A biopsy sample smaller than a pinhead was placed on a sterile towel at the Mayo Clinic in Rochester last year and whisked to a pathology lab. On arrival, the dab of human tissue was nowhere to be found.
“We were never able to discern what exactly happened to that specimen,” said Dr. Tim Morgenthaler, Mayo’s chief patient safety officer.
Nor could they test the sample to solve the mystery of their patient’s illness.
The misplacing of irreplaceable biological specimens has proved to be a vexing problem for Minnesota hospitals, which reported 31 instances in the 12 months that ended last Oct. 6.
The state’s 13th annual report on hospital “adverse events,” released Thursday, included 336 reportable mistakes, including operations on the wrong body parts and disabling medication errors. But few were as common as lost tissue samples, which also can have serious consequences.