[Histonet] Her2 Fixation Requirement

[Weems, Joyce]

We have the nurse document the time of removal on the requisition. The next requisition update will have a spot for this. They have been very cooperative and do a good job. 

In addition, you must document the "cold ischmic time" - that is the time from removal until time in formalin. This is important when the specimen goes for xray or whatever. So there is a removal time, an into formalin time and an out of formalin time. 

Then if we don't have time allowed to meet the fixation time with the regular, it is put on a late processor, if we have one available, or it is held overnight. And if it has to come off on Sunday, we have a med tech remove it from the processor and it waits for us to come on Monday to embed it. 

The pathologists document all this time in the report. 

Best! J

Joyce Weems 
Pathology Manager 
Saint Joseph's Hospital 
5665 Peachtree Dunwoody Rd NE 
Atlanta, GA 30342 
678-843-7376 - Phone 
678-843-7831 - Fax 



-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Paula Lucas
Sent: Wednesday, February 02, 2011 12:11
To: histonet <@t> lists.utsouthwestern.edu
Subject: [Histonet] Her2 Fixation Requirement 

Hello histoland
 
I was just given the task to find a solution that is easy and will also comply with the CAP guideline for formalin fixation documentation, and so I started my research on the Histonet archives.  I found some good information, but was hoping to get more feedback. 
 
Would you mind sharing with me the actions you are taking to comply with the guideline?  
 
We are a private lab and we provide histology/pathology service for 2 hospitals and a few surgery centers.  We send our blocks to Genzyme for Her2, and we must document on their test order sheet how many hours the tissues have been fixed in formalin.
 
I'm assuming I will need to start keeping a log here, with documentation that shows what time the tissue was excised and placed in formalin from the OR, and then documentation that shows the time it was dissected and then placed in the tissue processor.  
 
The problem that I may come across is getting the OR nurse to document the time for us.  I don't know...maybe we need to put another sections on our requisition form, or maybe something on the formalin container itself for the nurse to write on.  It'll be a hassle at first but if I can get the hospitals lab director involved, I'm sure it will work itself out.
 
Anyway, if you wouldn't mind sharing some of your ideas, I would really appreciate it.
 
Paula Lucas
Lab Manager
Bio-Path Medical Group
Fountain Valley, CA
 

 

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