Histopathology & Cytopathology Interns Duties and Responsibilities PDF

Histopathology and Cytopathology Interns Duties and Responsibilities: I. Morning Routine 1. Fill up tissue flotation bath with: Tap water (Mon-Tue-Thu-Fri-Sun) Distilled Water (Wed and Sat) Set temperature at 45-50℃ make sure that the orange light near the switch is...

Histopathology and Cytopathology Interns Duties and Responsibilities: I. Morning Routine 1. Fill up tissue flotation bath with: Tap water (Mon-Tue-Thu-Fri-Sun) Distilled Water (Wed and Sat) Set temperature at 45-50℃ make sure that the orange light near the switch is turned on. Fill up to 3/4 of the container. Leaving a half an inch of space from the mouth of the flotation bath. 2. Plug the hot plate check if the orange light is turned on. 4. Check Pap’s Stain and H&E stain reagent levels that reagents are enough to submerge slides being stained Coplin jars (3/4 of the container) Staining Jars (Slightly than half of the container). 3. Remove metallic sheen on Hematoxylin dye (this is due to oxidation of the dye). Before filtering, press carbon paper (matte side) with the staining rack to remove the metallic sheen on the surface. 4. Filter stains Hematoxylin and Eosin with the flower filter paper. 5. Always replace all tap water containers. 6. Set-up embedding area lay out scrap papers. II. Embedding of Tissues 1. After blocks are unloaded from the tissue processor by staff on duty, Arrange all blocks at the base of the oven by increasing accession number based on the loading logbook. Always double check numbers on the cassette and filter paper strip, if with inconsistencies always ask the staff on duty. 3. Start with the proper embedding procedure. If it is your first day, learn for the proper embedding of specimens from the staff on duty. 4. Place the first 5 blocks on top of the hotplate and place 4 embedding mold. 5. Pour wax on the embedding mold until it slightly overflows (this is to allow the paraffin wax to seep through the cassette for attachment of the block to the cassette). 6. Make sure that tissues are always close to each other but not overlapping. 7. Then carefully place mold on top of the flat surface of the ice block to freeze the bottom of the mold. To hold the specimen in place, press tissue with a teasing needle or forceps immediately after placing the mold on top of ice. 8. After cooling the molds, place the blocks at the blood bank freezer (blue refrigerator near the intern’s quarters) for 10 minutes only. Do this by batches of 10 blocks for faster progress. III. Trimming 1. After 10 minutes in the freezer, detach the block from the mold and trim the edge of the mold. Do not use blade or scissors to avoid injury. 2. Arrange blocks in order on top of the ice block in order for staff to start cutting. IV. Cutting 1. Before staff will proceed with cutting pre label slides with the arrangement of blocks at the loading logbook. Always double check numbers. 2. Staff will let the slides stand for a short period of time to let water drain from the slides 3. Clean hot plate with paper blot surface until excess paraffin was absorbed by the paper. 4. Ask staff on duty if the first 10 slides produced can proceed on the hotplate for 10 minutes. (always learn the pattern of the placement on the hotplate) 4. After 10 minutes at the hot plate.Arrange slides at the staining rack and place slides at the oven for 15 minutes. V. Staining 1. After 15 minutes at the oven remove slide rack then, proceed to step 1 (Neoclear) of the staining procedure. 2. Make sure that all slides are submerged at all stations. 3. Do not let slides dry during staining  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 1 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 1. Introduction 1.1 Purpose of the Manual The purpose of this manual is to provide comprehensive guidelines for maintaining and improving the quality of histopathological practices within the laboratory. It outlines the procedures, responsibilities, and standards required to ensure accurate, reliable, and timely diagnostic results. 1.2 Scope This manual applies to all aspects of histopathological processes, from specimen collection to report distribution. It is intended for use by all laboratory personnel, including pathologists, histotechnicians, and administrative staff. 2. Quality Control Policy 2.1 Mission Statement Our mission is to deliver exceptional histopathological services that play a critical role in facilitating precise and timely diagnosis. By maintaining the highest standards of quality, we aim to support healthcare professionals in making informed clinical decisions, ultimately ensuring that patients receive the most appropriate and effective care. Our commitment to accuracy and efficiency underscores our dedication to enhancing overall patient outcomes and promoting excellence in healthcare delivery. 2.2 Quality Objectives Ensure histological methods are executed with high accuracy and precision. Maintain uniformity in the processing and staining of specimens. Reduce errors and achieve consistent, reproducible results. 2.3 Quality Management System Overview This section presents a comprehensive overview of the laboratory's quality management system (QMS), detailing the key components that ensure effective operation and adherence to standards. It covers essential aspects such as document control, which governs the creation, management, and accessibility of all laboratory documentation, and process control, which ensures that all procedures are consistently followed and properly regulated. Additionally, it highlights the laboratory’s commitment to continuous improvement practices, focusing on regularly evaluating and refining processes to enhance efficiency, accuracy, and overall quality in laboratory operations. 3. Pre-Analytical Phase 3.1 Specimen Reception Acceptance Criteria: o Specimen Identification and Labeling ▪ Properly labeled: Each specimen container must be clearly labeled with patient details (name, identification number). Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 2 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 ▪ Specimen source: The label must indicate the anatomical site or source of the specimen. ▪ Accurate documentation: The accompanying requisition form must match the specimen label and contain relevant clinical information. o Specimen Integrity ▪ Intact tissue sample: The specimen should be free of physical damage (e.g., crush injuries, tears) that could affect histological evaluation. ▪ Sufficient size: The specimen must be of an adequate size to allow for thorough examination (size may vary depending on the biopsy type). ▪ For small biopsies (Less than 1.0 cm), the receiving staff or medtech intern should ask the pathology ROD for checking o Fixation ▪ Correct fixative: The specimen must be placed in the appropriate fixative: ▪ 10% neutral buffered formalin: For small biopsies, lymph nodes and other specimens intended for IHC testing ▪ 10% formalin: all others. ▪ Proper volume: The volume of fixative must be at least 8-10 times the volume of the specimen to ensure thorough penetration. o Requisition Form and Clinical Information. ▪ Complete clinical history: The requisition form should include relevant patient history, clinical findings, and preoperative diagnosis. ▪ Surgeon's or clinician’s name and signature: should be present ▪ Clear specimen description: The requisition should detail the type and number of specimens collected and any requests for special stains or molecular testing. o Special Specimen Types ▪ Frozen sections: Must be transported immediately, often fresh, without fixative ▪ Cytology specimens: Should