We are anticipating a JCAHO inspection soon and are re-thinking how to best 
meet the safety requirements for having formalin in different 
areas/departments of our hospital.  I was wondering if any of you have had 
to revise older, existing protocols recently? Or if you have recently been 
inspected and can give me an idea of what the expectations are now. 
Pathology/Histology/Cytology seems well covered but there are problems with 
Labor & Delivery, the Operating Room and the Emergency Room where cubes of 
formalin are kept for the large specimens they are dealing with. We also 
have the issue of Endoscopy, Minor OR and the Cancer Center where they 
ordinarily keep the smaller, 15ml, prefilled bottles. The problems seem to 
be storage, spill and ventilation.
I would appreciate any feedback.
Thank You,
Theresa Rohr, BA HT(ASCP)
Section Head, Histology
Nyack Hospital, NY
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