Sync template from atomicqms-style deployment
This commit is contained in:
0
SOPs/Autopsy/.gitkeep
Normal file
0
SOPs/Autopsy/.gitkeep
Normal file
0
SOPs/Cytology/.gitkeep
Normal file
0
SOPs/Cytology/.gitkeep
Normal file
112
SOPs/General/SOP-001-Document-Control.md
Normal file
112
SOPs/General/SOP-001-Document-Control.md
Normal file
@@ -0,0 +1,112 @@
|
||||
# Standard Operating Procedure: Document Control
|
||||
|
||||
| Document ID | SOP-001 |
|
||||
|-------------|---------|
|
||||
| Title | Document Control |
|
||||
| Revision | 1.0 |
|
||||
| Effective Date | [DATE] |
|
||||
| Author | [AUTHOR] |
|
||||
| Approved By | [APPROVER] |
|
||||
| Department | Quality Assurance |
|
||||
|
||||
---
|
||||
|
||||
## 1. Purpose
|
||||
|
||||
To establish a procedure for the creation, review, approval, distribution, and control of documents within the Quality Management System.
|
||||
|
||||
## 2. Scope
|
||||
|
||||
This procedure applies to all controlled documents including:
|
||||
- Policies
|
||||
- Standard Operating Procedures (SOPs)
|
||||
- Work Instructions
|
||||
- Forms and Templates
|
||||
- Specifications
|
||||
- External documents of external origin
|
||||
|
||||
## 3. Responsibilities
|
||||
|
||||
### 3.1 Document Owner
|
||||
- Responsible for document content and accuracy
|
||||
- Initiates document creation and revision
|
||||
- Ensures periodic review is performed
|
||||
|
||||
### 3.2 Quality Assurance
|
||||
- Maintains the document control system
|
||||
- Assigns document numbers
|
||||
- Manages document distribution
|
||||
- Archives obsolete documents
|
||||
|
||||
### 3.3 Approvers
|
||||
- Review and approve documents before release
|
||||
- Ensure documents are adequate for intended purpose
|
||||
|
||||
## 4. Procedure
|
||||
|
||||
### 4.1 Document Creation
|
||||
|
||||
1. Identify the need for a new document
|
||||
2. Request document number from Quality Assurance
|
||||
3. Draft document using appropriate template
|
||||
4. Include all required header information
|
||||
5. Submit for review and approval
|
||||
|
||||
### 4.2 Document Review and Approval
|
||||
|
||||
1. Route document to appropriate reviewers
|
||||
2. Reviewers provide comments within 5 business days
|
||||
3. Author addresses all comments
|
||||
4. Final approval by designated approver
|
||||
5. Quality Assurance releases document
|
||||
|
||||
### 4.3 Document Numbering
|
||||
|
||||
Documents shall be numbered according to the following convention:
|
||||
|
||||
| Type | Prefix | Example |
|
||||
|------|--------|---------|
|
||||
| Policy | POL | POL-001 |
|
||||
| SOP | SOP | SOP-001 |
|
||||
| Work Instruction | WI | WI-001 |
|
||||
| Form | FRM | FRM-001 |
|
||||
|
||||
### 4.4 Revision Control
|
||||
|
||||
1. All changes require documented justification
|
||||
2. Changes follow same review/approval process as new documents
|
||||
3. Revision number increments with each approved change
|
||||
4. Revision history maintained in document footer
|
||||
|
||||
### 4.5 Document Distribution
|
||||
|
||||
1. Current versions available in document control system
|
||||
2. Obsolete versions marked and archived
|
||||
3. Training on new/revised documents as needed
|
||||
|
||||
### 4.6 Periodic Review
|
||||
|
||||
1. Documents reviewed at least every 2 years
|
||||
2. Review documented even if no changes made
|
||||
3. Reviews may result in revision or reaffirmation
|
||||
|
||||
## 5. Related Documents
|
||||
|
||||
- FRM-001 Document Change Request Form
|
||||
- FRM-002 Document Review Record
|
||||
|
||||
## 6. Definitions
|
||||
|
||||
| Term | Definition |
|
||||
|------|------------|
|
||||
| Controlled Document | Document managed under document control system |
|
||||
| Obsolete | Document no longer valid for use |
|
||||
| Revision | Updated version of a document |
|
||||
|
||||
---
|
||||
|
||||
## Revision History
|
||||
|
||||
| Rev | Date | Description | Author |
|
||||
|-----|------|-------------|--------|
|
||||
| 1.0 | [DATE] | Initial release | [AUTHOR] |
|
||||
134
SOPs/General/SOP-002-CAPA.md
Normal file
134
SOPs/General/SOP-002-CAPA.md
Normal file
@@ -0,0 +1,134 @@
|
||||
# Standard Operating Procedure: Corrective and Preventive Action (CAPA)
|
||||
|
||||
| Document ID | SOP-002 |
|
||||
|-------------|---------|
|
||||
| Title | Corrective and Preventive Action |
|
||||
| Revision | 1.0 |
|
||||
| Effective Date | [DATE] |
|
||||
| Author | [AUTHOR] |
|
||||
| Approved By | [APPROVER] |
|
||||
| Department | Quality Assurance |
|
||||
|
||||
---
|
||||
|
||||
## 1. Purpose
|
||||
|
||||
To establish a systematic process for identifying, investigating, correcting, and preventing nonconformities and potential nonconformities.