be adequately smeared and fixed if applicable, or preserved in the appropriate medium (e.g., alcohol-based fixative). Rejection Protocol: o Specimen Labeling Errors ▪ Unlabeled specimen container: If the container has no label or identifier, have the specimen be labeled  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 3 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 ▪ Mismatched labeling: If the label on the specimen container does not match the information on the requisition form (e.g., patient name or specimen site), have the label be corrected ▪ Inadequate labeling: Missing critical information, such as patient identification, specimen source, or anatomical site. o Inappropriate Fixation ▪ Wrong fixative: If the specimen is placed in an incorrect fixative (e.g., using formalin when a fresh sample is required or using the wrong preservative for special stains). ▪ Inadequate fixation: Specimen is under-fixed (not in fixative long enough) or over-fixed (in fixative too long), affecting tissue morphology. ▪ Absence of fixative: Specimen sent without fixative or dry, leading to tissue degradation or autolysis. ▪ Refer immediately to the Anatomic pathology ROD o Specimen Integrity Issues ▪ Crushed or damaged specimen: Specimens that are physically damaged or crushed during collection or transport, making it impossible to evaluate tissue architecture. ▪ Desiccated specimen: Specimen dried out due to improper fixation or prolonged exposure to air, resulting in autolysis. ▪ Missing specimen/ Inappropriate size: Specimen is too small or insufficient for proper histopathological evaluation. o Incomplete Documentation ▪ Missing requisition form: If the specimen is received without a corresponding requisition form, it may be rejected. ▪ Inadequate clinical information: Requisitions lacking essential clinical data (e.g., patient history, surgical procedure details, specimen site) required for proper interpretation may lead to rejection. ▪ Lack of physician or clinician details: Missing information regarding the requesting physician or surgeon, especially if special instructions for processing are required. 3.2 Specimen Storage Tissue and fluid specimens are kept for one (1) month or until after the surgery audit (every first Monday of the month) whichever is later. 4. Analytical Phase 4.1 Tissue Processing Fixation Protocols: o For small specimens (tissues less than 1.0 cm): Adequate fixation is at least six (6) hours. If less than 6 hours, delay the specimen’s processing and inform anatomic pathology ROD  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 4 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 o For medium to big specimens: Adequate fixation is at least 12 hours. If less than 12 hours, delay the specimen’s processing and inform anatomic pathology ROD Dehydration, Clearing, and Infiltration: Done via the tissue processing machine. Only histopathology rotating staff can load and operate the machine. No medtech intern is allowed to touch or manipulate the machine once its processing commences. Embedding Procedures: o All small specimens, on-edge specimens, or other specimens labeled as “care of staff” by the anatomic pathology ROD must be embedded by the histopathology staff on duty ▪ The staff should cross-reference the number of tissues per cassette in the tissue processing logbook o 4.2 Microtomy Quality Control o The sections are visually inspected for any imperfections such as tears, folds, or uneven thickness. o If the sections are damaged, the process may need to be repeated, and new sections are cut. 4.3 Staining Procedures 4.4 Quality control Evaluation: The stained slides are visually inspected under a microscope for quality control. The hematoxylin should stain nuclei blue, and eosin should stain cytoplasmic and extracellular components pink to red. Repeat Staining if Necessary: If the staining is uneven, too light, or too dark, the process may be adjusted, and the section may need to be restained. 5. Post-Analytical Phase 5.1 Reporting of Results 5.1A: Standard Format The pathology report should contain the following information o Patient Data ▪ Accession number / Specimen number: ▪ Complete name: Format: (Last name), (Given name) and (Middle name) ▪ Physician: Format: Attending physician / Assist / Residents ▪ Hospital number: ▪ Age: ▪ Sex: Male / Female ▪ Civil Status: Child / Single / Married / Widow / Widower Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 5 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 ▪ Date Submitted: Date wherein specimen was received at the histopathology section ▪ Date Reported: Date of signing by the attending pathologist and cleared for distribution ▪ Post-operative Diagnosis: o Pathology Consultation Report ▪ Gross description: Complete gross description of the specimen submitted Includes accurate measurement of the specimen Includes designation of letters depicting specific areas of the specimen For cytology specimens: o Color o Appearance o Volume ▪ Microscopic description Preferential and not required in all reports, but may be included Describes in detail the microscopic appearance of the specimen ▪ Histopathologic diagnosis: ▪ Comment: Includes comments or relevant information regarding the diagnosis May include differential diagnosis Includes immunohistochemistry stains or other tests relevant to the diagnosis o Signatures ▪ The complete name of the Pathologist should be indicated, including his / her License No. ▪ Reports are personally signed by the attending pathologist o Miscellaneous ▪ The resident on duty involved with the gross examination of the specimen and accomplishment of the written report is indicated in the report 5.1B: Review and Verification o All cases are signed out with the consultant involved ▪ The resident on duty will describe in detail the related history, past medical history, physical examination and additional tests (imaging / laboratory tests) to the consultant signing out the case to arrive with a diagnosis. o Accomplishment of the report is done by the resident on duty  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 6 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 ▪ The resident ensures that all the information provided in the report are accurate and verified The reports are checked initially after typing by the residents on duty to ensure that all information are correct A second verification is done by the consultant to ensure that the details of the report are correct A third verification is done by the resident to ensure that all 3 copies of the reports are signed o Three (3) copies of the report are printed and signed: ▪ File copy ▪ Physician’s copy ▪ Patient’s copy 5.2 Report Distribution 5.2A: Protocols o All histopathology and cytopathology results released must observe the “Data Privacy Act” of 2012 ▪ Hard copy formats Patients / watchers claiming the results should present a valid ID prior to claiming the histopathology result Doctors claiming the results should present a valid ID that would identify him / her as the doctor who requested for the histopathology report Resident doctors who were tasked to get results should present a valid ID and evidence that he / she was tasked by the attending physician to retrieve the histopathology results ▪ Electronic delivery systems To ensure that electronic data is safeguarded. The following must be observed prior to sending the electronic copy o The histopathology report to be sent should be verified and signed o The electronic copy must be clear and all data should be easily seen o The attending physician should be double checked in all reports to be sent electronically o The attending