Re: [Histonet] tissue retention times
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 cing...@uwhealth.org Sent by: histonet-boun...@lists.utsouthwestern.edu 01/21/2010 12:11 PM To histonet@lists.utsouthwestern.edu cc Subject [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 ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet - All electronic data transmissions originating from or sent to Baptist Health Care Corporation (BHC) are subject to monitoring. This message along with any attached data, are the confidential and proprietary communications of BHC and are intended to be received only by the individual or individuals to whom the message has been addressed. If the reader of this message is not the intended recipient, please take notice that any use, copying, printing, forwarding or distribution of this message, in any form, is strictly prohibited and may violate State or Federal Law. If you have received this transmission in error, please delete or destroy all copies of this message. For questions, contact the BHC Privacy Officer at (850) 434-4472. Rev.10/07. ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] tissue retention times
We are a small Mohs operation, but we just process and paraffin block all our remaining specimens and file them with the rest of our pathology cases. This worked for CAP anyway. Kim Kolman, HT, (ASCP) VA Eastern Kansas Health Care System Leavenworth, Ks 66048 -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Ingles Claire Sent: Thursday, January 21, 2010 12:11 PM To: histonet@lists.utsouthwestern.edu Subject: [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 ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
RE: [Histonet] tissue retention times
We do the same. We aren't a MOHs operation but we do many frozen cases and we process the tissue, cut a permanent processed slide of the frozen sections and then retain them for 10 years along with our other blocks. Cheri Cheryl Miller HT ASCP CM Histology Supervisor Physicians Laboratory Services Omaha, NE. 402 731 4148 -Original Message- From: histonet-boun...@lists.utsouthwestern.edu [mailto:histonet-boun...@lists.utsouthwestern.edu] On Behalf Of Kolman, Kimberly D. Sent: Thursday, January 21, 2010 12:18 PM To: Ingles Claire ; histonet@lists.utsouthwestern.edu Subject: RE: [Histonet] tissue retention times PRIVILEGED / CONFIDENTIAL INFORMATION may be contained in this message. If you are not the addressee intended / indicated or agent responsible for delivering it to the addressee, you are hereby notified that you are in possession of confidential and privileged information. Any dissemination, distribution, or copying of this e-mail is strictly prohibited. If you have received this message in error, please notify the sender immediately and delete this email from your system. ___ Histonet mailing list Histonet@lists.utsouthwestern.edu http://lists.utsouthwestern.edu/mailman/listinfo/histonet