|
||||
|
||||
## 2. Scope
|
||||
|
||||
This procedure applies to:
|
||||
- Product and process nonconformities
|
||||
- Customer complaints
|
||||
- Audit findings
|
||||
- Process deviations
|
||||
- Potential nonconformities identified through risk analysis
|
||||
|
||||
## 3. Definitions
|
||||
|
||||
| Term | Definition |
|
||||
|------|------------|
|
||||
| Corrective Action | Action to eliminate the cause of a detected nonconformity |
|
||||
| Preventive Action | Action to eliminate the cause of a potential nonconformity |
|
||||
| Root Cause | Fundamental reason for a nonconformity |
|
||||
| Effectiveness Check | Verification that implemented actions achieved desired results |
|
||||
|
||||
## 4. Responsibilities
|
||||
|
||||
### 4.1 CAPA Owner
|
||||
- Investigates the issue
|
||||
- Identifies root cause
|
||||
- Develops and implements corrective/preventive actions
|
||||
- Verifies effectiveness
|
||||
|
||||
### 4.2 Quality Assurance
|
||||
- Manages CAPA system
|
||||
- Assigns CAPA numbers
|
||||
- Tracks CAPA status
|
||||
- Reviews and approves CAPAs
|
||||
- Reports CAPA metrics to management
|
||||
|
||||
### 4.3 Management
|
||||
- Provides resources for CAPA implementation
|
||||
- Reviews CAPA trends
|
||||
- Ensures timely closure
|
||||
|
||||
## 5. Procedure
|
||||
|
||||
### 5.1 CAPA Initiation
|
||||
|
||||
1. Identify nonconformity or potential nonconformity
|
||||
2. Document issue on CAPA Form (FRM-003)
|
||||
3. Classify severity and priority
|
||||
4. Assign CAPA owner
|
||||
|
||||
### 5.2 Investigation
|
||||
|
||||
1. Gather relevant data and evidence
|
||||
2. Interview personnel involved
|
||||
3. Review related documents and records
|
||||
4. Use appropriate investigation tools:
|
||||
- 5 Whys
|
||||
- Fishbone Diagram
|
||||
- Failure Mode Analysis
|
||||
|
||||
### 5.3 Root Cause Analysis
|
||||
|
||||
1. Identify potential root causes
|
||||
2. Verify root cause through evidence
|
||||
3. Document root cause determination
|
||||
4. Consider systemic implications
|
||||
|
||||
### 5.4 Action Development
|
||||
|
||||
1. Develop corrective/preventive actions
|
||||
2. Assign responsibilities and due dates
|
||||
3. Assess actions for:
|
||||
- Appropriateness to problem severity
|
||||
- Impact on other processes
|
||||
- Resource requirements
|
||||
|
||||
### 5.5 Implementation
|
||||
|
||||
1. Execute approved actions
|
||||
2. Document implementation evidence
|
||||
3. Update affected documents/processes
|
||||
4. Provide training as needed
|
||||
|
||||
### 5.6 Effectiveness Verification
|
||||
|
||||
1. Define effectiveness criteria
|
||||
2. Allow sufficient time for actions to take effect
|
||||
3. Collect and analyze data
|
||||
4. Document verification results
|
||||
5. If ineffective, reopen CAPA for further action
|
||||
|
||||
### 5.7 Closure
|
||||
|
||||
1. Review all CAPA documentation
|
||||
2. Verify all actions completed
|
||||
3. Confirm effectiveness verified
|
||||
4. Obtain approval for closure
|
||||
|
||||
## 6. CAPA Metrics
|
||||
|
||||
Quality Assurance shall track and report:
|
||||
- Number of open CAPAs
|
||||
- CAPA aging
|
||||
- On-time closure rate
|
||||
- Effectiveness rate
|
||||
- CAPAs by category/source
|
||||
|
||||
## 7. Related Documents
|
||||
|
||||
- FRM-003 CAPA Form
|
||||
- SOP-003 Nonconforming Product Control
|
||||
- SOP-004 Customer Complaints
|
||||
|
||||
---
|
||||
|
||||
## Revision History
|
||||
|
||||
| Rev | Date | Description | Author |
|
||||
|-----|------|-------------|--------|
|
||||
| 1.0 | [DATE] | Initial release | [AUTHOR] |
|
||||
123
SOPs/General/SOP-003-Training.md
Normal file
123
SOPs/General/SOP-003-Training.md
Normal file
@@ -0,0 +1,123 @@
|
||||
# Standard Operating Procedure: Training and Competence
|
||||
|
||||
| Document ID | SOP-003 |
|
||||
|-------------|---------|
|
||||
| Title | Training and Competence |
|
||||
| Revision | 1.0 |
|
||||
| Effective Date | [DATE] |
|
||||
| Author | [AUTHOR] |
|
||||
| Approved By | [APPROVER] |
|
||||
| Department | Human Resources / Quality |
|
||||
|
||||
---
|
||||
|
||||
