SAN DIEGO The best way to avoid safety and quality violations is to stay abreast of guidelines prescribed by the Occupational Safety and Health Administration and by the Clinical Laboratory Improvement Amendments, Dr. Richard Hoang said at a meeting sponsored by the American Society for Mohs Surgery.
The lack of an up-to-date plan for control of blood-borne-pathogen exposure was among the most common violations for which Mohs surgeons were cited by OSHA during the period from January to August 2003, said Dr. Hoang, a dermatologist and dermatologic surgeon in private practice in San Diego.
"There are always unusually high fines for blood-borne-pathogen-exposure control-plan citations, so make sure yours is updated annually," Dr. Hoang said.
OSHA inspections are typically prompted by complaints or accidents. If an OSHA citation is given, there is always an opportunity to contest the violation, he noted.
In addition to the need for a blood-borne-pathogen-exposure control plan, OSHA guidelines that are particularly relevant to Mohs surgery practices include those on the identification of hazardous materials in the office. OSHA requires a safety data sheet for each chemical. Also, surgeons who work with hazardous materials must label all chemical containers and, when transferring chemicals to other containers, make sure all transfer containers reflect the original information about the chemical, Dr. Hoang said.
The Clinical Laboratory Improvement Amendments (CLIA), first published in 1992, were prompted by the poor quality of Pap smear results produced by large laboratories. CLIA classifies laboratory tests based on levels of complexity, and ranks Mohs histopathology tests as highly complex, Dr. Hoang said. Because of that ranking, Mohs practices must apply for a certificate, pay the required fees, and participate in proficiency testing.
The manual includes directions for performing tests. "All you have to do is make any revisions to the basic manual that are specific to your lab, and update it annually," Dr. Hoang explained.
In the section on specimen collection and handling, for example, Mohs surgeons should note that the surgeon will correlate the tissue with the Mohs map. Any tests performed should be documented with a test requisition in the patient's chart. In addition to this required documentation, Dr. Hoang recommends keeping a special Mohs log with the patient's name, the site worked on, and the number of slides to help the surgeon create an operative report.
Quality control in a Mohs practicedefined as the monitoring of testing procedures to achieve accurate, consistent resultsalso falls under CLIA requirements. To achieve accurate, consistent results, confirm the quality and sterility of reagents and record the expiration dates and lot numbers. Document the cleaning and maintenance of microscopes and report the daily temperature of the cryostat. The cryostat should be cleaned regularly.