NEXT PAGE
PREVIOUS PAGE
RETURN TO TABLE OF CONTENTS
United States Government Work, uncopyrighted, public-domain,
DRAFT COPY ONLY. This document does not necessarily represent the views
or policies of any United States Government agency.
This document is provided "as is", without warranty of any kind,
express or implied, including but not limited to the warranties
of merchantability, fitness for a particular purpose and
non-infringement. In no event shall the authors be liable
for any claim, damages or other liability, whether in an
action of contract, tort or otherwise, arising from, out of,
or in connection with the document or the use or other dealings
made with the document.
See also: 1: Main objectives;
2: Receipt of Specimens;
4, 5,
6: Specimen Accessioning;
7: VistA® Computer.
Frozen section policies: 25,
26, 27,
41, 86.
PRINCIPLE OF THE TEST.
Acceptance of specimen, number assignment, identification.
SPECIMEN REQUIRED.
All human tissue excised at surgery, outpatient clinics,
fresh or in fixative, along with a filled-out Tissue Examination Form
(U. S. Standard Form 515, USSF515).
REAGENTS, INSTRUMENTATION.
Plastic containers.
Tissue-Tek VIP®5 Vacuum Infiltration Processor.
Neutral 10% buffered formalin.
70% Flex Solution.
80% Flex Solution.
95% Flex Solution.
100% Flex Solution.
Clearing Solution.
Paraffin.
Decalcifying solution (RDO),
Hematoxylin and eosin stain.
Microtome.
Water bath.
Alcoholic iodine solution.
5% sodium thiosulfate.
13% Thioacetamide.
Fluted filter paper.
STEP-BY-STEP DESCRIPTION.
1. After acceptance of specimen,
including specimens from Fort Howard and Perry Point,
the specimen is unpacked and the specimen container
and requisition are matched.
Notation is made of the origin of the specimen
if not already designated on the requisition. Irregularities in receipt
of the specimen, such as absence of identification, absence of
requisition slip, mismatching of patient's name on bottle and requisition,
breaking of container or breakage of fixative, are brought to the
attention of the
Attending Pathologist
as soon as possible.
2. The specimen is assigned a surgical number, the first
portion indicating BSP for Baltimore Surgical Pathology, then
hyphenated for the year, followed by the consecutive accession digit
(e.g., BSP-06-123, for the 123rd accession in year 2006).
The Surgical number is transcribed onto the requisition and into
the paper Surgical logbook. Beside the number in the paper logbook,
the patient's full name, hospital number (which is the Social Security
Number), date, origin of specimen, nature of tissue or organ (skin,
gallbladder, etc.) is transcribed.
3. Receipt and registration of an in-house specimen follows
a similar course. The delivery of these specimens from the operating rooms
and Outpatient Clinics is the responsibility of the Operating Room and
clinical staffs, not the pathology department.
4. All specimens must be properly identified
when received, and accompanied by a properly completed
surgical requisition, identifying patient and physician.
Any specimen lacking these prerequisites, or
which is associated with confusion in its identification, becomes the
subject of immediate inquiry with the submitting physician, and must
be reconciled. If the histology staff cannot reconcile the problem
with the submitting physician, then the Chief, Surgical Pathology
is notified, and takes any steps necessary to reconcile the problem.
Submissions to surgical pathology must ultimately have submission
problems reconciled, as no specimens can be simply rejected. This
situation is somewhat different for cytology, and a procedure for
rejection of cytology specimens has been entered elsewhere:
(See Procedure 90).
5. A single accession may come with multiple specimens,
which must be listed on the submission sheet and numbered,
and the numbers specified must also appear
on the specimen containers, and the numbers must
carry over to the gross diagnosis, the slides, the blocks,
and the final pathology report.
6. Specimens are normally logged in
with a 4:00 p.m. cut-off time.
Specimens received after 4:00 P.M. are held to the following day.
Exceptions to this are cases for which frozen sections are needed after
4:00 P.M., cases for which special requests are made to the department
by the clinician submitting, and cases for which the pathology resident
reaches an independent decision that a particular specimen should be
logged in after 4:00 P.M.
7. Receipt of consultation specimens.
Consultation cases sent to the VA consist entirely of cases where a
patient with care provided by another institution has their care
transferred to the Baltimore VA. We perform no consultations for the
benefit of pathologists in outside hospitals.
Pathologic studies done at the institutions where the patient received
prior care are requested by VA clinicians for review by pathology.
There is no difference between accessioning an outside consultation
cases and tissue received from the VAMC.
Consultation cases must consist of a report, slides, and any other
correspondence attached.
8. Consultation cases are accessioned and grossed.
The gross description should consist of a description of the received slides,
and should include a statement that the report from the outside source is
included and attached to the VAMHCS report. The accession numbers of the
received slides must match the accession number of the attached
outside report. The VAMHCS accession number is added, as a label
applied to the back of the received slides. If there is a request
that the slides be returned to the submitting institution upon completion
of the case, the slides are returned after the case has been signed out
and released to the VistA® computer system. We do not send copies
of our reports to the institutions who sent us material for two reasons:
8.1. This would be a violation of the Veteran's right of privacy,
which is protected by specific federal statutes written
for the Veteran patient population.
8.2. Consultations are done for patients whose care is transferred to
the VA, and not an ongoing responsibility of the institution submitting
the consultation. In other words, it would not be of benefit to the
patient to send our report to the submitting institution, and therefore
there is no medical justification for ignoring the federal statute.
