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The results of a misread pathology report and results unnecessary mastectomy at the Hotel-Dieu Grace Hospital in Windsor, Ontario has led hospitals throughout the region to reconsider their surgical protocols.

Officials at Windsor hospitals said that surgeons are generally the only ones looking over the final pathology and clinical diagnosis report before surgery, even though many pairs of eyes may see a patient's chart and test results throughout the cancer diagnosis and treatment process, as is the case in most hospitals across Ontario.

The changes may include having more than one health care professional read over the pre-surgery report in certain types of cases or making sure that the surgeon has re-read the pathology report at least one more time before he or she starts cutting.

Laurie Johnston was diagnosed with breast cancer and had one of her breasts removed by a Hotel-Dieu surgeon in November of 2009, but the pathology report showed the lump in Johnston's breast was benign. For reasons unknow, the surgeon, who carries 28 years of experience and handles about 100 cases a year, misread the report.

Hotel-Dieu has launched an investigation which will likely result in recommendations for procedural changes. Dr. Kevin Tracey, the hospital's chief of staff, said there will be a systemic review that could result in changes not just at Hotel-Dieu, but at other hospitals as well.

All hospitals across the province are implementing Ministry of Health-mandated surgical safety checklists. The hospital is offering Johnston anything she needs, including breast reconstruction surgery if she wants it. Johnson has not yet filed a lawsuit.

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