physician’s contact / electronic delivery name should be verified prior to sending o The electronic copy is then sent via electronic delivery system o The sender should double check that he / she sent the right file / picture to the appropriate receiver  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 7 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 Only attending pathologists may send electronic copies to the attending consultants o Releasing of histopathology and cytopathology results ▪ Ask the name, date of submission / surgery and official receipt of the patient ▪ Search for the patient’s profile in the logbook or census ▪ If results are available OPD cases o Results are filed accordingly and are retrieved in the Histopathology section of the laboratory Currently admitted cases o Results are released to the nurses’ station of their corresponding ward Discharge cases o Results are charted to the medical records and patients are directed to the medical records for release 5.2 B: Confidentiality o Results should be handled only by authorized personnel o Data included in reports should not be discussed outside of its intended purpose o All histopathology and cytopathology results released must observe the “Data Privacy Act” of 2012 5.3 Archiving of slides and reports 5.3A: Long-Term storage o Filing of histopathology and cytopathology results ▪ Separate histopathology results: patient, physician and file copies ▪ Chronologically arrange with the highest number always on top in a properly labeled folder ▪ Results are filed upon release and book bound by the end of the year ▪ Book bounded results are kept for 10 years and shredded thereafter o Filing of histopathology and cytopathology requests ▪ Separate histopathology results: patient, physician and file copies ▪ Chronologically arrange with the highest number always on top in a properly labeled folder ▪ Requests are kept in the section and are shredded after 2 years o Filing of histopathology and cytopathology slides ▪ Slides received from the pathologist are allowed to settle in their respective trays for 3 days to allow the mountant to harden. This is  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 8 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 done to avoid leakage of the mountant and sealing together of slides when filed. ▪ The slides of each case are chronologically arranged and taped accordingly ▪ The slides of histopathology specimen and cytopathology slides are separately filled in their designated slide cabinets ▪ Slides are kept for a period of 10 years ▪ All filed blocks are logged at the “filed slides and blocks” logbook for record keeping o Filing of histopathology and cytopathology blocks ▪ Histopathology and cytopathology blocks are separated accordingly ▪ The trimmed area is sealed with paraffin to prevent tissue decomposition ▪ Blocks are arranged chronologically and filed on sturdy boces ▪ Blocks are kept for a period of 10 years ▪ All filed blocks are logged at the “filed slides and blocks” logbook for record keeping 5.3B. Digital archiving o The electronic copy is named according to the accession number o The copies are stored in their respective folders o The files are indefinitely kept in a safeguarded computer located in the histopathology office 5.4 Disposal of Specimens 5.4A. Biohazardous waste handling o All histopathology or surgical specimens are kept at the stock room or cabinets located below the grossing area for a period of 1 month or 1 week after Departmental audits. o Specimen are then counter checked with released histopathology results o Specimens are re-sealed and placed in a puncture proof container and are collected by the Waste Management team of the institution for proper disposal. o Cytopathology specimens are stored for 7 days in the refrigerator, treated with 10% sodium hypochlorite solution. The sample is then sealed and sent to the Hospital Waste Management team for proper disposal. 5.4B. Disposal records o All specimen are counter-checked with the available histopathology results to verify that the case have been accomplished o All discarded specimen are recorded in the “Specimen discard” logbook including the date of discard  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 9 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 6. Quality Assurance and Improvement 6.1 Internal Quality Control (IQC) 6.1A: Routine Checks o Daily checks for instruments are done accordingly ▪ Refrigerator temperatures are recorded daily, every 4 hours ▪ Tissue embedding station temperature is recorded every 4 hours when in use ▪ Room temperature is recorded every 8 hours ▪ Cryostat temperature is recorded accordingly to ensure adequate temperature is reached when needed o Reagents and solutions are checked accordingly for expiration monitoring ▪ Graduated cylinders should be used to measure liquids ▪ The following preparations are for preparing one liter of the solution needed ▪ Fixative: 10% formalin o 37% formalin: 270 ml o Distilled water:730 ml ▪ Dehydrating agents 95% alcohol o 100% alcohol: 950 ml o Distilled water: 50 ml 70% alcohol o 100% alcohol: 700 ml o Distilled water: 300 ml ▪ Decalcifying agent Formol-Nitric acid o Concentrated nitric acid: 10 ml o 37% formalin: 5 ml o Distilled water: 85 ml ▪ Bluing agent Ammonia water o Ammonium hydroxide: 3 ml o Distilled water: 1000 ml o Tissue processors and embedding stations are checked accordingly ▪ Reagents should be changed twice a month or as needed. ▪ Control blocks are used to assess tissue processing after reagent change ▪ After the gross examination, the tissues are then loaded in the automatic tissue processor for overnight processing (6 pm to 5 am). ▪ Tissue processor settings Bucket 1: 10% Neutral Buffered Formalin for min of 1hour Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 10 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 Bucket 2: 10% Neutral Buffered Formalin for min of 1hour Bucket 3: 70% Ethyl Alcohol for 1 hour Bucket 4: 95% Ethyl Alcohol for 1 hour Bucket 5: Absolute Alcohol for 1 hour Bucket 6: Absolute Alcohol for 1 hour Bucket 7: Absolute Alcohol for 1 hour Bucket 8: Xylene for 1 hour Bucket 9: Xylene for 1 hour Bucket 10: Xylene for 1 hour Bucket 11: Paraffin for 1 hour Bucket 12: Paraffin for 1 hour o Staining procedure: ▪ Hematoxylin and Eosin Xylene/Xylene substitute: 10-15 minutes Xylene/Xylene substitute: 10-15 minutes Absolute alcohol: 2 minutes Absolute alcohol: 2 minutes 95% alcohol: 15 dips 95% alcohol: 15 dips 95% alcohol: 15 dips Tap water: Rinse/ 2 changes Harris Hematoxylin: 2 minutes Tap water: Rinse/ 2 changes Ammonia water: 15 dips 95% alcohol: 15 dips Eosin: 5 dips 95% alcohol: 5 dips Absolute alcohol: 5 dips Absolute alcohol: 5 dips Xylene/Xylene substitute: 10-15 minutes Xylene/Xylene substitute: 10-15 minutes ▪ Papanicolau Staining 95% alcohol: 10-15 minutes 70% alcohol: 5 dips 50% alcohol: 5 dips Harris hematoxylin: 10 minutes Distilled water: Rinse 95% alcohol: 5 dips Ammonia water: 1 minute 95% alcohol: 5 dips OG-6: 3 minutes 95% alcohol: 5 dips Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 11 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 EA-50: 3 minutes 95% alcohol: 5 dips ▪ Important considerations to staining Dirty slides may result in the failure of the section to adhere on the slide during staining. If sections do not stain, hematoxylin is not fully ripened. Remedy this with prolonged staining time with hematoxylin. If the section does not appear clear after staining, xylene/xylene substitute should be replaced; there may be excess water or weak alcohol. Timing in every solution depends on the ripeness of the stains, so