## 1. Purpose
|
||||
|
||||
To ensure personnel performing work affecting product quality are competent based on appropriate education, training, skills, and experience.
|
||||
|
||||
## 2. Scope
|
||||
|
||||
This procedure applies to:
|
||||
- All employees performing quality-affecting activities
|
||||
- Contractors and temporary personnel
|
||||
- Personnel requiring GxP training
|
||||
|
||||
## 3. Responsibilities
|
||||
|
||||
### 3.1 Supervisors/Managers
|
||||
- Identify training needs for their personnel
|
||||
- Ensure training is completed before performing tasks
|
||||
- Evaluate competence of personnel
|
||||
- Maintain department training records
|
||||
|
||||
### 3.2 Human Resources
|
||||
- Coordinate training programs
|
||||
- Maintain central training database
|
||||
- Track training compliance
|
||||
- Archive training records
|
||||
|
||||
### 3.3 Quality Assurance
|
||||
- Develop QMS-related training
|
||||
- Approve training curricula for GxP activities
|
||||
- Audit training compliance
|
||||
|
||||
### 3.4 Employees
|
||||
- Complete assigned training on time
|
||||
- Maintain current qualifications
|
||||
- Report training needs to supervisor
|
||||
|
||||
## 4. Procedure
|
||||
|
||||
### 4.1 Training Needs Assessment
|
||||
|
||||
1. Identify competence requirements for each role
|
||||
2. Document requirements in job descriptions
|
||||
3. Assess current competence of personnel
|
||||
4. Identify training gaps
|
||||
|
||||
### 4.2 Training Curriculum Development
|
||||
|
||||
1. Define learning objectives
|
||||
2. Develop training materials
|
||||
3. Identify delivery method:
|
||||
- Classroom
|
||||
- On-the-job
|
||||
- Self-study
|
||||
- Computer-based
|
||||
4. Define assessment criteria
|
||||
5. Obtain approval from Quality (for GxP training)
|
||||
|
||||
### 4.3 Training Delivery
|
||||
|
||||
1. Schedule training session
|
||||
2. Document attendance
|
||||
3. Deliver training per curriculum
|
||||
4. Assess comprehension through:
|
||||
- Written test (minimum 80% passing)
|
||||
- Practical demonstration
|
||||
- Supervisor observation
|
||||
|
||||
### 4.4 Training Documentation
|
||||
|
||||
Training records shall include:
|
||||
- Employee name and ID
|
||||
- Training title and date
|
||||
- Trainer name and qualifications
|
||||
- Assessment results
|
||||
- Signatures
|
||||
|
||||
### 4.5 Retraining Requirements
|
||||
|
||||
Retraining is required when:
|
||||
- Significant document revisions occur
|
||||
- Performance deficiencies identified
|
||||
- Extended absence from job function
|
||||
- Periodic requalification due
|
||||
|
||||
### 4.6 New Employee Orientation
|
||||
|
||||
All new employees shall complete:
|
||||
1. Company orientation
|
||||
2. Quality system overview
|
||||
3. Job-specific training
|
||||
4. SOP read and understand for applicable procedures
|
||||
|
||||
## 5. Training Records Retention
|
||||
|
||||
- Training records maintained for duration of employment
|
||||
- Records retained 3 years after employee departure
|
||||
- Records available for regulatory inspection
|
||||
|
||||
## 6. Related Documents
|
||||
|
||||
- FRM-004 Training Record Form
|
||||
- FRM-005 Training Assessment Form
|
||||
- Job Descriptions
|
||||
|
||||
---
|
||||
|
||||
## Revision History
|
||||
|
||||
| Rev | Date | Description | Author |
|
||||
|-----|------|-------------|--------|
|
||||
| 1.0 | [DATE] | Initial release | [AUTHOR] |
|
||||
136
SOPs/General/SOP-004-Internal-Audit.md
Normal file
136
SOPs/General/SOP-004-Internal-Audit.md
Normal file
@@ -0,0 +1,136 @@
|
||||
# Standard Operating Procedure: Internal Audit
|
||||
|
||||
| Document ID | SOP-004 |
|
||||
|-------------|---------|
|
||||
| Title | Internal Audit |
|
||||
| Revision | 1.0 |
|
||||
| Effective Date | [DATE] |
|
||||
| Author | [AUTHOR] |
|
||||
| Approved By | [APPROVER] |
|
||||
| Department | Quality Assurance |
|
||||
|
||||
---
|
||||
|
||||
## 1. Purpose
|
||||
|
||||
To establish a systematic approach for conducting internal audits to verify the effectiveness of the Quality Management System.