9. Assuring proper numbering of specimens.
Once the specimen is entered into the logbook,
the same identifiers are maintained throughout,
so that the same name and accession number
are entered into the VISTA Computer System (formerly, DHCP),
the specimen containers, the cassettes, the tissue-blocks,
and the slide. In addition to the accession number,
the tissue-block identification number is kept on the cassettes,
the tissue-blocks and the slide, a written paper entry is made by the
resident pathologist detailing the block numbers submitted, the surgical
pathology report also details the tissue-blocks submitted, and the embedding
technologist checks off the blocks embedded against the list of the
blocks submitted and rectifies any discrepancies with the resident
pathologist. The same number is maintained for any special stains
performed on these blocks, including immunostains, and slides are
filed and retrieved by this number. Before releasing any case, the
pathologist assures matches for the identification of the patient, the
specimen number on the slide, the specimen number on the submitted
specimen sheet, the specimen number and name on the final report, and
checks that all the tissue-block designations
(e.g., specimen 4, tissue-block 6) match
the gross description on the report.
10. ASSURING PROPER IDENTIFICATION OF THE PATIENT.
THERE ARE SEVEN STEPS AT WHICH A STAFF PERSON MATCHES
THE PATIENT'S IDENTIFIERS ON THE TISSUE EXAMINATION FORM
(U. S. Standard Form 515, USSF515)
WITH THOSE ON THE FINAL PATHOLOGY REPORT.
Step 10.1.
The specimen and tissue examination form are received
in the histology laboratory (4D-124, ext 5359), and logged
into the computer and into the paper logbook by the histology technician.
Occasionally, login is performed by the resident pathologist
or by the attending pathologist.
Step 10.2.
The resident pathologist examines the specimen grossly, and reads
the patient identifiers from
USSF515
and the specimen-containers
into the transcription system, as part of the GROSS DESCRIPTION.
Step 10.3.
The gross dictation is transcribed by the clerk-typist, who has
the USSF515 at hand. The clerk-typist checks
the dictated patient identifiers against the USSF515 identifiers.
Step 10.4.
The resident pathologist receives the paperwork from the clerk-typist,
including USSF515 forms and printed
VistA® pathology reports. The resident pathologist matches
the patient identifiers on the two forms, and makes any necessary
corrections on the gross dictations.
Step 10.5.
The resident pathologist presents the paperwork and slides in the
quality assurance conference with the attending pathologist,
and the identifiers are checked at that time. Additional clinical history
might be sought from the CPRS system, and again the identifiers are checked.
Step 10.6.
Either the clerk-typist or the attending pathologist enters
the MICROSCOPIC DIAGNOSIS, and the identifers are checked again.
Step 10.7.
Any necessary corrections are made in the microscopic diagnosis,
and the report is signed electronically (RELEASED).
The identifers are checked again by the attending pathologist.
At the time that the paper report is signed by the attending pathologist,
he/she checks the identifiers a final time.
11. If there are any questions regarding patient identifiers
at any of these steps, and appropriate action is taken,
involving the Section Chief, and the submitting physician
if a report has already been electronically released.
REFERENCES.
1. Berte LM, Charlton BJ, Kirkley B, Schiffgens J,
Wilson JI, Woodcock SM.
Clinical Laboratory Technical Procedure Manuals;
Approved Guideline -- Fourth Edition.
NCCLS Document GP2-A4. 2002;2(5):.
ISBN 1-56238-458-9, 64 pages.
National Committee for Clinical Laboratory Standards (NCCLS).
940 West Valley Road, Suite 1400. Wayne, PA 19087-1898.
... presents the important components of writing and managing procedures
for the clinical laboratory.
2. Hoeltge GA, Dynek DA, Delahunty DC, McClatchey KD,
Rabinovitch A, Robinowitz M, Travers EM.
National Committee for Clinical Laboratory Standards (NCCLS).
Clinical Laboratory Technical Procedure Manuals. Third Edition.
Approved Guideline GP2-A3. 1996;16(15):.
3. Rosai J.
Rosai and Ackerman's Surgical Pathology. Ninth Edition.
St Louis: C.V. Mosby. 2004;:.
ISBN: 0323013422, 3080 pages.
4. Mills SE, Carter D, Greenson JK, Oberman HA,
Reuter VE, Stoler MH, eds.
Sternberg's Diagnostic Surgical Pathology. Fourth Edition.
New York: Lippincott Williams & Wilkins. 2004;:.
ISBN: 0781740517, 3089 pages.
5. Moore GW, Berman JJ.
Anatomic Pathology Data Mining.
Chapter 4. In: Cios KJ. Medical Data Mining and Knowledge Discovery.
Berlin: Springer Verlag. 2000;4:61-107.
ISBN: 3-7908-1340-0, 502 pages.
Published within the series: "Studies in Fuzziness and Soft Computing",
Physica-Verlag Heidelberg, a Springer-Verlag Company.
http://www.netautopsy.org/apdmchap.htm
5. Chassin MR, Becher EC.
The Wrong Patient.
Ann Intern Med. 2002 Jun 4;136(11):826-833.
6. Anon.
New safety standards address wrong-patient procedures.
RN 2002 Oct;65(10):24hf11-24hf12.
7. Parisi LL.
Patient Identification. The foundation for a culture of patient safety.
J Nurs Care Qual. 2003;18(1):73-79.