[Histonet] Critical Incident?

[Sarah Jones]

Hi Lynda,
  I personally would think that the discrepancy in the initial alcohols
would not cause that much of a problem, since they are followed by 3
absolutes (were these ok?) and xylene.  If anything they would have
caused an underprocessing problem and you said the tissues were "too
dehydrated and brittle to be of any 
diagnostic use".  It sounds to me to possibly be a heat problem rather
than dehydration.  Maybe there was a processor malfunction that just
coincidentally happened at the same time.  I think it would be best to
withhold a reprimand until the cause is positively worked out.  Maybe
some sample tissues could be run with the erroneous alcohol percentages
and see if the problem with the tissue is reproducible.  I had a run of
small tissues get fried on the tissue processor a few years ago (on a
short 15 minute run) and it was just a variation of 1-2 degrees misread
on the sensor on the paraffins.  It was reading the proper temp on
screen, but in reality, the paraffin temp was too high.  They were as
you said "too dehydrated and brittle to be of any diagnostic use".   I
couldn't save them even using the "mummified tissue retrieving" protocol
and they were finally trashed.  Overly dehydrated tissues can usually
just be soaked longer on an ice tray, but once they are freedom fried,
they are not salvageable. 
 Hope this helps.  Sarah


Sarah Jones HT(ASCP)
Dept. of Vet. Anatomy & Public Health
Histology Lab
Texas A&M University
College Station, TX 77843-4458
phone: 979-845-3177
fax:  979-458-3499


>>> "JENNIFER SCHUMACHER" <JSCHUMA1 <@t> FAIRVIEW.ORG> 2/12/2004 2:44:08 PM
>>>
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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