there is no definite time for each. Slides could be restained by repeating the staining from the start then correct the wrong procedure. Alcohol could be used in cleaning the slides but be careful not to touch the stained section to prevent decolorization of the eosin resulting in poor differentiation. Stains should be changed regularly depending on the load and frequency of use. o Staining criteria ▪ Complete and document results of a H&E control prior to staining routine workload. The number of dips for hematoxylin and eosin are included Slide stain controls are given to pathologist / residents for assessment prior to the staining of the main slides. Documentation to include changes or actions taken to correct substandard staining of the control. ▪ Hematoxylin: When applied correctly, in well-fixed, well-processed tissues, epithelial cells will demonstrate: A well-defined nuclear membrane Clear, open (vesicular) karyoplasm (cytoplasm of the nucleus) Crisp, fine-spiculated chromatin patterns o Also, in most tissue sections, there are some dense closed (hyperchromatic) nuclear patterns present in lymphoid tissue. Prominent “eosinophilic” nucleoli (if present) Cartilage and calcium deposits stain dark blue The hematoxylin should appear blue to blue-black ▪ Eosin: When applied correctly, in well-fixed, well processed tissue, eosin produces, at least, a “tri-tonal” (three-color) effect.  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 12 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 Muscle cells (smooth, skeletal, cardiac) and epithelial cell cytoplasm will stain deep red-pink. Collagen will stain a distinct lighter pink. Red blood cells (RBC) will stain a bright orange-red. Nucleoli (if present) should exhibit a reddish-purple color due to their high protein and RNA content It is essential, when applying eosin, that the smooth muscle/cell cytoplasm and collagen be differentially stained (different shades of red/pink). 6.1B: Proficiency testing: ▪ Daily quality control of H and E slides are assessed by pathologists to ensure proper staining. ▪ The number of dips per stain is recorded and adjusted depending on the assessment of the pathologist 6.2 External Quality Assurance (EQA) 6.2. Involvement: Currently the laboratory is not participating in any external quality assessment schemes for histopathology 6.3 Continuous Quality Improvement (CQI) o All problems, error or deviations are initially troubleshooted by staff ▪ Machine technical errors / problems are troubleshoot by the involved staff using guidelines from the user manual ▪ Notifying of technical team for possible visit o Problems that cannot be resolved by staff are then referred to residents for further management ▪ Residents are to inform the consultant on duty after proper investigation of the problem ▪ Resolution for the said problem is suggested o The Head Pathologist assesses the problem and orders procedures for resolution and prevention o Resolutions are followed up and monitored by staff, residents and consultants to ensure preventive measures are enforced to ensure that problems / errors are not repeated 6.4 Error Management 6.4A: Incident reporting o All problems, errors or deviations that have implications to a patient's treatment are required to have an incident report to document previous occurrences that lead to the event. ▪ A detailed written report regarding the event should be made  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 13 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 ▪ Timeline of the events leading to the problem should be well documented ▪ Individuals involved should be properly named o Incident reports should be submitted to the consultant / resident within 24 hours from the event 6.4B: Risk management o Risk management plans should be made and implemented to prevent errors, and reduce staff injury. o Histopathology training seminars are required as part of continuing education of staff rotating in the histopathology section 7. Equipment and Maintenance 7.1 Equipment Selection and Validation Selection criteria: o Machine / equipment for histopathological procedures are based on: ▪ Increase in productivity and efficiency ▪ Training needed ▪ Cost effectiveness ▪ Waste produced Validation procedures o Machines are calibrated prior to use. Ensuring that it meets performance standards prior to routine use and operations 7.2 Preventive Maintenance and Calibration Maintenance Schedules, Records and repairs: All schedules, previous private maintenance reports, repairs and calibration reports are documented in the “Histopathology Preventive maintenance and Calibration” clear book o Leica TP 1020 Tissue processor: Quarterly preventive maintenance ▪ Leica CM 1350 Cryostat: Quarterly preventive maintenance o Ventana benchmark GX: Yearly preventive maintenance o CX23 Microscopes: Yearly preventive maintenance o Bx43F 5 header Microscope: Yearly preventive maintenance o Drying Oven: Yearly preventive maintenance o Flotation Bath: Yearly preventive maintenance o Condura Refrigerator: Yearly preventive maintenance o Alpinum centrifuge: Quarterly preventive maintenance Calibration: o Calibration are done yearly by authorized personnel o Certificates of calibration are given after the machine / equipment has passed the required standards 7.4 Equipment Failure and Downtime Management Failure protocols:  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 14 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 o Once a machine / equipment failure is identified troubleshooting must be initially done by the staff o Information about the machine / equipment failure should immediately be relayed to the resident and consultants o Call the hospital technician for possible immediate repairs that can be done o Call the technician involved in the repair of a specific machine / equipment and relay the problem for possible on-the-line troubleshooting o If the failure cannot be resolved via phone call or on-line means then a visit by the involved technician/engineer should be scheduled Downtime Management: o If machines / equipment failure have delayed the laboratory operations, the affected attending clinical consultant / surgeons should be informed of the delay of results / downtime of machines. o Preventive maintenance for the cryostat should be announced and disseminated at least 3 days before the scheduled maintenance and down time. 8. Personnel Training and Competency 8.1 Staff Training Programs Initial training: o All new staff should rotate in the histopathology department ▪ The staff shall be given practice blocks for assessment of initial aptitude for histopathology. These slides are presented to the pathologist for initial evaluation ▪ The staff should be able to cut and make a Rush frozen section slide from a fresh practice specimen. ▪ The staff should be able to efficiently produce a slide for reading during an RFS simulation o Staff with aptitude in histopathology are given the chance to assist the histotech staff during an RFS procedure and allowed to cut at least one specimen during an actual rush-frozen-section. Ongoing Training: o Histotech staff are required to attend histopathology lectures, conferences and seminary to increase their knowledge and sharpen their skills in the department. 8.2 Competency Assessment Ongoing Training: o Histotechs are regularly advised by consultants on released slides for immediate improvement or adjustment. o Competency is assessed by the department head and section head for the need of training.  