealt by the patient relations section. I am talking about it because this kind of maleficence is something we all need to be aware of, as doctors and as patients. We need to always ensure that abbreviations or short forms are not used for drugs or tests during diagnosis and treatment. After all it is a matter of someone's life or death. There is a thin line, a very thin one. Thankfully this incident was something that could be handled, if it was something else I couldn't have forgiven myself for being a part of such a work team! It sends a shiver down my spine, every time I think of it. "Do No Harm" is sometimes easier said than done.
*PAP Smear- The Pap smear is a screening test for cervical
cancer. Cells scraped from the opening of the cervix are examined under
a microscope. The cervix is the lower part of the uterus (womb) that
opens at the top of the vagina.
**PCR- The polymerase chain reaction (PCR) is a
technology in molecular biology used to amplify a single copy or a few
copies of a piece of DNA across several orders of magnitude, generating
thousands to millions of copies of a particular DNA sequence.
-R.
