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Proper Tissue Management

Accreditation Monthly

February 11, 2010

You may have noticed in the 2010 Hospital Accreditation Standards manual that The Joint Commission no longer requires temperature monitoring of tissue stored at ambient or indoor room temperature (TS.03.01.01, EPs 8–9). However, this does not change your responsibility in the proper receipt and management of this tissue. Even though temperature logs are not required for room temperature storage, the suppliers' recommendations and hospital policy should be maintained.

Over the past two years, Greeley consultants have continued to identify problems related to tissue storage and management during hospital on-site accreditation assessments. Most notably, hospitals are missing key elements of the tissue management process, including:

  • Written notation regarding the integrity of the tissue upon receipt
  • Lack of recording and tracking of the tissue recipient
  • Documentation of bidirectional tracking missing
  • Expired tissue in active storage
  • The failure to have a clear process in place for adverse events such as patient notification of recalled tissue or an infected tissue site

Staff members should be able to articulate the process for notification of the oversight bodies when tissue problems arise, including notification of the Perioperative Care Committee, infection control, and risk management. If you are not already doing so, try performing a tissue tracer from supplier to post-discharge record review to assess for any breakdowns in your process.

Laure Dudley 2/11/2010

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