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 15 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 8.3 Continuing Education Professional development: o Opportunities are given for staff to attend conferences, workshop and online courses to stay current with the advances in histopathology o Training that are given by accredited bodies are reiterated to staff to ensure that they are up to date in their practice Competency is assessed CE Credits: o All staff must submit a list of continuing education credits o The need for CE credits should be relayed to the head medical technologist so that he / she can be assisted in acquiring the needed credits prior to licensure renewal and expiry 9. Documentation and Records 9.1 Document Control Manual Updates: Procedures for regularly updating the QC manual, including version control and document distribution. o Quality control checks include patient to specimen identification, fixation, adequate processing, appropriate embedding techniques, microtomy, unacceptable artifacts, and inspection of controls to determine correctness of stains and immunohistochemical methods. ▪ Pre-analytical phase: Quality assurance monitors include labeling errors, accessioning errors, adequacy of clinical history, lost of specimens ▪ Analytical phase: grossing, processing, embedding, cutting/microtomy, staining, cover slipping, assortment/distribution of cases to pathologists, examination/interpretation of slides by pathologists, rendering diagnosis, writing report ▪ Peer review for quality monitoring suggestions: ▪ Second pathologist review before sign-out ▪ Review randomly selected number/percentage of cases ▪ Focused internal review of the specific organ system or malignancy type ▪ Intra- and interdepartmental conferences (tumor boards) ▪ Frozen section/Permanent section correlation ▪ Cytology/surgical pathology correlation ▪ Review of previous pathology material in repeat biopsies  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 16 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 ▪ Intradepartmental review of material before release to other institutions ▪ Review of outside diagnosis of in-house cases ▪ Clinical indicators ▪ Pathology turnaround times ▪ Post-analytical phase: transcription errors, report delivery errors, incomplete reports o External quality assessment schemes (?) o SOPs: Standardized formats for creating and maintaining SOPs, ensuring they are clear, concise, and easily accessible to staff. o Standard operating procedure for receiving, handling and charging of histopathology and cytopathology specimens. It includes the following but not limited to checking completeness of data in the request and submitted specimen, appropriate fixative, sample accession, rejections of the sample. o Standard operating procedure for processing tissue and fluid samples including but not limited to fixation, grossing, cell blocking, decalcifying. Standard operating procedure for manual instruction on use of tissue processing machine and its maintenance. o Standard operating procedure for manual instruction on embedding following guide for safe operation and maintenance of embedding machine o Standard operating procedure for manual instruction on Microtome and tissue sectioning should follow guide for safe operation, disposal of blades, and maintenance of microtome and water bath. o Standard operating procedure for staining and mounting specimens. Troubleshooting guide for H&E staining and papanicolaou staining. o Standard operating procedure for sample examination management, including turn-around -time from receipt of specimen to release of results. Standard operating procedure for use and maintenance of microscope. o Standard operating procedure on releasing of histopathology, cytopathology and immunohistochemistry results. o Standard operating procedure for rush frozen section and adequacy procedures. o Standard operating procedure for assisting ultrasound-guided fine needle biopsy, CT-guided core needle biopsy, and Bone marrow aspiration and core needle biopsy. o Standard operating procedure for processing specimens for immunohistochemistry staining. o Standard operating procedure for storing and disposal of histopathologic and cytopathologic specimens. Cytopathologic specimens discarded after the seventh day while histopathologic specimens are discarded after the respective audits of the department.  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 17 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 o Standard operating procedure for filling, retention and disposal of documents (results and requests), slides and blocks for histopathology, cytopathology, immunohistochemistry, and rush frozen study. o Standard operating procedure for loaning and returning of slides and blocks o Standard operating procedure on returning of specimen or body part to a patient o Appropriate storage, handling and preparation of chemical reagents with minimal use of PPE specified. Guide in handling spills and proper waste disposal according to law. Guide in exposure to chemicals o Appropriate handling and disposal of sharps 9.2 Record Keeping Standardized Forms: Use of standardized forms and logs for documenting QC activities, including equipment maintenance and incident reports. o Written information about policies, processes and procedures. ▪ A policy is “a documented statement of overall intentions and direction defined by those in the organization and endorsed by management”. Policies give broad and general direction to the quality system ▪ Processes are the steps involved in carrying out quality policies. It defines a process as a “set of interrelated or interacting activities that transform inputs into outputs”. Another way of thinking about a process is as “how it happens”. Processes can generally be represented in a fl ow chart, with a series of steps to indicate how events should occur over a period of time. ▪ Procedures are the specific activities of a process or the performance of the test. A procedure tells “how to do it”, and shows the step-by-step instructions that laboratory staff should meticulously follow for each activity. The term standard operating procedure (SOP) is often used to indicate these detailed instructions on how to do it. Job aids, or work instructions, are shortened versions of SOPs that can be posted at the bench for easy reference on performing a procedure. They are meant to ▪ supplement, not replace, the SOPs. o Quality manual—this is the overall guiding document for the quality system and provides the framework for its design and implementation o Establish formats for recording and reporting information by the use of standardized forms Retention Periods: Guidelines for how long different types of records should be retained, in compliance with regulatory requirements.  