[Histonet] Critical Incident?

[JENNIFER SCHUMACHER]

Unfortunately, I do not have an answer but another question to add . . .
we have had two incidents in the last year in which we believe we had a
contamination problem, and our tissues were mostly destroyed.  Some
samples had to be repeated, and our pathologists are determined to find
someone to blame.  Has this ever happened to anyone else?  Were you able
to pinpoint the problem, and how can you "guarantee" it will never
happen again?  All suggestions are welcome, offline is fine if you are
not comfortable answering online.  Thanks.  Jennifer

>>> Derek and/or Lynda Leopold <leopold <@t> mnsi.net> 02/12/04 01:25PM >>>
Hi Histonetters,
     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!
Thanks
Lynda Leopold
Harrow, Ontario


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