Labels for two monkeypox test samples got mixed up. Here’s what the laboratory says
Remember the monkeypox case reported in Canyon County last week?
The Idaho Department of Health and Welfare now says the test result was a false positive.
The sample label for the Canyon County resident was accidentally applied to a test tube for another Idaho resident, and vice versa. Only one of the residents tested positive.
The critical sample-handling error by the lab’s staff prompted an internal investigation by the Idaho Bureau of Laboratories, which discovered the mix-up on Monday and suspended monkeypox testing for a few hours to figure out what happened.
Bureau Chief Dr. Christopher Ball told the Statesman in a video call Tuesday that his staff moved quickly to remedy the situation as soon as the error was discovered.
“The sample labels accidentally got mixed up,” Ball said. “There’s nothing wrong with the sample-testing process. It was purely a mistake in putting the wrong set of labels on the wrong tubes.”
Staff members at the bureau’s emergency response and sentinel labs aren’t used to processing more than one sample at a time, Ball said. The high-containment labs are typically reserved for biological and chemical threats.
The mix-up was discovered after the lab sent the sample to the Centers for Disease Control and Prevention for confirmation. When the CDC received the sample, the label didn’t match the corresponding form also sent by the state lab.
“We originally thought that we just sent the wrong sample,” Ball said. “When we went back and did our investigation, we discovered the label mismatch.”
Once the mistake became apparent, the laboratory notified its testing partners and submitted amended reports.
Ball said his staff members are “really feeling horrible” about the labeling error.
“We’ve obviously learned the hard way that we need to fix our process here,” he said. “We’re just trying to be fully transparent about the mistake that happened.”
He says the mismatch was a one-time incident. To make sure it doesn’t happen again, and until a long-term solution can be implemented, the staff at the laboratory will be taking photocopies of each sample and its label.
The photocopies will be disposed of once the samples are reviewed.
“Mistakes, unfortunately, are part of the laboratory business,” Ball said. “How they’re handled is the measure of the staff we have here.”
Greg Stahl, public information officer for the state health department, wasn’t able to say what county the resident who did test positive is from.
The first positive case of monkeypox in Idaho was reported July 6 within the Central District Health area, which includes Ada, Boise, Elmore and Valley counties. To date, there have been five cases of the virus reported in the state, according to the CDC.
This story was originally published August 2, 2022 at 2:52 PM with the headline "Labels for two monkeypox test samples got mixed up. Here’s what the laboratory says."
