#06-5558 Accrd Manual V7 - COLA

HISTOPATHOLOGY859. EAre the stained slides reviewed daily for the expected staining characteristics?The histopathology laboratory must ensure that stains have been tested to ensure predictable staining characteristicson a daily basis.860. EDoes the laboratory document all control procedures on a daily basis?The histopathology laboratory must document all control procedures including slide staining reactions,expiration dates of stocks, reagents, working stains and solutions made in the laboratory. Measurements,reactions, and/or observations that demonstrate that controls were tested prior to use must be recorded.861. EAre the remnants of tissue specimens maintained in a manner that ensures proper preservation of the tissuespecimens until the portions submitted for microscopic examination have been examined and a diagnosis madeby a qualified pathologist?Remnants of fresh and fixed tissue specimens must be kept in adequate amounts of fixative in such a way asto prevent tissue desiccation. Frozen tissue samples should be maintained at –40 degrees C. Large tissuespecimens should be refrigerated. These tissues must be kept until final reports have been issued by a qualifiedpathologist, ideally for two weeks after the final report to allow for reexamination if questions arise afterthe attending physicians review the report.The laboratory shall have written policies and procedures for autopsy pathology.862. RAre there procedures for the admission, identification and release of bodies?The procedures should address the exact documentation required during the admission, identification andrelease of bodies. Name, numerical identification (hospital number or social security number), age and sexof the deceased should be included. Persons responsible for the admittance, identification and release ofbodies should be recorded.863. RDo procedures address the methods of examination, tissue sampling, and documentation?The methods and extent of autopsy examinations should be outlined, the type of organ dissection describedand the tissue samples to be collected should be addressed. The documentation of the autopsy shouldinclude an external examination, an internal examination and a description of individual organs. The finalreport should also include a description of the microscopic findings and a listing of the final diagnoses.References such as Ludwig’s Current Methods of Autopsy Practice should be included.Ensuring Quality of Examination ProceduresThe laboratory shall establish and follow written policies and procedures for a quality assessment plan todetect errors and to ensure the accuracy of histological examinations.864. EDoes the laboratory has and follows written policies and procedures to detect errors and ensure accuracy of histologyexaminations?Policies and procedures should ensure that all tissue specimens are positively identified, that tissue sectionsand slides maintain identification, and that request forms are reviewed for consistency of identification andpatient history during microscopic examination.102. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FOR MORE INFORMATION CONTACT COLA PHONE 800.981.9883 | FAX 410.381.8611 | ON-LINE www.cola.org