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 18 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 o Annual review of policies, processes and procedure records, equipment and instrument preventive maintenance records, inspection, audit and assessment records, management review records, quality control records, reagent, materials and supplies records, supplier qualification records - Retention of 2 years o Specimen rejection records - Retention of 1 years o Requests, Temperature records, Waste disposal records, Tissue processing and Loading logbook: Retention of 2 years o Policies and Procedures: Retention of 2 years following discontinuance o Accession logbooks (histopathology and cytopathology) - Indefinitely (CAP) o Loaning of slides and blocks- 10 years o Releasing of results- 2 years o Returning of slides and blocks- 10 years o Receiving of specimen-2 years o Filling of slides, blocks and results- 10 years o Histopathology, cytopathology, rush frozen study, and immunohistochemistry results: Retention of 10 years o Histopathology, rush frozen study, immunohistochemistry, cytology positive/suspicious slides, fine needle aspiration biopsy and blocks: Retention of 10 years o Cytology negative/unsatisfactory, gynecologic slides and blocks slides and blocks: Retention of 5 years o All records and reports known to have medicolegal implications, Forensic autopsy (including slides and blocks): Permanent 10. Audits and Reviews 10.1 Internal Audits Frequency: Regular internal audits of all laboratory processes, with a focus on compliance with SOPs and regulatory standards. o Laboratories may choose to conduct a full laboratory audit annually or biannually, or to audit parts of their system every month. Generally it is recommended that a laboratory audit every part of its management system, including its testing and/or calibration activities, at least once every twelve months. Scope: Comprehensive audits covering pre-analytical, analytical, and post-analytical phases. o Documents and records, management reviews, organization and personnel, equipment, purchasing and inventory, occurrence/incident management, facilities and safety  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 19 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 o Pre-analytical: ▪ Completeness of request and matched with submitted specimen (container labeling matching request) ▪ Specimen transport (i.e large specimen in a small container) ▪ Fixative type and volume used ▪ Specimen adequacy, lost of specimen ▪ Specimen accessioning ▪ Wrong payment or charging o Analytical: ▪ Tissue processing (i.e. re-embedding) ▪ Technical performance/sectioning (i.e. holes, folds, debris, chatters, absence of a full transverse section) ▪ Quality of staining o Post-analytical: ▪ TAT (calculated from surgery, to tissue receipt to final reporting, including delay due to tissue fixation and/or decalcification; frozen TAT was period from receipt till frozen section diagnosis) ▪ Typing errors ▪ Second opinion obtained from our reports ▪ Filling of results, request, slides and blocks 10.2 Management Review Review Process: Regular management reviews of QC outcomes, including the evaluation of audit results, incident reports, and proficiency testing data. o Six Professional Practice Guidelines that should be developed are (1) retention of pathology records and materials, (2) minimum qualification, training and experience of professional personnel working in a pathology laboratory, (3) laboratory construction and design, (4) maintenance and operation of equipment in a pathology laboratory, (5) safe laboratory practice, and (6) sample management o Written report from the audit is provided within 2 weeks (provide summary of findings, checklist of findings, cite the standard used to identify any non-conformances, identify any action required, submit overall conclusions and recommendations. Report is given to section audited and a copy to management Action Plans: Development of action plans to address identified issues and improve overall quality. o This section should include the signatures/dates of the management staff accountable for the audit findings. It is recommended that nonconformances and corrective actions be shared with all staff in the relevant laboratory section  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 20 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 o Response and/or results of root cause analysis with a statement of action: Detail any corrections made while identifying the underlying cause. Include a statement of the corrective action for each nonconformity/deficiency. Perform a root cause analysis of the problem or use another form of analysis such as Define, Analyze, Resolution, Action(s) taken, also known as “The Five Whys;” cause mapping; fishbone diagrams; or Plan, Do, Check, Act (PDCA) o Proof of commitment: Indicate changes in documentation. If there was a written procedure that was not being followed, then provide other evidence (e.g., document name and section if updated) o Objective evidence of compliance: Provide copies of laboratory records demonstrating compliance or provide a timeline/deadline of when the compliance will be achieved. 10.3 Corrective and Preventive Actions (CAPA) Implementation: Procedures for implementing corrective and preventive actions in response to audit findings, incidents, or deviations from SOPs. o Both preventive and corrective actions are steps taken to improve a process or to correct a problem. A record of OFIs should be kept, along with actions that are taken. Preventive and corrective actions should be carried out within an agreed-upon time. o Review immediate correction for effectiveness. This may include reviewing specific logs (after a period of time determined by the remediation plan) to ensure nonconformances are appropriately documented. o Review corrective actions for effectiveness. This may include updating an SOP, retraining and monitoring periodically over a longer period of time (typically 3 months to 1 year). o All actions and findings from the monitoring should be recorded so the laboratory can learn from its activities. Monitoring: Ongoing monitoring of the effectiveness of CAPA measures, with adjustments as needed. o Continuous monitoring is the key element to success in the quality system. It is through this process that we are able to achieve the continual improvement that is our overall goal. o If the results were not effective, a root cause analysis should be performed if not completed already, and further corrective actions identified, with a new plan and another review for follow-up effectiveness. 11. Health and Safety Identify hazardous effect from associated chemicals. Store, handle and dispose the chemicals according to MSDS sheet. The permissible exposure limits (PEL) of the  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 21 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 Occupational Safety and Health Administration (OSHA) should be observed. A protocol to handling spills and exposure to chemicals. Appropriate hazard warning symbols and basic information must be seen on the labels of chemical containers. Risks from equipment can be minimized by proper installation, care and personnel training. Electrical shock can be minimized by properly polarizing and grounding all the outlets. Refrigerators and freezers must never be used to store highly flammable chemicals. Mechanical injuries due to hot surfaces of instruments can be avoided by adapting safety measures. Broken glass particles and disposable microtome blades should be disposed in special ‘sharp’ containers. Microtomes and cryostats must be cleaned after the removal of blades. Biological risk in handling fresh tissue and body fluids. Fixed specimens have a reduced risk. The potential routes through which laboratories workers can get exposed to biohazard are inhalation of aerosols, contact with non-intact skin and contact with mucous membranes. Exposure can occur in the course of receiving, processing and disposal of these material Adequate ventilation for general air circulation and for removal of hazardous fumes. All personnel should possess knowledge of basic first aid. Ingestion or contact of chemicals will depend on the nature of the chemical, provision for emergency eye wash station and immediate removal of contaminated clothing. Fire extinguisher, emergency eye washers, first aid must be checked in a monthly basis Laboratory accidents must be documented and investigated with incident reports and industrial accident reports. 