|
||||
|
||||
## 2. Scope
|
||||
|
||||
This procedure covers:
|
||||
- QMS process audits
|
||||
- Compliance audits
|
||||
- Product audits
|
||||
- System audits
|
||||
|
||||
## 3. Definitions
|
||||
|
||||
| Term | Definition |
|
||||
|------|------------|
|
||||
| Audit | Systematic, independent examination to determine conformance |
|
||||
| Auditor | Person qualified to perform audits |
|
||||
| Finding | Observation of conformance or nonconformance |
|
||||
| Observation | Noted item not rising to level of finding |
|
||||
|
||||
## 4. Responsibilities
|
||||
|
||||
### 4.1 Lead Auditor
|
||||
- Plans and schedules audits
|
||||
- Prepares audit checklists
|
||||
- Conducts audit activities
|
||||
- Reports audit findings
|
||||
|
||||
### 4.2 Quality Manager
|
||||
- Maintains audit program
|
||||
- Qualifies auditors
|
||||
- Reviews audit reports
|
||||
- Reports to management
|
||||
|
||||
### 4.3 Auditee
|
||||
- Provides access to areas/records
|
||||
- Responds to findings
|
||||
- Implements corrective actions
|
||||
|
||||
## 5. Procedure
|
||||
|
||||
### 5.1 Annual Audit Schedule
|
||||
|
||||
1. Develop annual audit schedule considering:
|
||||
- Previous audit results
|
||||
- Process criticality
|
||||
- Regulatory requirements
|
||||
- Changes to processes
|
||||
2. Ensure all QMS processes audited at least annually
|
||||
3. Obtain management approval
|
||||
4. Communicate schedule to affected areas
|
||||
|
||||
### 5.2 Auditor Qualification
|
||||
|
||||
Auditors shall:
|
||||
- Complete auditor training course
|
||||
- Conduct at least 2 audits under supervision
|
||||
- Be independent of area being audited
|
||||
- Maintain competence through ongoing audits
|
||||
|
||||
### 5.3 Audit Preparation
|
||||
|
||||
1. Review applicable procedures and standards
|
||||
2. Review previous audit reports
|
||||
3. Prepare audit checklist
|
||||
4. Notify auditee of audit scope and schedule
|
||||
5. Confirm auditor availability
|
||||
|
||||
### 5.4 Conducting the Audit
|
||||
|
||||
1. Hold opening meeting with auditee
|
||||
2. Execute audit checklist
|
||||
3. Gather objective evidence:
|
||||
- Document review
|
||||
- Personnel interviews
|
||||
- Process observation
|
||||
4. Document findings with evidence
|
||||
5. Classify findings:
|
||||
- Major Nonconformance
|
||||
- Minor Nonconformance
|
||||
- Observation
|
||||
6. Hold closing meeting
|
||||
|
||||
### 5.5 Audit Reporting
|
||||
|
||||
1. Complete audit report within 5 business days
|
||||
2. Report shall include:
|
||||
- Audit scope and criteria
|
||||
- Personnel interviewed
|
||||
- Findings with evidence
|
||||
- Recommendations
|
||||
3. Distribute report to auditee and management
|
||||
|
||||
### 5.6 Finding Resolution
|
||||
|
||||
1. Auditee responds with corrective action plan within 10 business days
|
||||
2. Quality reviews and approves plan
|
||||
3. Auditee implements corrective actions
|
||||
4. Auditor verifies effectiveness
|
||||
5. Close finding upon verification
|
||||
|
||||
## 6. Audit Records
|
||||
|
||||
Maintain for 5 years:
|
||||
- Audit schedules
|
||||
- Checklists
|
||||
- Reports
|
||||
- Corrective action records
|
||||
|
||||
## 7. Related Documents
|
||||
|
||||
- FRM-006 Audit Checklist Template
|
||||
- FRM-007 Audit Report Template
|
||||
- SOP-002 CAPA
|
||||
|
||||
---
|
||||
|
||||
## Revision History
|
||||
|
||||
| Rev | Date | Description | Author |
|
||||
|-----|------|-------------|--------|
|
||||
| 1.0 | [DATE] | Initial release | [AUTHOR] |
|
||||
114
SOPs/General/SOP-005-Management-Review.md
Normal file
114
SOPs/General/SOP-005-Management-Review.md
Normal file
@@ -0,0 +1,114 @@
