After a lab technician was fired for failing to report a testing error, the union grieved. Anyone can make a mistake, the union said, and, while some discipline was warranted, termination was excessive.
Hired in 2006 to work at a cytogenetics lab, B.M. had an advanced degree in biology. She was also the primary breadwinner in her family, providing for her retired husband, their daughter and their four grandchildren.
In her position as a Technologist I, it was B.M.’s job to perform various cancer-screening tests according to rigorous and verifiable protocols.
Lab policies and practices require technicians to report testing errors at the first opportunity.
On October 26, 2009 B.M. received a STAT (urgent) request to perform a test for childhood leukemia.
In the process of preparing about 12 other slides at the time, B.M. incorrectly used a green probe for the leukemia test instead of an aqua probe as required.
B.M. discovered her error the next day as soon as she went to score the test at about 4 pm.
However, instead of stopping the test, notifying a supervisor and arranging to re-run the STAT test with the correct probe, B.M. continued to assess the test and log the results with the incorrect probe.
No attempt to notify supervisor
B.M. left work at 5 pm. She made no attempt to alert a supervisor to the error or leave a note for the second scorer or prepare a new test slide.
While B.M. returned to work at 8:45 am the next day, she did not immediately report the problem with the test and instead began doing other work.
Upon discovering the error at about 9:30 am, the second scorer rechecked her own work and then contacted the supervisor. She also reviewed B.M.’s worksheet, which gave no indication that an incorrect probe had been used.
Later questioned by the supervisor about what happened, B.M. acknowledged that she should have used the aqua probe and that she had failed to report the error.
B.M. was instructed to re-run the test, which she did and, ultimately, the results were provided 24 hours later than they would have been had the error not occurred.
The employer conducted an investigation and B.M. was terminated by letter on November 16, 2009.
B.M. had not provided an acceptable explanation for her actions, the letter stated. Error notification was necessary to protect public safety. As a lab technician, B.M. was in a position of trust and required to uphold the highest standards of ethical and professional conduct. In the circumstances, her lapses in judgment had created an “irreparable breach” of trust in the employment relationship.
The union grieved. Before the Arbitrator the union argued that the termination was not in accord with the principles of progressive discipline. B.M. had admitted her error and never denied responsibility for it. Also, poor lab storage practices — since changed and not the fault of B.M. — contributed to the error.
Moreover, despite the employer’s claim that it had lost faith in B.M., it had asked her to redo the test in question and she continued to perform tests in the interim period between the test error and her termination. A termination in the circumstances would spell significant financial hardship, the union said. Suspension was the appropriate penalty in the circumstances.
Violation of professional trust
The Arbitrator disagreed. “[T]he failure of [B.M.] to report her test error was such a serious violation of professional trust that discharge was warranted.”
Because the tests literally involve questions of “life and death,” the necessity of providing accurate results is obvious, the Arbitrator said. Alongside the requirement for accuracy and reliability is the fact that humans make mistakes, the Arbitrator said. That’s why labs establish testing protocols to verify procedures and results. “It is not mistakes in testing per se, that threaten public health. It is the failure to detect and correct mistakes before a compromised test is relied upon for diagnosis that is the real danger,” the Arbitrator said.
B.M. discovered her error and was in a position to report it to other colleagues still at the lab late in the afternoon of October 27. She could have left a note. She could have telephoned a supervisor. She did none of those things. Neither did she report the error immediately upon reporting for work the next morning.
Despite knowing that she had used the wrong probe, B.M. nevertheless marked the results without indicating that the test had been compromised.
While the Arbitrator agreed with B.M.’s assertion that the second scorer was almost certain to pick up the error, that wasn’t good enough.
“While it is likely true … that there was a high probability that the second scorer would recognize the error, the whole point of having two scorers is to minimize the risk and enhance patient safety. By knowingly failing to report the error, [B.M.] unilaterally turned a two scorer protocol into a one scorer system, with attendant heightened risk. This is an unacceptable gamble with public health.”
There were mitigating factors, the Arbitrator said, but they were outweighed by the seriousness of B.M.’s misconduct.
“[T]he failure of [B.M.] to report a testing error without any acceptable explanation constitutes a fundamental breach of her professional responsibilities, demonstrates a disregard for public safety, and undermines the necessary trust and confidence to which the Employer and the pubic are entitled.”
The grievance was dismissed.
