The 2012 Hospital & Laboratory Accreditation Standards
Joint Commission Standards for Tissue
The hospital/organization traces all tissues bi-directionally.
Elements of Performance for TS.03.02.01
A 1. The hospital’s or organization’s records allow any tissue to be traced from the donor or tissue
supplier to the recipient(s) or other final disposition, including discard, and from
the recipients(s) or other final disposition back to the donor or tissue supplier.
C 2. The hospital/organization identifies, in writing, the materials and related instructions used to
prepare or process tissues.
C 3. The hospital/organization documents the dates, times, and staff involved when tissue is
accepted, prepared, and issued. (See also TS.03.01.01, EP 6)
A 4. The hospital/organization documents in the recipient’s medical record the tissue type and its
A 5. The hospital/organization retains tissue records on storage temperatures, outdated procedures,
manuals, and publications for a minimum of 10 years. If required by state and/or
federal laws, hospitals/organizations may have to retain tissue records longer than 10 years.
(See also TS.03.01.01 EPs 2 and 8 )
A 6. The hospital/organization retains tissue records for a minimum of 10 years beyond the date of
distribution, transplantation, disposition, or expiration of tissue (whichever is
latest). If required by state and/or federal laws, hospitals/organizations may have to retain tissue
records longer than 10 years. Records are kept on all of the following:
- The Tissue Supplier
Note: For medical devices, the manufacturer may be the tissue supplier
- The original numeric or alphanumeric donor and lot identification
- The name(s) of the recipient(s) or the final disposition of each tissue
- The expiration dates of all tissue
(See also TS.03.01.01, EPs 6 and 7)
A 7. The hospital/organization completes and returns tissue usage information cards requested by
the tissue supplier.*
For more information on The Joint Commission Standards visit www.JointCommission.org