|
||||
# Standard Operating Procedure: Management Review
|
||||
|
||||
| Document ID | SOP-005 |
|
||||
|-------------|---------|
|
||||
| Title | Management Review |
|
||||
| Revision | 1.0 |
|
||||
| Effective Date | [DATE] |
|
||||
| Author | [AUTHOR] |
|
||||
| Approved By | [APPROVER] |
|
||||
| Department | Quality Assurance |
|
||||
|
||||
---
|
||||
|
||||
## 1. Purpose
|
||||
|
||||
To ensure top management reviews the Quality Management System at planned intervals to ensure its continuing suitability, adequacy, and effectiveness.
|
||||
|
||||
## 2. Scope
|
||||
|
||||
This procedure applies to the periodic management review of the QMS, including all processes and quality objectives.
|
||||
|
||||
## 3. Frequency
|
||||
|
||||
Management reviews shall be conducted:
|
||||
- At least annually
|
||||
- More frequently if significant changes occur
|
||||
- As needed based on quality performance
|
||||
|
||||
## 4. Responsibilities
|
||||
|
||||
### 4.1 Quality Manager
|
||||
- Prepares management review agenda and materials
|
||||
- Facilitates the meeting
|
||||
- Documents meeting minutes and action items
|
||||
- Tracks completion of action items
|
||||
|
||||
### 4.2 Top Management
|
||||
- Attends management review meetings
|
||||
- Reviews QMS performance data
|
||||
- Makes decisions on QMS improvements
|
||||
- Allocates resources as needed
|
||||
|
||||
### 4.3 Department Managers
|
||||
- Provides input data for their areas
|
||||
- Attends management review
|
||||
- Implements assigned action items
|
||||
|
||||
## 5. Management Review Inputs
|
||||
|
||||
The following shall be considered:
|
||||
|
||||
### 5.1 Actions from Previous Reviews
|
||||
- Status of action items
|
||||
- Effectiveness of implemented actions
|
||||
|
||||
### 5.2 Changes in Context
|
||||
- Internal changes (organization, resources)
|
||||
- External changes (regulations, market)
|
||||
|
||||
### 5.3 QMS Performance
|
||||
- Customer satisfaction and feedback
|
||||
- Quality objectives achievement
|
||||
- Process performance metrics
|
||||
- Nonconformities and corrective actions
|
||||
- Audit results
|
||||
- Supplier performance
|
||||
|
||||
### 5.4 Resource Adequacy
|
||||
- Personnel
|
||||
- Infrastructure
|
||||
- Work environment
|
||||
|
||||
### 5.5 Risk and Opportunities
|
||||
- Risk assessment results
|
||||
- Effectiveness of risk controls
|
||||
- New opportunities identified
|
||||
|
||||
### 5.6 Improvement Opportunities
|
||||
- Process improvements
|
||||
- Product improvements
|
||||
- QMS enhancements
|
||||
|
||||
## 6. Management Review Outputs
|
||||
|
||||
Decisions and actions related to:
|
||||
- Improvement of QMS and processes
|
||||
- Product improvement
|
||||
- Resource needs
|
||||
- Changes to quality policy or objectives
|
||||
|
||||
## 7. Documentation
|
||||
|
||||
### 7.1 Meeting Minutes
|
||||
- Date and attendees
|
||||
- Items discussed
|
||||
- Decisions made
|
||||
- Action items with owners and due dates
|
||||
|
||||
### 7.2 Record Retention
|
||||
- Management review records retained for 5 years
|
||||
- Available for regulatory inspection
|
||||
|
||||
## 8. Related Documents
|
||||
|
||||
- FRM-008 Management Review Agenda Template
|
||||
- FRM-009 Management Review Minutes Template
|
||||
|
||||
---
|
||||
|
||||
## Revision History
|
||||
|
||||
| Rev | Date | Description | Author |
|
||||
|-----|------|-------------|--------|
|
||||
| 1.0 | [DATE] | Initial release | [AUTHOR] |
|
||||
0
SOPs/Histology/.gitkeep
Normal file
0
SOPs/Histology/.gitkeep
Normal file
0
SOPs/Molecular/.gitkeep
Normal file
0
SOPs/Molecular/.gitkeep
Normal file
1
SOPs/Safety/.gitkeep
