RE: [Histonet] RE: Barcoding specimen tracking, lessons you learned
Dumpster diving should be rare among histotechs, but I suspect we have all done it in one form or another at some point in our careers. Vinnie, yours is the most extreme senerio I recall. Bill -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Della Speranza, Vinnie Sent: Tuesday, April 24, 2012 3:55 PM To: Della Speranza, Vinnie; Kim Donadio Cc: Histonet; Morken,Timothy Subject: RE: [Histonet] RE: Barcoding specimen tracking, lessons you learned in order to protect the innocent I want to mention that the "lost" kidney biopsy that was successfully found in a mountain of red bag waste occurred at another facility and not where I am currently employed. This is one of those experiences you never forget but fortunately had a happy ending and has been the subject of workshops I've given for NSH. Vinnie Della Speranza, MS, HTL(ASCP) Manager for Anatomic Pathology Services Medical University of South Carolina 165 Ashley Avenue MSC 908 Charleston, SC 29425 tel. 843-792-6353 fax. 843-792-8974 - ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet This electronic mail and any attached documents are intended solely for the named addressee(s) and contain confidential information. If you are not an addressee, or responsible for delivering this email to an addressee, you have received this email in error and are notified that reading, copying, or disclosing this email is prohibited. If you received this email in error, immediately reply to the sender and delete the message completely from your computer system. ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: Barcoding specimen tracking, lessons you learned
in order to protect the innocent I want to mention that the "lost" kidney biopsy that was successfully found in a mountain of red bag waste occurred at another facility and not where I am currently employed. This is one of those experiences you never forget but fortunately had a happy ending and has been the subject of workshops I've given for NSH. Vinnie Della Speranza, MS, HTL(ASCP) Manager for Anatomic Pathology Services Medical University of South Carolina 165 Ashley Avenue MSC 908 Charleston, SC 29425 tel. 843-792-6353 fax. 843-792-8974 - ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: Barcoding specimen tracking, lessons you learned
Thanks for contacting me Kim. I think that staff feel compelled to be more vigilant when manual systems are in place and may get a bit too complacent, expecting the electronic tools to think for us. we are working on developing our own tools for scanning cassettes before they are loaded into the tissue processors, but the tool is in development stage and I can't offer specifics yet, however it is supposed to go live in July. We are creating a version of CoPath that will be married to Cerner Millenium. At the grossing table, the cassettes will be scanned when the tissues are collected and held in formalin, then scanned again at the tissue processor and again at the embedding station. At embedding, a screen pops up on a monitor that will alert the tech is there are special embedding instructions. This is entirely home grown and not an off the shelf product. I share this because the scenarios you mentioned are in fact possible, I lived through the nightmare of having to search through two tractor trailer loads of red bag waste to find a missing kidney biopsy. The specimen was found, but it was the most unpleasant experience imaginable. And I survived to tell about it ! Vinnie Della Speranza, MS, HTL(ASCP) Manager for Anatomic Pathology Services Medical University of South Carolina 165 Ashley Avenue MSC 908 Charleston, SC 29425 tel. 843-792-6353 fax. 843-792-8974 -Original Message- From: Kim Donadio [mailto:one_angel_sec...