Fixation on Histology

Tips from a CAP Inspector – The Importance of Labeling

  
Labeling Secondary ContainersI’ve been involved in preparing for CAP inspections for over 20 years.  Most of those years, I have been a key stakeholder in making sure we were CAP ready, and have even been the “lucky person” who gets to spend the day with the inspector.  I have also had the opportunity to don the hat of CAP inspector for the AP, Cytopathology, and AP/Cyto All Common checklists at an outside institution, and when I’m out on a CAP inspection, I thoroughly inspect reagent labeling and check to make sure the policy/procedure matches the practice in the lab. To better understand why this is a crucial element in the CAP inspection answer the questions below and read my recommendations.
  

QUESTION:​ Do you label your secondary containers?  If so, what do you label them with?  

RECOMMENDATION​:  You should have a mechanism to trace back each reagent in a secondary container to the primary container using reagent name, lot number and expiration date.  Some labs keep paper charts. If that works for you, great!  I recommend finding a way to label ALL your secondary containers with reagent name, lot number, expiration dates and appropriate Global Harmonized System (GHS) labels.  Some of you may ask, why do we need to do this?  Think about those irretrievable patient samples you are working with.  If you experienced a processing or staining failure, how would you begin to troubleshoot?  What if your issue was reagent driven and you had no way to trace your secondary containers back to a primary container?  You would have no crucial information on the lots and expiration dates for the reagents you were using.  If you are like most Histology labs, you have multiple different reagent bottles open at once and they may have different lot numbers and expiration dates. If that is the case, how would you know what lot number you put in the processing bottle or staining container unless your secondary containers are labeled individually?  It is best practice is to be able to trace back every secondary container to its original primary container.  

QUESTION:​ Do you have a policy for labeling reagents?  If so, do you follow your policy?  ​

RECOMMENDATION:​ I would recommend that you verify your department has a labeling policy and that your practice matches your policy.  Bravo if you have a policy for reagent labeling, but make sure your practice matches your policy.  CAP inspectors are very careful to observe current lab practice and compare them to your written policy. 

If you answered no to either of these questions and you are being inspected, it is highly likely you have just earned yourself a CAP deficiency. I hope this information gives you something to think about and I hope it helps as you prepare for your next inspection! 



Written by: Nicole Leon, HTL(ASCP)


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