As histology professionals, we have several roles we play in the laboratory, but one of the more challenging tasks can be that of troubleshooting. Histology professionals are often presented with slides from a pathologist that are less than exceptional quality with very little supporting information. I like to equate this task to solving crimes as a detective: The Tissue Detective.
The challenge can be daunting, but if you approach the issue like a detective, it can make the process much more efficient. There are several steps to solving a crime as a detective that translate to troubleshooting quality issues in the laboratory. Let’s look at how similar the two jobs really are!
Define the “Crime”!
The first step in this process is to make sure you have a real understanding of what the quality issue is. A pathologist will often say, “The quality of the stain is poor today.” With no other feedback. And from this we are expected to determine the issue. This statement would equate to, “Someone stole something” if we were playing the detective in a police drama. There is so much more we need to know before we start the next part of the investigation. Push your pathologist for more details…here are some questions to ask: Is the nuclear staining good? How about the cytoplasmic staining? Does the sample demonstrate good architectural integrity? Are there issues with the nuclear detail? How is the microtomy? Could the section be too thick? Ask as many questions as necessary to narrow down your “suspect” pool.
Narrow Down and Investigate the “Crime Scene”
Once we have more information on what the quality issue is, we can start the next step: Investigate the “crime scene”. Just like true crime investigation, we may suspect the crime scene is one location only to find that it was somewhere totally different! In most quality issues, there will be a few potential areas of interest you will have to evaluate. Easy ones (areas of interest) that everyone knows could be processing and staining. Other areas that can cause issues that are more difficult to pin down include the clinic where the sample was obtained, grossing, microtomy and embedding. We often start with processing, which isn’t necessarily bad, but don’t forget to consider all aspects of the process if you find that processing is fine.
Review the “Crime Scene”
Based on the artifact, you will be able to narrow down potential scenes of the “crime”. Review each area of suspected fallacy for clues. Have there been cases of recurring artifacts? If so, review each step at each “crime scene”. In the processor, there are a lot of clues to look for to aid in identifying potential suspects. If you are looking at processing, some things to ask would be: What processor was used for the problem specimen(s)? Were there multiple events, and if so, were all the problem cases on the same processor? What is the quality of the reagents? Has the processor been serviced recently? Has the issue been a problem in the past? The more questions you ask, the more you will narrow down your suspect pool. Don’t always assume processing is the issue though. I worked with a customer that was convinced their processing was the issue, but it turned out to be a fixation issue caused by poor quality formalin.
Take note of any potential cause and the clues that point to that cause. By noting the clues, you will be able to come up with the list of suspects, which leads us to the next step.
The Usual Suspects
Once you have determined the “crime” and have an idea of where the transgression was committed, it is time to round up the suspects. Always list the potential sources for the artifact, and then work your way through the list, just like a detective. Look for alibis that will help eliminate a suspect from the list (ex. All the reagents on the Stainer are new, so we can rule out “Not Changing the Stainer Correctly” from the suspect list.) You must rule out the suspects one at a time. And, just like a detective, avoid premature elimination or targeting of suspects in your suspect pool. Keep an open mind. Use deductive reasoning to help in your assessment of the list of potential artifact contributors. Consider that you may pre-determine in your assessment that the lab assistant used the wrong reagent because it has occurred before. By making that your primary suspect without further research can result in you missing that your tissue processor rotary valve is malfunctioning and allowing your reagents to mix in the processing cavity. It is important to rule out ALL potential suspects before moving on the proving the cause of your artifact.
Proof
There are a few ways to rule out or rule in suspects, and all involve obtaining proof. You need to be able to definitively show that you have identified the root cause of the quality issue, and from there you look for supporting clues. What would be supporting clues, you ask? Anything that points to the suspect as the criminal. Once you have determined the suspect, do testing to prove you are correct. Fix the issue, then do testing on non-patient tissue to ensure you have identified the right cause of error. If you fail to follow this step, it is very likely that the quality issue will resurface again.
Court
Just like our judicial system, you will have to present your case to the authorities. This would be presenting what you have determined to be the cause to your pathologist or director. Be sure to show the work you did to determine what the root cause really is. Then, ask for feedback. Does the pathologist agree? If so, it’s time to send the suspect to jail!
Jail
Once you have gone through the process and resolved the quality issue, it’s time to jail the offender. What do I mean by this? I mean eliminate the cause from the lab. If you have a recurrence after removing what you thought was the issue, then you’ll need to start the process over again.
Conclusion
Troubleshooting quality issues can often take time and resources away from the lab, but not doing a thorough job working through the root cause analysis (solving the crime) can create even more issues down the line. Take the time to really look at all the potential sources for quality errors. Start at the beginning and work your way all the way to the end of the sample processing process. By looking at all potential sources for errors, you will eventually catch the culprit and bring him to justice!
Written By: Michelle Bell, HT (ASCP)
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