St. Dominic-Jackson Memorial Hospital
Title: Collection of Pathology and Cytology Specimens
Date Authenticated By Policy
Management Committee:
Number:
Document Type: Guideline
Approved By: James Almas, MD
Owner/Author: Wanda Wince
Histology Manager
Date Approved: 6/20/2002/0710/14
Applies To: St. Dominic Hospital
Inception Date: 6/21/2002
Category: Clinical
Date(s) Reviewed* or Revised**: 07/08/2014
*Reviewed but not change
**Revised for details
POLICY:
St. Dominic Reference Laboratory accepts anatomical specimens and cytology specimens
for analysis only when handled and properly labeled per our regulatory and hospital
policies. Requisitions must contain all required information.
Internally, formal Incident Reports will be filed for mislabeled or inappropriate
demographic labeling. Quality measurement reports will be discussed with external
clients when processes are not being performed.
Analysis of specimens cannot begin if clinical information is missing, illegible, or
incomplete.
10% formalin specimen containers may be ordered from the supply requisition sheet
DEMOGRAPHIC LABELING REQUIREMENTS:
Specimen container label and the requisition are to be properly
labeled and legible with the following:
Patient’s full name
Identification number (medical record number and account number where
applicable, is required)
3. Date of specimen collection
4. Employee number of collector where applicable
1.
2.
CLINICAL INFORMATION ON REQUISTION REQUIREMENTS:
This information is required for appropriate diagnosis and is also
required by regulatory agencies:
1. Operative surgeon and attending physician’s name ( first and last)
2. Tissue container must be numbered if more than one container is being sent
from same patient
3. Body source and description of specimen
3.1 This must be descriptive; example is “discolored and irregular nevus from
upper right forearm”
3. Clinical data
4. Operative diagnosis
5. Prior tissue diagnosis
TRANSPORT OF TISSUE SPECIMENS
All routine tissues are to be placed in a labeled 10% formalin specimen container. These
containers must be properly labeled with complete patient information. Tissues requiring
frozen sections must be delivered to the Histology lab immediately for processing.
1. Tissues sent directly from the Surgery Suites via the Dumbwaiter will be taken off by
Histology personnel
2. Tissues from Endoscopy, L/D Surgery, and Ambulatory Surgery are hand delivered
directly to the Histology Lab. They are logged into a manual Log Sheet with time of
delivery. They are placed in the specimen box with the Pathology Requisition form
completed with all of the pertinent information for the patient. After hours, the
specimens are delivered to Client Services who handles the receipt.
3. Tissues from clients located in the SDH Medical Towers are picked up by a
Laboratory courier and delivered to Client Services for clerical registration processing
before delivery to the Histology Lab.
5. Tissues or Cytology specimens from remote clients will be picked by up by
Laboratory courier, delivered to Client Services for clerical registration processing before
delivery to the Histology Lab.
TRANSPORT OF CYTOLOGY SPECIMENS
The specimens should be labeled as noted above for tissue specimens. Specimens
received after 3:30 p.m. are processed the next day.
1. All sputum samples are to be collected as for culture (early morning deep cough
specimen). Immediately after collection, send fresh specimen to the Histology Lab.
2. Bronchial wash specimens should be collected in a sterile container with only saline
added.
3. Pap smears should be collected in Thin prep vials.
4. Bronchial brush specimens should be placed in Cytolyt Fixative (provided by
Cytology department.)
5. All urine specimens should be collected in a sterile container and sent fresh to the
Laboratory immediately after collection.
6. All body cavity fluids (pericardial, peritoneal, pleural, joint cyst fluids, CSF) should
be brought immediately in an unfixed state to the laboratory. No fixative is added.
Fixatives for Cytology and/or Pathology:
Fixatives used in Cytology to prevent cellular degeneration are as follows:
Cytolyt Solution
TYPE OF SPECIMEN
Fine needle aspirations
Breast Secretions
Breast Smears (slide)
Body cavity fluids
(pericardial, peritoneal,
pleural, joint cyst fluids, urine
and CSF)
Bronchial brush
Gastric brush
Bronchial Wash
Esophageal Wash
Frozen Section
Renal Biopsy
Muscle Biopsy
Sputum
Surgical Tissue
GYN Smears
PREFERRED FIXATIVE
Secretions discharged onto
slides. Put in 95% alcohol.
Use pap kits - fixative
included.
Preferred fresh (unmixed).
Bring to the Laboratory
immediately.
ALTERNATE
FIXATIVE
Cytolyt
Thin Prep
Protocol
Refrigerate
Brush in Cytolyt solution.
Bring fresh to Laboratory
immediately.
FRESH TISSUE ONLY
Fresh tissue
Fresh Tissue
Bring fresh specimen to
Lab immediately.
Formalin
Thin prep protocol.
Reference: Personal policies of St.Dominic Anatomic Lab. Jackson, MS 2014
Refrigerate
Refrigerate
Thin Prep
Protocol