The mistake that happened here in Minnesota was not a technical error by a Histotechnician.  It was a mix up in QA and not comparing the slide # to the requisition and I believe it was on the end of the Pathologist.  From what I understand there was a detailed system of QA in that particular lab but the mistake still happened.  They have introduced some changes to the  steps and how slides are given to the pathologists to minumize the chance that it would happen again. 

Thanks



-----Original Message-----
From: Martin, Ronald [mailto:Ronald.Martin@umassmed.edu]
Sent: Wednesday, January 29, 2003 8:25 AM
To: JHoffpa464@aol.com
Cc: histonet@pathology.swmed.edu
Subject: RE: Minnesota histology mistake


By having several similar cases (ie. breast,prostate,colon bx's) on one cold plate at a time and having slides already numbered/made up. I have seen techs accidently place the wrong tissue on the wrong numbered slide. I have also seen techs write the wrong numner on slides before. Sorry for the confusing question.

-----Original Message-----
From: JHoffpa464@aol.com [mailto:JHoffpa464@aol.com]
Sent: Wednesday, January 29, 2003 9:15 AM
To: Martin, Ronald; Lynne.Bell@hitchcock.org;
histonet@pathology.swmed.edu
Subject: Re: Minnesota histology mistake


how do you put the worng tissue on the wrong slide. i know for a fact you can only operate one microtome at a time. i have tried to use two at once, when very busy.