[Histonet] RE: Formalin in the OR

[joelle weaver]

Thank you for your story about this patient event with formalin in the OR. I am sometimes confronted with the response that I am overly detailed about things and particularly with regulations and safety. If you have never experienced something like this,  it is easy to get lax and expect that it will never occur.This is a good reminder, that while mistakes like this one may be infrequent, when they do happen it can be terribly tragic. No one ever wants to be involved with anything remotely similar to the circumstance you describe. In my opinion, just best to do everything you can think of to not even invite the possibility. Keep the formalin where you can limit the handlers and potential mix ups as much as possible! 




Joelle Weaver MAOM, HTL (ASCP) QIHC
 
> Date: Fri, 13 Jun 2014 20:31:10 +0000
> From: koellingr <@t> comcast.net
> To: tbraud <@t> holyredeemer.com
> Subject: Re: [Histonet] RE: Formalin in the OR
> CC: histonet <@t> lists.utsouthwestern.edu
> 
> Heartbreakingly sad, 
>   
> I do not know where the current regulations are but safety, as Terri rightly pointed out, is an accident that did happen.  Not an anecdote, you can look up March 1985, Jackson Memorial Hospital in Miami (years after I left). 
> Patient went to surgery, had some cerebrospinal fluid (CSF) removed during operation but an UNMARKED container of gluteraldehyde (aldehyde) fixative got marked as CSF with all the comings and goings over many hours. When the CSF was set to be reinjected as replacement, the fixative got reinjected as replacement instead of his CSF.  Patient obviously died.  Can't believe that is the only actual safety issue that has ever cropped up with surgery and formalin. 
>   
> So maybe a warning for both;  no unlabeled bottles and no fixative right in the actual surgery suite. 
>   
> Ray 
> Seattle WA 
> 
> ----- Original Message -----
> 
> From: "Terri Braud" <tbraud <@t> holyredeemer.com> 
> To: histonet <@t> lists.utsouthwestern.edu 
> Sent: Friday, June 13, 2014 10:52:43 AM 
> Subject: [Histonet] RE: Formalin in the OR 
> 
> Wow, this is such a safety issue with an accident waiting to happen.  I 
> totally agree with Peggy that Formalin should not be allowed in an OR 
> room.  Even a gallon spill would be cause to evacuate and can you 
> imagine the consequences of that? 
> We have a small room off of the OR suites stocked with a 5 gallon carboy 
> over a 5 gal spill container 
> 
> Terri L. Braud, HT(ASCP) 
> Anatomic Pathology Supervisor 
> Holy Redeemer Hospital Laboratory 
> 1648 Huntingdon Pike 
> Meadowbrook, PA 19046 
> Ph: 215-938-3676 
> Fax: 215-938-3874 
> 
> 2. Re: Formalin in operating (surgery) rooms (Lee & Peggy Wenk) 
> 
> -----Original Message----- 
> From: Lee & Peggy Wenk 
> Sent: Friday, June 13, 2014 7:44 AM 
> To: Candace J. Wagner ; histonet <@t> lists.utsouthwestern.edu 
> Subject: Re: [Histonet] Formalin in operating (surgery) rooms 
> 
> I think this is mostly a safety issue, and suggest NOT allowing any 
> amount of formalin in OR/surgery rooms. 
> 
> 
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