@yahoo.com] Sent: Tuesday, April 24, 2012 4:25 PM To: Della Speranza, Vinnie Cc: Morken, Timothy; Histonet Subject: Re: [Histonet] RE: Barcoding specimen tracking, lessons you learned Vinnie. I as well found some quirks with this technology and I'm glad you brought up that it isn't perfect. I had a bog issue with the fact that you couldn't scan all your cassettes when putting on the machine as I felt that was the time errors needed to be noticed and fixed. Because finding out even the next day that a specimen is missing is not a good time. Ie. Specimen got tossed into garbage upon grossing and garbage has been incinerated. Not that I've seen this. Just that it could happen. I also noticed that errors at microtomy can still happen. Think about this, you pick up a block. Scan it and then can't get a section. You put block back in decal or on ice. You pick up next block. Whamo. You better pay attention So in essence with what ever we use technology wise it's up to us if we are paying attention and should never be complacent with our tools. Because our tools still require us to think. Kim D Sent from my iPhone On Apr 24, 2012, at 2:25 PM, "Della Speranza, Vinnie" wrote: > Hi Tim, > > One thing I did not anticipate that was an unfortunate eye opener. > > When humans are given a scanner to read barcodes they seem to trust the > technology so much that they stop reading with their eyes. > > We had an unfortunate incident where the wrong barcode label was placed onto > a specimen container at accessioning. Keep in mind the label containing the > barcode also contained a patient name and MRN. Had the next individual in the > chain of events, the individual at the grossing table, read the label, she > might have noticed the discrepancy. Instead, the barcode on the cassettes was > for the wrong patient and of course, the slides likewise. > > So while I adopted barcodes to reduce the likelihood of error, this event > made me feel a bit more vulnerable because once the scanners are in use, you > may find that staff become so reliant on the technology that they are no > longer vigilant in keeping an eye out for problems. I'm sharing this in the > hope that by alerting your staff to this pitfall you can avoid experiencing > this in your lab. > > > Vinnie Della Speranza, MS, HTL(ASCP) > Manager for Anatomic Pathology Services > Medical University of South Carolina > 165 Ashley Avenue MSC 908 > Charleston, SC 29425 > tel. 843-792-6353 > fax. 843-792-8974 > > > -Original Message- > From: histonet-boun...@lists.utsouthwestern.edu > [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Morken, > Timothy > Sent: Monday, April 23, 2012 1:31 PM > To: Histonet > Subject: [Histonet] Barcoding specimen tracking, lessons you learned > > To anyone who has implemented a barcoding/specimen tracking system in your > lab. What lessons did you learn that would make it easier if you did it over? > We're starting the process and I would like to get some input on things to > look out for! > > Thanks for any info and comments! > > Tim Morken > Department of Pathology > UC San Francisco Medical Center > 505 Parnassus Ave, Box 1656 > Room S570 > San Francisco, CA 94132 > > (415) 353-1266 (ph) > (415
Re: [Histonet] RE: Barcoding specimen tracking, lessons you learned
Vinnie. I as well found some quirks with this technology and I'm glad you brought up that it isn't perfect. I had a bog issue with the fact that you couldn't scan all your cassettes when putting on the machine as I felt that was the time errors needed to be noticed and fixed. Because finding out even the next day that a specimen is missing is not a good time. Ie. Specimen got tossed into garbage upon grossing and garbage has been incinerated. Not that I've seen this. Just that it could happen. I also noticed that errors at microtomy can still happen. Think about this, you pick up a block. Scan it and then can't get a section. You put block back in decal or on ice. You pick up next block. Whamo. You better pay attention So in essence with what ever we use technology wise it's up to us if we are paying attention and should never be complacent with our tools. Because our tools still require us to think. Kim D Sent from my iPhone On Apr 24, 2012, at 2:25 PM, "Della Speranza, Vinnie" wrote: > Hi Tim, > > One thing I did not anticipate that was an unfortunate eye opener. > > When humans are given a scanner to read barcodes they seem to trust the > technology so much that they stop reading with their eyes. > > We had an unfortunate incident where the wrong barcode label was placed onto > a specimen container at accessioning. Keep in mind the label containing the > barcode also contained a patient name and MRN. Had the next individual in the > chain of events, the individual at the grossing table, read the label, she > might have noticed the discrepancy. Instead, the barcode on the cassettes was > for the wrong patient and of course, the slides likewise. > > So while I adopted barcodes to reduce the likelihood of error, this event > made me feel a bit more vulnerable because once the scanners are in use, you > may find that staff become so reliant on the technology that they are no > longer vigilant in keeping an eye out for problems. I'm sharing this in the > hope that by alerting your staff to this pitfall you can avoid experiencing > this in your lab. > > > Vinnie Della Speranza, MS, HTL(ASCP) > Manager for Anatomic Pathology Services > Medical University of South Carolina > 165 Ashley Avenue MSC 908 > Charleston, SC 29425 > tel. 843-792-6353 > fax. 843-792-8974 > > > -Original Message- > From: histonet-boun...