North District Hospital has accepted the findings of a Hospital Authority investigation into the contamination of a breast biopsy specimen.

The inquiry panel found the contamination of the specimen most likely occurred in the surgical ward and both medical and nursing staff were involved in the processing of the core tissue biopsy. The incident happened in July.

The specimen was tainted with a piece of malignant core tissue from another patient which led to the wrong surgery being performed. DNA analysis found the malignant tissue belonged to a patient who had a breast core biopsy done in the same surgical ward two weeks earlier.

The panel believed more than one specimen bottle had been used in the biopsy procedure of the source patient. The bottles were not immediately labelled and left behind at the bedside after the procedure. One of them, presumed to be unused, was used later for collecting the biopsy specimens of the affected patient.

Key recommendations

The panel suggested a staff member be designated to be responsible for the labelling of specimens after each biopsy procedure.

The hospital should reinforce the importance of immediate labelling of the specimen after biopsy procedures. Any opened and unused specimen bottles after procedures should be discarded.

Hospital management should consider supplying the specimen bottles with breakable seals so any bottle with broken seal should not be used.

Only one nurse should be designated to assist throughout each biopsy procedure, and the hospital should have better documentation of biopsy procedures.

The hospital said it will provide appropriate care and any assistance needed to the affected patient.