[Histonet] tissue retention times

[Kim.Donadio <@t> bhcpns.org]

We are not a MOHS lab. I know many laws have changed since I worked in 
one, this being one of them I think. I would not go as far as to getting a 
-80 freezer for this. If you cant send them out to another lab for 
processing or do it there, both which are very costly. I might try saving 
the samples in the small 20 ml 10% buffered formalin bottles. Not sure 
what your laws are there about the disposal of formalin but here we can 
neutralize it and toss it. So this might be a cost efficient way for you 
to meet this requirement without processing your samples. 




Kim Donadio 
Pathology Supervisor
Baptist Hospital
1000 W Moreno St.
Pensacola FL 32501
Phone (850) 469-7718
Fax (850) 434-4996



"Ingles Claire " <CIngles <@t> uwhealth.org> 
Sent by: histonet-bounces <@t> lists.utsouthwestern.edu
01/21/2010 12:11 PM

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[Histonet] tissue retention times






OK, everybody crack open your JCAHO requirement manuals...
We are a MOHS lab and were surveyed by Joint Commission about 2 months 
ago. During the survey, we were cited because we only retain our physical 
tissue specimens for 24 hours, as they remain fresh and are not fixed. We 
throw the tissue the following afternoon vs. retaining for the "1 week 
after microscopic sections are examined and reports are reviewed and 
signed." (Standard #QC.2.120) 
Has anyone else (specifically a Mohs lab) been cited for this? We are 
currently trying to appeal, but have been denied so far. I am having a 
teleconference with the JCAHO powers that be to try and get the appeal 
going again, but I'm not the lawyer type.
The letter states that their interpretation is that even if the tissue is 
not regarded as 'gross' tissue, any 'useable' tissue must be retained for 
a minimum of a week after the case is signed off on.I am thinking on 
focusing on the 'useable' bit as related to diagnostic value of delayed 
retained fresh tissue processing i.e. freeze artifact, tissue degredation, 
inability to perform ancillary testing, etc. Also, what is the definition 
of 'reviewed and signed reports'? Does this mean when the case is 
finalized, or just the tissue sections in question? We sometimes have 
patients that go a month + between Mohs procedures on the same positive 
lesion.
We will probably have to get a -80 freezer for this if the appeal doesn't 
go through. Not to mention the fact that some of our cases are not 
resolved for months. We would have constantly search when cases are 
finalized to know when we can dispose of the tissue. FYI, the letter also 
states that the JCAHO standard is more stringent than the CLIA standard, 
so I'm not even really going to use it in arguments. 
 
HELP!
Claire Ingles
UW Hospital & Clinics
Madison WI
 

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