[Histonet] RE: slide labeling

[Morken, Timothy]

"" The error here occurred when writing the number on the slide,...""

>From  experience I know that the hand-written label is the glaring weak link. There are so many ways to do that wrong! Mis-numbering happens all the time by transposing numbers, leaving a number off, being illegible, and just memory issues - I've seen slides that were labeled with the previous case number because the person labeling simply had that number stuck in their head. When a tech is writing hundreds of slides per day there is no way to prevent these kinds of mistakes. Expand that over a many techs every day...we catch them daily at the block/slide matching station.

IF you enforce one block to one slide labeling using barcode scanning of the block and on-demand printing of the slide AT THE MICROTIOME, then the labeling errors should be nearly eliminated. One example I saw from a real life lab went from 1000 mis-labels per year to less than 10. And each of those "mistakes" were deliberate shortcuts of the system. So when the system was followed, there were no mis-labeled slides. 

We plan to forgo hand writing on slides and just apply a label at the microtome from a scanned block. That makes some nervous, but the key is to make everyone understand, and enforce one-block on-demand label (or direct slide) printing. As a check we will still compare blocks to slides after staining. 

These "engineered controls" are usually the best way to eliminate mistakes because they force a person to do it the right way. I think the key to enforcing that is to have everyone understand that if they follow the method they will not make mistakes. And I tell our techs that few pathologists will remember (or even know) how fast they are at cutting - they will, however, remember every mistake that gets though!



As to the CAP, the CAP does not say anything about how your institution should label a slide, except to recommend (and sometimes require, in the case of (pre-accessioned samples) two separate identifiers. 

The labeling method should be in your SOP's and discrepancies documented and resolved from QA investigations. Whether one or each number is "recognized" is up to you. In practice that is not really a solution because, as you show, either number could be the wrong number, so "designating" one of the numbers as the "correct" number will lead to mistakes at some point. The solution is simply to resolve those cases that end up with two different numbers and document/resolve why that happened. But, as I outline above, using hand-written labels is always going to lead to a certain level of mistakes. So maybe you just live with that if the other institution is requiring that to be done.

CAP is working on a universal slide labeling proposal. We'll see what gems they come up with!


Tim Morken
Supervisor,Histology,  Electron Microscopy and Neuromuscular Special Studies
UC San Francisco Medical Center
San Francisco, CA

-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Curt
Sent: Tuesday, January 07, 2014 11:28 AM
To: Curt; histonet <@t> lists.utsouthwestern.edu
Subject: [Histonet] RE: slide labeling

To add clarity, there is a 2D barcode on the block, we scan at microtomy and then label the slide. The system is really idiot proof "ASSUMING" the techs cut and label one block at a time, which we strictly enforce. The error here occurred when writing the number on the slide, I think he looked at the wrong block here, so in effect he did label a number of slides at the same time but the slide label was already affixed to the slide. I guess the rule should be to write the number as it's seen on the slide.

Curt


-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Curt
Sent: Tuesday, January 07, 2014 10:33 AM
To: histonet <@t> lists.utsouthwestern.edu
Subject: [Histonet] slide labeling

So we have a facility we do some work for that requires both the hand written number and the slide label be viewable, so we place the slide label a little lower and write the number on the top of the frosted end. Does CAP recognize both numbers as a legal record? The reason I ask is because there was a case that the hand written number was wrong but the slide label was correct. That being said, there's still a QA issue with the slide not being accurately labeled. Slides are labeled at microtomy too, the hand written number and the slide label. I contend internally that the slide WAS accurately labeled because the sticker number and block number correspond accurately, the discrepancy was in the hand written number.

Thoughts? Does CAP have any guidance on this?

Thanks,

Curt

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