11.1 Laboratory Safety Policies General Safety Rules: Comprehensive safety guidelines covering all laboratory activities, including the use of personal protective equipment (PPE) and safe handling of chemicals. o Universal precaution o Laboratory coats must be worn. Long hair should be tied back away from the shoulders. Enclosed footwear must be worn. Cover any open cuts and other exposed skin surfaces and/or wear gloves. o Avoid placing any object in mouth o When working with biological substances all work is carried out in the designated working area. It is essential that all books, writing materials and other personal belongings are kept separate from this working area for the duration of the practical session. o Carry out procedures to minimise the risks of spills, splashes and the production of aerosols  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 22 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 Safety Training: Mandatory safety training for all laboratory staff, including training on fire safety, chemical spills, and emergency procedures. 11.2 Personal Protective Equipment (PPE) PPE Requirements: Specific PPE requirements for different laboratory activities, including gloves, lab coats, face shields, and masks. o Laboratories must have available appropriate protective gears for all individuals: safety devices, goggles, gloves, lab coats and face shields o Protect hands and forearms by wearing either gloves and lab coat or suitable long gloves to avoid contact of the toxic materials PPE Maintenance: Guidelines for the proper use, cleaning, and disposal of PPE. o Gowns are laundered regularly o Proper disposal of gloves then practice handwashing. 11.3 Chemical and Biohazard Safety Hazardous Material Handling: Procedures for the safe handling, storage, and disposal of hazardous chemicals and biohazardous materials. o Collect and seal all the absorbed material into a labeled container for disposal (I.e tissue = should be stored in formalin and maybe disposed by incineration or putting them through a tissue grinder attached to a large sink) o Biological materials should not be stored in hallways, in unlocked freezers or in refrigerators o Biohazard signs should be placed in appropriate areas o Cutting areas or surfaces may be sterilized with chlorine bleach or suitable commercial disinfectant before and after use o Proper handling and storage of chemicals should be guided by MSDS sheet o Used chemicals must not be released into soils,drains, and waterways Spill Response: Detailed protocols for responding to chemical and biohazard spills, including evacuation procedures and spill kits. o Use an absorbent such as sand or kitty litter or a commercial product to collect the spills and contain the spread o Small spills can be safely handled by the immediate staff making use of quality PPES (latex gloves, disposable plastic aprons/gowns) and Clean up aids (Dustpan and brush, Sponges, Towels and mops, Adsorbent material (kitty litter or a commercial sorbent), Bleach (sodium hypochlorite), Baking sodas, Vinegar (5 % acetic acid) for alkalines, Commercial neutralizing product, Sealable plastic bucket, Heavy plastic bags)  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 23 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 o If Spilled materials is limited to few grams or mL, simply wipe off with towel or sponge. Used towel or sponge must be disposed appropriately. Do not put the used towel to the general trash. Protect room from its vapors o If Significant spills of dangerous materials, all personnel should evacuate the room or immediate vicinity. First aid must be given to anyone who has gotten splashed or is feeling the effects of vapors. Area must be sealed off. Experienced emergency response team must be called o Work space and equipment should be decontaminated with10% bleach solution. Contaminated equipment and clean up debris must be disposed of as hazardous waste o Wash hands thoroughly with soap and copious amounts of water after removal of glove 11.4 Emergency Procedures Emergency Contacts: A list of emergency contacts, including internal and external resources. o Establishing communication protocols Emergency Drills: Regular drills for fire, chemical spills, and other emergencies to ensure staff readiness. o Disaster preparedness plan (conducting risk assessment, establishing emergency response procedures, creating an evacuation plan, ensuring adequate emergency response equipment and supplies) o Reviewing and updating the plan (Identifying evacuation routes and procedures, Assigning responsibilities, Establishing a communication plan, Considering special needs, Practicing drills, Testing the effectiveness of emergency response procedures and identifying areas for improvement) o Training staff on disaster response o Identifying and securing critical equipment and supplies o Participating in disaster drills and exercised 12. References 12.1 Cited Literature Key References: List of books, articles, and guidelines referenced in the QC manual, including relevant editions of CAP guidelines, CLIA regulations, and ISO standards. 12.2 Standard Operating Procedures (SOPs)  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 24 of 24 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY HISTOPATHOLOGY SECTION Revision 00 Histopathology Quality Control Manual No. Document Control No. Effectivity August SLUHSH-TP-LABHP-015-0 Date 1, 2024 Linked SOPs: Index of all SOPs mentioned in the manual, with links to their full text. 12.3 Regulatory and Accreditation Guidelines Guideline Documents: Copies of or links to key regulatory and accreditation guidelines that the laboratory follows.  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 1 of 3 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY Revision PREPARATION OF SOLUTIONS No. 00 Document Control No. Effectivity August 1, SLUHSH-TP-LABHP-014-00 Date 2024 1.0 POLICY All Histotechnologists shall be oriented and knowledgeable in the preparation of reagents or solutions which are to be diluted. 2.0 PURPOSE To guide the Histotechnologist in the preparation of solutions and reagents needed for processing and staining of specimens. 3.0 EQUIPMENTS, REAGENTS and SUPPLIES 3.1 Containers such as reagent jars and plastic bottles 3.2 Proper protective gear (gloves, mask and goggles) 3.3 100% Alcohol 3.4 Concentrated Nitric acid 3.5 Ammonium hydroxide 3.6 Distilled water 4.0 TECHNICAL PROCEDURE 4.1 DEHYDRATING AGENTS 4.1.1 95% Alcohol 100% Alcohol 950 mL Distilled water 50 mL 4.1.2 70% Alcohol 100% Alcohol 700 mL Distilled water 300 mL 4.1.3 50% Alcohol 100% Alcohol 500 mL Distilled water 500 mL  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 2 of 3 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY Revision PREPARATION OF SOLUTIONS No. 00 Document Control No. Effectivity August 1, SLUHSH-TP-LABHP-014-00 Date 2024 4.2 DECALCIFYING AGENT 4.2.1 Formol-Nitric Concentrated Nitric acid 10 mL 37% Formalin 5 mL Distilled water 85mL 4.3 BLUING AGENT 4.3.1 Ammonia water Ammonium hydroxide 3 mL Distilled water 1000 mL 5.0 QUALITY CONTROL 5.1 Graduated cylinders should be used to measure liquids. 5.2 The formula of C1V1=C2V2 is used if the desired volume to be diluted is more than 1 (one) liter. The above preparations are for preparing 1 (one) liter only. 6.0 REFERENCE VALUES N/A 7.0 PRECAUTIONS All Medical technologists handling reagents must observe and wear prescribed Personal Protective Equipment and good laboratory practices. Proper dilution should be observed. Acids are added to water and never water to acid as this can cause explosion.  