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 +
From: koelli...@comcast.net
To: tbr...@holyredeemer.com
Subject: Re: [Histonet] RE: Formalin in the OR
CC: histonet@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 tbr...@holyredeemer.com
To: histonet@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@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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