@lists.utsouthwestern.edu > [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Morken, > Timothy > Sent: Monday, April 23, 2012 1:31 PM > To: Histonet > Subject: [Histonet] Barcoding specimen tracking, lessons you learned > > To anyone who has implemented a barcoding/specimen tracking system in your > lab. What lessons did you learn that would make it easier if you did it over? > We're starting the process and I would like to get some input on things to > look out for! > > Thanks for any info and comments! > > Tim Morken > Department of Pathology > UC San Francisco Medical Center > 505 Parnassus Ave, Box 1656 > Room S570 > San Francisco, CA 94132 > > (415) 353-1266 (ph) > (415) 514-3403 (fax) > tim.mor...@ucsfmedctr.org > > > ___ > Histonet mailing list > Histonet@lists.utsouthwestern.edu > http://lists.utsouthwestern.edu/mailman/listinfo/histonet > > ___ > Histonet mailing list > Histonet@lists.utsouthwestern.edu > http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] RE: Barcoding specimen tracking, lessons you learned
Unfortunately (or is that fortunately?), pretty much all technology can be foiled by human beings. We've seen this scenario before as well. We tell our accession personnel that they must accession and label one case at a time, but when it comes down to it, there is no real way to FORCE people to follow a policy. This is why we have inquiry come up automatically at Gross, Transcription, and Pathology workcenters. Ostensibly, one or more people need to confirm the correct labeling of the case. ...at least that's the theory ... and of course there's that people part of the equation again. Michael Mihalik PathView Systems | cell: 214.733.7688 | 800.798.3540 | fax: 952.241.7369 -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Della Speranza, Vinnie Sent: Tuesday, April 24, 2012 11:25 AM To: Morken, Timothy; Histonet Subject: [Histonet] RE: Barcoding specimen tracking, lessons you learned Hi Tim, One thing I did not anticipate that was an unfortunate eye opener. When humans are given a scanner to read barcodes they seem to trust the technology so much that they stop reading with their eyes. We had an unfortunate incident where the wrong barcode label was placed onto a specimen container at accessioning. Keep in mind the label containing the barcode also contained a patient name and MRN. Had the next individual in the chain of events, the individual at the grossing table, read the label, she might have noticed the discrepancy. Instead, the barcode on the cassettes was for the wrong patient and of course, the slides likewise. So while I adopted barcodes to reduce the likelihood of error, this event made me feel a bit more vulnerable because once the scanners are in use, you may find that staff become so reliant on the technology that they are no longer vigilant in keeping an eye out for problems. I'm sharing this in the hope that by alerting your staff to this pitfall you can avoid experiencing this in your lab. Vinnie Della Speranza, MS, HTL(ASCP) Manager for Anatomic Pathology Services Medical University of South Carolina 165 Ashley Avenue MSC 908 Charleston, SC 29425 tel. 843-792-6353 fax. 843-792-8974 -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Morken, Timothy Sent: Monday, April 23, 2012 1:31 PM To: Histonet Subject: [Histonet] Barcoding specimen tracking, lessons you learned To anyone who has implemented a barcoding/specimen tracking system in your lab. What lessons did you learn that would make it easier if you did it over? We're starting the process and I would like to get some input on things to look out for! Thanks for any info and comments! Tim Morken Department of Pathology UC San Francisco Medical Center 505 Parnassus Ave, Box 1656 Room S570 San Francisco, CA 94132 (415) 353-1266 (ph) (415) 514-3403 (fax) tim.mor...@ucsfmedctr.org ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