Normal file
1
SOPs/Safety/.gitkeep
Normal file
@@ -0,0 +1 @@
|
||||
# Placeholder
|
||||
0
SOPs/Specimen-Handling/.gitkeep
Normal file
0
SOPs/Specimen-Handling/.gitkeep
Normal file
293
SOPs/Specimen-Handling/SOP-PATH-001-Specimen-Accessioning.md
Normal file
293
SOPs/Specimen-Handling/SOP-PATH-001-Specimen-Accessioning.md
Normal file
@@ -0,0 +1,293 @@
|
||||
# Standard Operating Procedure: Pathology Specimen Accessioning
|
||||
|
||||
| Document ID | SOP-PATH-001 |
|
||||
|-------------|-------------|
|
||||
| Title | Pathology Specimen Accessioning and Processing |
|
||||
| Revision | 1.0 |
|
||||
| Effective Date | [DATE] |
|
||||
| Author | [AUTHOR] |
|
||||
| Approved By | [APPROVER] |
|
||||
| Department | Anatomic Pathology |
|
||||
|
||||
---
|
||||
|
||||
## 1. Purpose
|
||||
|
||||
To establish standardized procedures for the receipt, accessioning, and initial processing of pathology specimens to ensure proper identification, optimal preservation, and regulatory compliance.
|
||||
|
||||
## 2. Scope
|
||||
|
||||
This procedure applies to all anatomic pathology specimens including:
|
||||
- Surgical pathology specimens
|
||||
- Cytology specimens
|
||||
- Skin biopsies
|
||||
- Bone marrow biopsies
|
||||
- Autopsy specimens
|
||||
|
||||
## 3. Responsibilities
|
||||
|
||||
### 3.1 Accessioning Staff
|
||||
- Receive and log specimens
|
||||
- Verify specimen-requisition match
|
||||
- Assign case numbers
|
||||
- Distribute to appropriate areas
|
||||
|
||||
### 3.2 Histology Technician
|
||||
- Process tissue specimens
|
||||
- Embed and section specimens
|
||||
- Prepare slides for pathologist review
|
||||
|
||||
### 3.3 Pathologist
|
||||
- Perform gross examination
|
||||
- Dictate gross description
|
||||
- Review slides and render diagnosis
|
||||
|
||||
### 3.4 Laboratory Director
|
||||
- Ensure quality standards
|
||||
- Review policies and procedures
|
||||
- Oversee accreditation compliance
|
||||
|
||||
## 4. Definitions
|
||||
|
||||
| Term | Definition |
|
||||
|------|------------|
|
||||
| Accession | Process of receiving and logging specimens |
|
||||
| Fixation | Chemical preservation of tissue |
|
||||
| Grossing | Macroscopic examination and description |
|
||||
| Cassette | Container for tissue during processing |
|
||||
| Block | Paraffin-embedded tissue section |
|
||||
|
||||
## 5. Equipment and Materials
|
||||
|
||||
- Specimen containers (various sizes)
|
||||
- 10% neutral buffered formalin (NBF)
|
||||
- Requisition forms
|
||||
- Barcoded labels
|
||||
- Cassettes
|
||||
- Tissue processor
|
||||
- Embedding station
|
||||
- Microtome
|
||||
- Slides and coverslips
|
||||
|
||||
## 6. Procedure
|
||||
|
||||
### 6.1 Specimen Receipt
|
||||
|
||||
#### 6.1.1 Verification at Receipt
|
||||
Upon receiving each specimen:
|
||||
- [ ] Container properly labeled with patient identifiers
|
||||
- [ ] Requisition form accompanies specimen
|
||||
- [ ] Container intact without leakage
|
||||
- [ ] Specimen in appropriate fixative (if applicable)
|
||||
- [ ] Time of collection documented
|
||||
|
||||
#### 6.1.2 Label Verification
|
||||
|
||||
**Minimum required on container:**
|
||||
| Element | Present |
|
||||
|---------|---------|
|
||||
| Patient name | ☐ |
|
||||
| Second identifier (MRN, DOB) | ☐ |
|
||||
| Specimen type/site | ☐ |
|
||||
| Date of collection | ☐ |
|
||||
| Collector identification | ☐ |
|
||||
|
||||
**Requisition must include:**
|
||||
| Element | Present |
|
||||
|---------|---------|
|
||||
| Patient name and identifiers | ☐ |
|
||||
| Ordering physician | ☐ |
|
||||
| Specimen source/site | ☐ |
|
||||
| Clinical history | ☐ |
|
||||
