KTPH wrong breast cancer results caused by 'human error',
inadequate quality control: Review committee
"Human error" and แชร์เทคนิค เล่นสล็อตออนไลน์ pantip inadequate quality control contributed to
the inaccurate test results that wrongly classified patients at Khoo Teck Puat Hospital (KTPH) as
having a more aggressive form of breast cancer, a review committee said on Monday (May 3).
At least 200 patients were affected by the errors, which took place over eight years at KTPH's
Department of Laboratory Medicine, Anatomic Pathology Section. About half of them may have
received unnecessary treatment.
The errors involved unusually high HER2 positive rates for breast cancer patients. HER2,
or Human Epidermal Growth Factor Receptor 2, is a gene that controls how a healthy cell grows,
divides and repairs itself.
HER2-positive breast cancers tend to be more aggressive than other types of breast cancer,
according to the Mayo Clinic.
An independent investigation by the National Health Group (NHG) Review Committee revealed
that inadequate quality control contributed to a failure to detect the error early. Five members
of KTPH's management and staff were identified for "not adequately performing their duties and
responsibilities", and were penalised.
The committee found that inaccurate HER2 positive rates were caused by a "suboptimal HER2
staining protocol" used by the HER2 immunohistochemistry section.
"The suboptimal HER2 staining protocol was caused by human error when establishing the protocol.
This led to over-staining of slides, which affected the interpretation of the slides, resulting in
a higher than usual HER2 positive rate," said the NHG.
"The calibration error was not discovered due to a failure to conduct rigorous checks at the point
when the protocol was established."
Investigations by the committee also showed "inadequacies" in the section's quality control.
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