[Histonet] CAP - ANP.11713 Phase II

Sebree Linda A. la.sebree <@t> hosp.wisc.edu
Wed Mar 22 14:10:49 CST 2006

In our lab (IHC & ISH), every case that goes out to the pathologist is
accompanied by the original request form that has a "QA" form on the
back.  The pathologist is obligated to select "satisfactory" or
"unsatisfactory" in response to the statement:  "I have reviewed the
patient and positive/negative control slides associated with the
immunostains requested on this case and find them
satisfactory/unsatisfactory" and initial his/her response.

Linda Sebree, HT(ASCP)
University of Wisconsin Hospital & Clinics
IHC/ISH Laboratory
600 Highland Ave.
Madison, WI 53792
FAX: (608)262-7174

-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu
[mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Rebecca
Sent: Wednesday, March 22, 2006 11:44 AM
To: histonet <@t> lists.utsouthwestern.edu
Subject: Re: [Histonet] CAP - ANP.11713 Phase II

I created a database that we enter our daily count (the date, first and
last case number, the number of blocks and slides).   Also there are 2
prompts to be checked by the pathologist, one for H & E and the other
for cytology stain.  We run a control as the first and last slide
everyday.  If the stain is ok he puts a check in both boxes, if there is
a problem there is a spot to enter comments.  I started doing it this
way so that if there is a problem with the stain I can easily go back
and see what cases it affected.  I have a report that I can print to
show the quality of stain if an inspector request it.  Previously we had
a sheet the pathologist kept at his desk and check each day if the stain
was ok and make comments if not. 

I also use the spot for comments to document if we have changed
something (trying a different stain, new paraffin, added time to a step
on the processor or stainer, etc).  So if there are questions or we need
to compare slides (because of a new product or new procedure) I have a
report that I run and I can easily pull the slides.  

I also use this database to enter all statistical information.  So at
any time I can give the pathologist or manager any number for anatomic

>>> "Demarinis, Carolyn" <cdemarinis <@t> SARATOGACARE.ORG> 3/22/2006
11:34:14 AM >>>
There is a new question on the CAP checklist:

ANP.11713 - Phase II 

"Is there documented evidence of daily review of technical quality of
histologic preparations by the pathologist?"


Our present procedure is the supervisor/technologist documents daily
review, but it is very clear that CAP is requiring the pathologist

to initial a document daily proving they have reviewed the technical
quality of slides.

How are other hospitals satisfying this requirement?  It seems crazy
make a pathologist initial a document daily,

when it is evident they review hundreds of slides a day, and they
certainly report a problem to the supervisor when the stain is

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