Description of Event or Problem · 1
IN THE SPRING OF 2000 THE DEPT OF PATHOLOGY AND LABORATORY MEDICINE (DPLM) ADDED THE CYTOGENETICS LABORATORY TO THE SOFTPATH SYSTEM. IN THE PROCESS OF ADDING THIS LABORATORY TO THE REPORTING SYSTEM, THE STAFF DETECTED THE CORRUPTION OF REPORTS. THE TEXT FROM OTHER PTS' PATHOLOGY REPORTS WAS BEING INSERTED INTO THE CYTOGENETICS REPORTS. FOR EXAMPLE, IN ONE PART OF THE REPORT THE GENOTYPE WAS SAID TO BE XX AND IN ANOTHER PART OF THE REPORT IT WAS SAID TO BE XY. IN THIS EXAMPLE, IT IS FAIRLY OBVIOUS THAT THE INFORMATION COULD NOT HAVE COME FROM THE SAME PERSON UNLESS CO WAS DEALING WITH A BONE TRANSPLANT PT, WHICH WAS NOT THE CASE. AT THAT TIME, TASK #1378 WAS OPENED ON NOVEMBER 17, 2000, AND THIS PROBLEM WAS FIXED ON MARCH 6, 2001. IT WAS NOTED IN THAT TASK (ITEM 63) TO "MAKE SURE THAT THE PATCH" WOULD BE IN THE 2.3.0 VERSION OF THE APPLICATION THAT WAS TO BE INSTALLED IN THE FUTURE. IN 2001, THE FACILITY UPGRADED TO SCC VERSION 2.3.0 SOFTWARE. SIX MONTHS LATER IT WAS AGAIN DISCOVERED THE CORRUPTION OF CYTOGENETICS REPORTS FOR THE SOFTPATH SYSTEM (TASK 2106). IT WAS EXACTLY THE SAME PROBLEM REPORTED IN THE PREVIOUS YEAR. SCC HAD FAILED TO ADD THE PATCH TO THE UPGRADED SYSTEM AS THE FACILITY HAD REQUESTED SCC TO DO THE PREVIOUS YEAR. THE DPLM FOUND 38 CYTOGENETICS REPORTS THAT CONTAINED DATA FROM ANOTHER PT. AGAIN, SCC ADDED THE PATCH ONTO THE TEST SYSTEM AND TOLD THE FACILITY THAT THE PROBLEM AROSE BECAUSE THE DPLM STAFF SIGNED OUT CYTOGENETICS CASES WITHOUT A DIAGNOSIS. THUS, WHEN THE SUPPLEMENTAL REPORT WAS CREATED AND A CERTAIN SERIES OF INTERFACE EVENTS OCCURRED, ERRONEOUS DATA WOULD BE INSERTED IN THE ORIGINAL REPORT. AT THIS POINT, THE DIRECTOR OF THE CYTOGENETICS LABORATORY CEASED USING THE SCC SOFTPATH SYSTEM TO REPORT RESULTS. SINCE THEY STOPPED USING SOFTPATH, THE PATCH WAS NOT INSTALLED ON THE LIVE SYSTEM. ON MARCH 7, 2002, THE DPLM DISCOVERED THAT WHEN REPORTS ARE REVISED CONSECUTIVELY, EXTRANEOUS DATA WAS INSERTED IN THE REPORTS AS HAD BEEN SEEN WITH SUPPLEMENTAL REPORTS THAT DID NOT HAVE A DIAGNOSIS. THE STAFF OPENED ANOTHER TASK ON MARCH 7 (TASK #2161) AND HAD AN EMERGENCY CONFERENCE ON THIS ISSUE. THE STAFF WAS THEN TOLD THAT THIS PROBLEM OCCURRED BECAUSE THE PATCH HAD NOT BEEN INSTALLED. THIS WAS THE FIRST TIME THIS FACILITY'S STAFF WAS EVER NOTIFIED THAT SUCH REPORT CORRUPTION COULD OCCUR IN REVISED REPORTS. THE PATCH WAS INSTALLED ON MARCH 12 AND IT WAS VERIFIED THAT IT PREVENTED THE PROBLEM. SCC SAID IT NOTED THAT REVISED REPORTS WERE AFFECTED IN TASK 2106 (ITEM 31). THE DPLM STAFF COULD NOT SEE THIS NOTE BECAUSE OF A BUG IN THE TMS SYSTEM THAT DID NOT ALLOW THE STAFF TO READ COMMENTS THAT FAR DOWN IN THE TASK. THE DPLM STAFF WOULD HAVE HOPED THIS ISSUE WOULD HAVE BEEN POINTED OUT TO THEM IN ONE OF THE NUMEROUS CONFERENCE CALLS BETWEEN THE DPLM STAFF AND SCC. (THE REMAINDER OF THIS EVENT DESCRIPTION IS LOCATED IN THE PT SECTION OF THIS REPORT. THE DPLM STAFF NOW KNOW THAT THERE IS A POTENTIAL FOR CORRUPTED REVISED OR SUPPLEMENTAL REPORTS GENERATED BETWEEN OCT. 20, 1999 AND THE INSTALLATION OF THE FIRST PATCH ON MARCH 6, 2001 AND FROM THE UPGRADE ON MAY 13, 2001 UNTIL THE PATCH WAS INSTALLED ON MARCH 11, 2002. DURING THESE INTERVALS THE DPLM STAFF REVISED OR ISSUED SUPPLEMENTAL REPORTS ON 2,688 ANATOMIC PATHOLOGY CASES. TO INSURE THAT ERRONEOUS DATA HAS NOT BEEN INSERTED IN THESE CASE REPORTS, THE DPLM STAFF ARE GOING TO PULL THE ORIGINAL SLIDES AND HAVE A GROUP OF PATHOLOGISTS RE-EXAMINE THE SLIDES AND READ THE REPORTS TO DETERMINE IF THESE REPORTS ARE CORRECT. THE DPLM SENIOR STAFF HAVE STRONGLY RECOMMENDED TO THE SCC SOFT COMPUTER COMPANY THAT THEY NOTIFY IMMEDIATELY ALL USERS OF THE SCC SOFTPATH SYSTEM OF THE POTENTIAL OF REPORTING ERRONEOUS INFORMATION WITH THE SYSTEM AND ADD THE SOFTWARE PATCH TO ALL EXISTING SOFTPATH USERS AS SOON AS POSSIBLE. AS OF 2002, THE FACILITY DPLM WILL CEASE USING THE SCC SOFTPATH SYSTEM AS SOON AS THEY CAN IMPLEMENT A REPLACEMENT SYSTEM.