A medical blunder resulted in a 59-year-old woman having her reproductive organs removed at a Hong Kong public hospital after she was wrongly diagnosed with endometrial cancer, health authorities have said.
The Hospital Authority apologised to the patient on Friday and said the incident occurred when biopsy samples from the woman and a 71-year-old patient diagnosed with cancer were mixed at Pok Oi Hospital in Yuen Long.
The woman had her reproductive organs removed at Tuen Mun Hospital on February 26, about five weeks after she was first informed of the news. She learned about the incorrect diagnosis on Friday, after hospital staff received a report about the contamination issues a day earlier.
“We know and understand that the incident will affect the patient’s physical and mental condition greatly, so I want to take the opportunity to give the patient our most heartfelt apology and our deepest condolence,” said Dr Wong Yiu-chung, chief executive of the authority’s New Territories West Cluster.
An investigation committee would determine how the blunder happened and a medical team would follow up on the woman’s condition, he added.
According to a statement from the hospital, the report from the committee would be submitted to the hospital authority’s head office in eight weeks.
Pok Oi Hospital’s chief executive Dr Chong Yee-hung said the two pathology department staff involved had been placed on leave. Related colleagues must strictly follow the relevant operational guidelines to prevent a repeat of the incident, he added.
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Hong Kong experts blame staff shortage for suspected medical blunder
Chong said the woman originally sought treatment for vaginal bleeding after menopause on January 5. Doctors collected biopsy samples from the woman’s uterus and surrounding tissue for examination that day. The specimens were delivered to the pathology department.
The woman was diagnosed with endometrial cancer on January 18 after a pathology report stated her samples had signs of the disease, and the patient underwent an operation at Tuen Mun Hospital on February 26 to remove her uterus, Fallopian tubes, ovaries and pelvic lymph nodes. The operation was uneventful and the patient was discharged four days later.
But a doctor at the hospital’s pathology department did not discover any signs of cancer when examining the removed tissue, triggering a further investigation.
“The head of the pathology department then conducted a comprehensive investigation, including the molecular test that I mentioned earlier, to test the DNA inside the samples,” Chong said. “We later confirmed that the sample report had issues. This patient does not actually have cancer.”
Dr Mak Siu-ming, the chief of service for the department of clinical pathology for Tuen Mun and Pok Oi Hospital, said their investigation included reviewing CCTV footage and DNA testing of the samples taken before and after the operation.
The hospital discovered that 30 minutes after the samples were collected from the 59-year-old woman, a 71-year-old female patient underwent a biopsy, and both specimens arrived at the laboratory the same day.
“After looking at the genetic test report, our conclusion is that the sample we examined on January 5 was mixed with the sample from the 71-year-old patient who already has cancer,” Mak said. “It is because of this mixed sample that the report we issued has a very serious deviation.”
Mak revealed that after viewing CCTV footage they suspected contamination to have occurred in the latter part of the process when samples were removed from their vials and placed in plastic cassettes, where it would be processed with paraffin wax later.
But he emphasised the issue was only confirmed after they conducted a DNA test on the samples.
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Dr Leung Ho-kei, chief of service of the department of obstetrics and gynaecology at Tuen Mun and Pok Oi Hospital, defended the use of the pathology report to diagnose the woman’s condition. Leung noted it was the most precise way to determine the illness and that the patient’s vaginal bleeding after menopause was already a risk factor for cancer.
He admitted that other examination procedures did not detect cancer.
Leung said the patient was discharged on March 1, with her condition normal so far.
