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Monday, August 9, 2010

Deja View all over again

Today I read in Dark Daily another sad Quality story.  I suspect it is a true story for a number of reasons; Robert Michel, the Editor of the Dark Report and related sources, including the Dark Daily has become an important source of medical laboratory information, both good and bad.
For those that don't read the Dark Daily regularly, I suggest that you give it a look.
But the story here is about a poor performance on HER2 breast tumor markers for drug resistance.  Of note, this is the same test that got the laboratory in Newfoundland in so much trouble.  HER2 test errors lead to wrong decisions about the requirements for surgery and drug therapy.
I suspect there is not a medical qualitologist  (see "Welcome to the new laboratory")  in North America  that doesn't know the story of Eastern Health and the Cameron Commission.  So why was this hospital ignoring history 3 years later? 

What makes this story tragic is that they had a major signal when thy failed an EQA sample (see Proficiency Testing - in all its guises), and elected to ignore it. 
What makes it irresponsible  is that the problem was detected by staff and ignored by Management.

There is a good part to this story, although the hospital may not exactly appreciate it.  Two accreditation bodies did their job properly  (see Quality Partners  -- sorry not posted yet, but soon!) and closed that section of the laboratory down.

So by the time we finish with all the mess that this laboratory will now have to endure, what will be the sum total of the costs of poor quality here, and how many ways do can we think that the money could have been better spent.

By the time the last dollar is spent, having a functional Medical Laboratory Quality Team and a real quality management system will look REALLY inexpensive.

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