| Date/time of collection | ☐ |
|
||||
| Date/time of receipt in lab | ☐ |
|
||||
|
||||
#### 6.1.3 Discrepancy Handling
|
||||
|
||||
If discrepancies exist:
|
||||
1. Do NOT accessioned until resolved
|
||||
2. Contact ordering physician/collector
|
||||
3. Document resolution in LIS
|
||||
4. Complete discrepancy log
|
||||
|
||||
| Discrepancy Type | Required Action |
|
||||
|------------------|-----------------|
|
||||
| Name mismatch | Contact collector, do not process |
|
||||
| Missing information | Request completion before accessioning |
|
||||
| Damaged container | Document, assess specimen integrity |
|
||||
| No requisition | Hold specimen, request requisition |
|
||||
| Unlabeled specimen | Do not process until properly labeled |
|
||||
|
||||
### 6.2 Accessioning
|
||||
|
||||
#### 6.2.1 Case Number Assignment
|
||||
1. Log specimen into Laboratory Information System (LIS)
|
||||
2. System assigns unique accession number
|
||||
3. Format: [Year]-S[Sequential#] (e.g., 2024-S12345)
|
||||
4. Generate specimen labels
|
||||
|
||||
#### 6.2.2 Labeling
|
||||
1. Apply barcoded labels to:
|
||||
- Specimen container
|
||||
- Cassettes
|
||||
- All associated paperwork
|
||||
2. Verify label matches requisition
|
||||
3. Apply orientation labels if applicable
|
||||
|
||||
#### 6.2.3 Specimen Categorization
|
||||
|
||||
| Category | Description | Priority |
|
||||
|----------|-------------|----------|
|
||||
| Routine | Standard turnaround | 2-3 days |
|
||||
| Rush | Expedited processing | 24-48 hours |
|
||||
| STAT | Emergency | Same day |
|
||||
| Intraoperative | Frozen section | Immediate |
|
||||
|
||||
### 6.3 Fixation Assessment
|
||||
|
||||
#### 6.3.1 Optimal Fixation Times
|
||||
|
||||
| Specimen Type | Minimum | Optimal | Maximum |
|
||||
|---------------|---------|---------|---------|
|
||||
| Small biopsy (≤5mm) | 6 hours | 6-12 hours | 24 hours |
|
||||
| Medium tissue (5-15mm) | 12 hours | 12-24 hours | 48 hours |
|
||||
| Large specimen (>15mm) | 24 hours | 24-48 hours | 72 hours |
|
||||
|
||||
#### 6.3.2 Fixative Requirements
|
||||
- Standard: 10% neutral buffered formalin (10:1 ratio)
|
||||
- Breast tissue for biomarkers: Cold ischemia <1 hour, fixed within 1 hour
|
||||
- Special fixatives per protocol (e.g., Bouin's, B5)
|
||||
|
||||
Document:
|
||||
- Time of collection (if available)
|
||||
- Time of receipt in fixative
|
||||
- Time placed in processor
|
||||
|
||||
### 6.4 Gross Examination (Grossing)
|
||||
|
||||
#### 6.4.1 Pre-Grossing Preparation
|
||||
1. Verify specimen identity
|
||||
2. Review clinical history and prior pathology
|
||||
3. Gather appropriate supplies
|
||||
4. Photograph specimen (if indicated)
|
||||
|
||||
#### 6.4.2 Gross Description Components
|
||||
|
||||
**Standard elements:**
|
||||
- [ ] Specimen type and site
|
||||
- [ ] How received (container, fixative)
|
||||
- [ ] Dimensions (3 measurements)
|
||||
- [ ] Weight (if applicable)
|
||||
- [ ] External appearance
|
||||
- [ ] Cut surface appearance
|
||||
- [ ] Lesion description (size, location, margins)
|
||||
- [ ] Sections submitted summary
|
||||
|
||||
**For resection specimens:**
|
||||
- [ ] Orientation (sutures, clips, inks)
|
||||
- [ ] Margin assessment
|
||||
- [ ] Lymph node identification
|
||||
- [ ] Relationship of lesion to margins
|
||||
|
||||
#### 6.4.3 Inking Protocol
|
||||
|
||||
| Color | Common Usage |
|
||||
|-------|--------------|
|
||||
| Black | Anterior/superficial |
|
||||
| Blue | Posterior/deep |
|
||||
| Green | Superior |
|
||||
| Orange | Inferior |
|
||||
| Red | Medial |
|
||||
| Yellow | Lateral |
|
||||
|
||||
Document inking scheme in gross description.