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 3 of 3 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY Revision PREPARATION OF SOLUTIONS No. 00 Document Control No. Effectivity August 1, SLUHSH-TP-LABHP-014-00 Date 2024 Prepared by: Checked by: Sally Cheeka Jayme M. Banjawan,RMT Corazon B. Aloo, RMT Section Head, Histopathology Supervising Medical Technologist Verified by: Dr. Myrna M. Espiritu, MD., FPSP Department Head  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 1 of 3 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY DISPOSAL OF HISTOPATHOLOGIC Revision 00 WASTES No. Document Control No. Effectivity August 1, SLUHSH-TP-LABHP-013-00 Date 2024 1.0 POLICY All Histotechnologists shall be oriented and knowledgeable in disposing Histopathology and Cytopathology specimens and wastes. 2.0 PURPOSE To guide the Histotechnologist in disposing Histopathology and Cytopathology specimens and wastes for in-patients and out-patients. 3.0 EQUIPMENTS, REAGENTS and SUPPLIES 3.1 Specimen containers 3.2 10% bleach 3.3 Lysol 3.4 Sponge 3.5 Gauze 3.6 Yellow trash bag 3.7 Black trash bag 3.8 Puncture- proof sharp container 3.9 Labeling tape 3.10 Empty boxes 3.11 Pen 4.0 TECHNICAL PROCEDURE 4.1 Tissue and Fluid Specimens The Histotechnologist shall do the following: 4.1.1 Wear personal protective equipment before handling tissue specimens. 4.1.2 There should be a permanent result released and filed and enough slides and blocks stored before disposing of the specimen. 4.1.3 Let the Waste Management officer and his/ her committee dispose of the tissue specimens that complies with the statutory and regulatory requirements of the Environmental Management and Laboratory Safety Committee of the Institution. 4.1.4 The fluid specimens are treated with 10 % bleach or lysol before flushing in the toilet. 4.2 Solid wastes The Histotechnologist shall do the following:  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 2 of 3 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY DISPOSAL OF HISTOPATHOLOGIC Revision 00 WASTES No. Document Control No. Effectivity August 1, SLUHSH-TP-LABHP-013-00 Date 2024 4.2.1 Wear personal protective equipment before handling tissue specimens. 4.2.2 Blades, needles and other sharp disposable objects are discarded into puncture-proof containers labeled as “sharps”. 4.2.3 Trash items soiled with blood or other potentially infectious material should be discarded into a yellow waste bag and labeled as “infectious waste”. 4.2.4 Used glassware and equipment are treated with Lysol, washed with running tap water and sterilized for further use. 4.3 Liquid wastes The Histotechnologist shall do the following: 4.3.1 Wear personal protective equipment before handling liquid waste. 4.3.2 Used Formalin are disposed in the sink with a continuous flow of tap water depending on the volume of formalin being disposed 4.3.3 Used Xylene is stored separately in a tightly capped, amber container labeled as “used xylene for disposal”. It is then disposed of following the standard recommendations for disposal of toxic substances. 4.3.4 Used Alcohols of any dilution are disposed through the sink with continuous flow of tap water. 4.3.5 Used Stains are disposed through the sink with continuous flow of tap water. 4.3.6 Used Paraffin Wax is allowed to harden, placed in a container labeled as “Used paraffin for disposal” and disposed of in a yellow waste bag. 4.0 QUALITY CONTROL 4.1 All histopathology and cytopathology specimens for disposal shall comply with the statutory and regulatory requirements of the Environmental Management and Laboratory Safety Committee of the Institution. 4.2 Storage period must be observed carefully and data must follow the “Data Privacy Act” of 2012. 5.0 REFERENCE VALUES N/A 6.0 PRECAUTIONS All Medical technologists handling laboratory specimens must observe and practice the Universal Precaution, wear prescribed Personal Protective Equipment and good laboratory practices.  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 3 of 3 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY DISPOSAL OF HISTOPATHOLOGIC Revision 00 WASTES No. Document Control No. Effectivity August 1, SLUHSH-TP-LABHP-013-00 Date 2024 Prepared by: Checked by: Sally Cheeka Jayme M. Banjawan,RMT Corazon B. Aloo, RMT Section Head, Histopathology Supervising Medical Technologist Verified by: Dr. Myrna M. Espiritu, MD., FPSP Department Head  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 1 of 3 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY STORAGE OF HISTOPATHOLOGY AND Revision 00 CYTOPATHOLOGY SPECIMENS No. Document Control No. Effectivity August 1, SLUHSH-TP-LABHP-12-00 Date 2024 1.0 POLICY All Histotechnologists shall be oriented and knowledgeable in storing Histopathology and Cytopathology specimens. 2.0 PURPOSE To guide the Histotechnologist in storing Histopathology and Cytopathology specimens for in-patients and out-patients. 3.0 EQUIPMENTS, REAGENTS and SUPPLIES 3.1 Specimen containers 3.2 10% Neutral Buffered Formalin 3.3 Absolute Ethyl Alcohol 3.4 Storage box 3.5 Packing tape 3.6 Labeling tape 3.7 Marker 3.8 Refrigerator 3.9 Histopathology Logbook 3.10 Cytopathology Logbook 4.0 TECHNICAL PROCEDURE 4.1 Tissue Specimen The Histotechnologist shall do the following: 4.1.1 Wear personal protective equipment before handling tissue specimens. 4.1.2 Check if the histopathologic specimen had already been grossed and has an official result before storing. 4.1.3 The tissue specimen container should be properly sealed and labeled with the specimen accession number, patient’s name and the type of specimen submitted. 4.1.4 Place tissue specimens in a sealed storage box. 4.1.5 With a marker, chronologically list the specimen number of the tissue specimens in a clean paper. 4.1.6 Seal the box properly and place the list of specimens in the body of the box. This will be used in easy retrieval of any specimen. 4.1.7 Place specimen boxes to the specimen morgue. Special Consideration: All histopathology specimens for storage shall have an official result before achieving it to the Specimen Morgue.  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 2 of 3 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY STORAGE OF HISTOPATHOLOGY AND Revision 00 CYTOPATHOLOGY SPECIMENS No. Document Control No. Effectivity August 1, SLUHSH-TP-LABHP-12-00 Date 2024 4.2 Fluid Specimens The Histotechnologist shall do the following: 4.2.1 Wear personal protective equipment before handling fluid specimens. 4.2.2 Check if the histopathologic specimen had already been examined and has an official result before storing. 4.2.3 The fluid specimen container should be properly sealed and labeled with the specimen accession number, patient’s name and the type of specimen submitted. 4.2.4 Place fluid specimens in the refrigerator for fluids. 4.2.5 With a marker, chronologically list the specimen number of the tissue specimens in a clean paper. 4.2.6 List the specimens in a clean sheet of paper and place it at the door of the refrigerator. This will be used in easy retrieval of any specimen. 4.0 QUALITY CONTROL 4.1 All histopathology and cytopathology specimens for storage shall have an official result before storing in the designated storage area. 4.2 Storage period must be observed carefully and data must follow the “Data Privacy Act” of 2012. 5.0 REFERENCE VALUES Storage period: Tissue Specimen 1 months Fluid Specimen 7 days 6.0 PRECAUTIONS All Medical technologists handling laboratory specimens must observe and practice the Universal Precaution, wear prescribed Personal Protective Equipment and good laboratory practices.  Saint Louis University-Hospital of the Sacred Heart Department of Pathology and Page No. 3 of 3 Laboratory Medicine HISTOPATHOLOGY AND CYTOPATHOLOGY STORAGE OF HISTOPATHOLOGY AND Revision