#06-5558 Accrd Manual V7 - COLA

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HISTOPATHOLOGY>Specimen Collection and ManagementThe laboratory shall have and must follow policies and procedures for the collection and handling of specimens.837. EAre the preferred methods of tissue specimen submission by clients described?The laboratory should provide written instructions for clients for the submission of tissue specimens, whichindicate if the specimen should be fresh, frozen, or in preservative and the desired preservatives for differentspecimens.838. EIs the laboratory’s accepted method of labeling tissue specimens described?Tissue specimens, like other laboratory specimens, must be labeled with all essential information (see COLAgeneral requirements for specimen labeling) and should include the source of the specimen and the nameof the attending physician.839. EAre the proper methods for handling and transportation of tissue samples described?The laboratory is responsible for developing written policy to define acceptable methods for handling andtransportation of tissue specimens. The following items are suggestions regarding acceptable practices.Tissue specimens should be handled in a sterile manner, placed in a sealed container, preserved in an appropriatemanner and transported in a timely fashion. Fresh specimens should be in normal saline or a tissuetransport medium; frozen specimens should be in a cryo-preservative medium or in isopentane cooled to -40 degrees C.; preserved (fixed) specimens should be in an adequate volume of preservative to ensureappropriate fixation. Specimens should be transported in such a manner as to insure specimen integrity.Are there policies and criteria for:840. EUnacceptable specimens?841. ERejection of specimens?842. ENotification of requesting physician when samples are unacceptable or are rejected?The laboratory examination request form shall contain sufficient information to identify the patient and therequestor, and shall provide pertinent clinical data.843. EIn addition to the general requirements for requisition forms, does the laboratory’s request form indicate thetissue source?844. EDoes the histopathology laboratory meet the general specimen requisition, collection and managementrequirements for COLA accreditation?The laboratory shall be in compliance with all criteria within this subsection as well as COLA general criteriafor Specimen Collection (PRE 10 – PRE 19) and Requisitions (PRE 1 - PRE 9). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org99
HISTOPATHOLOGYThe laboratory shall have policies and procedures for the authorization of autopsies and for the managementof human bodies for autopsies.845. RDo the policies and procedures include instructions for the handling, transportation, storage, and release ofhuman bodies?Policies and procedures for the handling and transportation of bodies should be developed in conjunctionwith the Nursing Service and should address preparation medication lines and medical devices left in placewhen appropriate), identification (toe tag) and transportation ( routes and means of conveyance) of bodies.Laboratory policies and procedures should address storage (refrigeration between 38 – 44 degrees F) andrelease (identification and authorization) of bodies.846. RAre there policies and procedures detailing the requirements for the authorization of autopsies and for compliancewith local and state legal requirements?Policies and procedures for the authorization of autopsies should be developed in conjunction with PatientAffairs and/or the Legal Department and should be in compliance with local and state legal requirements.Ask what local and state legal requirements are and check to see that policies and procedures address these.Examination ProceduresThe laboratory shall have and must follow a written procedure manual for the histopathology laboratory.847. RDoes the laboratory have a written procedure manual that complies with the procedure manual requirementsfor COLA accreditation?The laboratory shall be in compliance with all criteria within this subsection as well as COLA general laboratorycriteria for Procedure Manuals (APM 1 - 19). The procedure manual must be accessible to individuals performingthe processing of specimens and examination of specimens.The laboratory shall have and must follow written procedures for the appropriate gross examination, fixation,processing and staining for histology specimens.Do the procedures address the following:848. EGross specimen examination.849. ETissue fixation and processing,850. ERoutine hematoxylin and eosin stains,851. ESpecial stains,852. EFluorescent and Immunohistochemical stains,100. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org
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#06-5558 Accrd Manual V7 - COLA

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