|
||||
|
||||
#### 6.4.4 Section Submission
|
||||
|
||||
| Specimen Type | Standard Sections |
|
||||
|---------------|-------------------|
|
||||
| Small biopsy | Entire specimen |
|
||||
| Skin ellipse | 3mm cross-sections, all margins |
|
||||
| Breast lumpectomy | Lesion, margins (6 directions), representative |
|
||||
| Colon resection | Tumor (4 sections), margins, nodes, mucosa |
|
||||
|
||||
### 6.5 Tissue Processing
|
||||
|
||||
#### 6.5.1 Processing Steps
|
||||
1. Dehydration (graded alcohols)
|
||||
2. Clearing (xylene)
|
||||
3. Infiltration (paraffin)
|
||||
4. Total processing time: 8-14 hours
|
||||
|
||||
#### 6.5.2 Processing Schedules
|
||||
|
||||
| Schedule | Duration | Specimen Types |
|
||||
|----------|----------|----------------|
|
||||
| Routine overnight | 12-14 hours | Standard specimens |
|
||||
| Extended | 16-20 hours | Fatty tissue, large specimens |
|
||||
| Rapid | 2-4 hours | Urgent specimens |
|
||||
| Rush microwave | 1-2 hours | STAT specimens |
|
||||
|
||||
### 6.6 Embedding
|
||||
|
||||
1. Orient tissue in cassette per protocol
|
||||
2. Embed in paraffin at 60°C
|
||||
3. Cool on cold plate
|
||||
4. Verify block identity
|
||||
|
||||
### 6.7 Microtomy
|
||||
|
||||
1. Face block until full tissue visible
|
||||
2. Cut at specified thickness (typically 4-5 µm)
|
||||
3. Float sections on warm water bath
|
||||
4. Pick up on labeled slide
|
||||
5. Dry slides before staining
|
||||
|
||||
### 6.8 Slide Preparation
|
||||
|
||||
1. H&E staining (routine)
|
||||
2. Special stains per request/protocol
|
||||
3. Immunohistochemistry as ordered
|
||||
4. Coverslip slides
|
||||
5. Verify slide-block-patient match
|
||||
|
||||
## 7. Quality Control
|
||||
|
||||
### 7.1 Daily QC
|
||||
- [ ] Reagent checks
|
||||
- [ ] Processor function verification
|
||||
- [ ] Temperature monitoring
|
||||
- [ ] Staining controls
|
||||
|
||||
### 7.2 Specimen Quality Metrics
|
||||
|
||||
| Metric | Target |
|
||||
|--------|--------|
|
||||
| Specimen rejection rate | <2% |
|
||||
| Accessioning errors | <0.5% |
|
||||
| Lost specimens | 0 |
|
||||
| Turnaround time (routine) | ≤48 hours |
|
||||
| Block/slide discrepancies | <0.1% |
|
||||
|
||||
## 8. Documentation
|
||||
|
||||
- FRM-PATH-001 Specimen Receipt Log
|
||||
- FRM-PATH-002 Gross Description Template
|
||||
- FRM-PATH-003 Processing Log
|
||||
- Discrepancy reports
|
||||
- QC logs
|
||||
|
||||
## 9. References
|
||||
|
||||
- CAP Laboratory Accreditation Checklist
|
||||
- ASCO/CAP Guidelines for Biomarker Testing
|
||||
- CLIA regulations
|
||||
- Institutional policies
|
||||
|
||||
---
|
||||
|
||||
## Revision History
|
||||
|
||||
| Rev | Date | Description | Author |
|
||||
|-----|------|-------------|--------|
|
||||
| 1.0 | [DATE] | Initial release | [AUTHOR] |
|
||||
Reference in New Lab Ticket
Block a user