[Histonet] Critical Incident?
|From:||Derek and/or Lynda Leopold |
I am hoping to get some opinion off-list from supervisors (and
anyone else who may care to comment) on an event which happened recently
in our lab. To be as short as possible, the person who was responsible
for changing the solutions on our Tissue Tek 5 biopsy processor somehow
(PUH-leese don't ask me how) made up the first alcohol to 70% (instead
of 95%), and the second alcohol to 88% (instead of 95%). For context,
we do a short run, 20 minutes in each of formalin, 65% formal alcohol,
then 2 changes of 95%, then 3 changes of 100% and on to xylene and
paraffin. Now that you have the situation, I have two questions: 1)
What sorts of changes, if any, would one expect in the biopsy tissues
(endo, cervix, etc) exposed to this miscalculated regimen ? 2) If, as
some of us surmise, this mistake in solution calculation could be linked
to biopsy tissues that were too dehydrated and brittle to be of any
diagnostic use, should that constitute a critical error/reportable mistake?
We have apparently never experienced such terrible tissues in recent
memory, and there is some debate as to whether the low-concentration
alcohols could have been the cause.
I look forward to your very expert opinions!
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