A report on pathology laboratories' biopsy errors which resulted in five women undergoing unnecessary surgery has criticised the time it took for some women to be contacted about the mistakes.
The report of the 10-member expert panel, which was convened in June to investigate the biopsy errors which occurred over the past two years, was released by the Ministry of Health (MOH) on Thursday.
Four of the errors involved the patient's biopsy samples being mixed up with another patient's, while the fifth error resulted from a misinterpretation of the sample.
Three women had mastectomies following incorrect breast cancer diagnoses, while another woman had part of her jaw cut away.
The panel has recommended improved systems to reduce the likelihood of errors occurring.
In the report, MOH chief medical officer Dr Don Mackie, who chaired the panel, says the women involved described a lack of timely and effective communication, which they felt demonstrated a lack of compassion.
"In some cases it took a long time for the laboratory to contact the women, apologise and explain what was happening," Dr Mackie said.
"There should be no cause for delay in contacting, apologising and explaining events to patients who have been harmed. The laboratory has a duty to the patients and a duty to explain how they have come to harm."
The panel has recommended that District Health Boards and private health providers, including laboratories, examine their support measures in place for patients and staff affected by errors.
These measures should include the prompt acknowledgement and understanding of the full impact of the mistake and the full disclosure of all information to the patient.
The panel also noted private laboratories don't have to report serious sentinel events to the Health Quality and Safety Commission and has recommended that they should be required to do so.
The panel has recommended that the report be used to drive improved systems in all of New Zealand's laboratories.
Dr Mackie said he would check what improvements laboratories have made to reduce the likelihood of biopsy errors occurring in the future.