Hospitals must preserve tissue removed during operations, identify it, arrange pathologist examination unless an exception applies, and file the resulting report in several places.
Handling Tissue in Hospitals Regulation, M.R. 37/2022 The Health System Governance and Accountability Act , C.C.S.M. c. H26.5 Regulation 37/2022 Registered March 25, 2022 bilingual version (HTML) Table of Contents Section 1 Definition 2 Hospital's duties re tissue 3 Identification and examination of tissue 4 Delivery of tissue 5 Filing of pathologists report re tissue 6 Review of pathologist reports on tissue 7 Transitional application 8 Coming into force Definition 1 In this regulation, "pathologist" means a person registered in the general pathology specialty field of practice under the College of Physicians and Surgeons of Manitoba General Regulation , Manitoba Regulation 163/2018. Hospital's duties re tissue 2 Every hospital must (a) take possession of, and suitably preserve, all tissue removed from any person during an operation in the hospital; and (b) obtain a statement from the surgeon removing tissue that sets out the reason for its removal, together with pertinent clinical data, and the statement so obtained and suitably identified must be kept with the tissue at all times. Identification and examination of tissue 3(1) When a hospital takes possession of any tissue, it must ensure that the tissue (a) is identified at the time of the removal by a member of its medical staff; and (b) subject to subsection (2), is examined by a pathologist. Examination of tissue not required 3(2) Except when otherwise directed by the surgeon who removed the tissue, examination by a pathologist is not required for the following tissue: (a) amputation stumps - secondary; (b) bone fragments and ligaments; (c) bony ossicles (ears); (d) cartilage, external ear (plastic); (e) fingers; (f) foreign bodies (including bones, plates, nails, and screws); (g) hernia sac; (h) hydrocele sac; (i) intervertebral discs; (j) meningocele sac; (k) nasal septa when removed only for obstruction; (l) optic lens; (m) placenta; (n) prepuces under 25 years of age; (o) ribs removed incidental to chest surgery; (p) scar tissue; (q) semilunar cartilages; (r) teeth; (s) tendon segments removed incidental to orthopaedic procedures; (t) toe and finger nails; (u) toes; (v) tonsils and adenoids under 25 years of age; (w) vaginal wall fragments (plastic repair); (x) varicocele; (y) vein strippings. Delivery of tissue 4 When tissue is to be examined by a pathologist, the hospital must deliver it to the pathologist promptly and in good condition. Filing of pathologists report re tissue 5 When tissue has been examined, the hospital must obtain copies of the pathologist's report and file (a) a copy with the relevant standards committee established or designated by the provincial health authority under section 23.1 of The Health System Governance and Accountability Act ; (b) a copy with the surgeon who removed the tissue; (c) a copy in the patient record; and (d) a copy with the cancer authority if the pathologist considers it advisable. Review of pathologist reports on tissue 6 A hospital must ensure that all pathology reports on tissue which has been removed from patients in the hospital are reviewed regularly by the relevant standards committee established or designated by the provincial health authority under section 23.1 of The Health System Governance and Accountability Act . Transitional application 7 The reference to "the cancer authority" in clause 5(d) is to be read as "CancerCare Manitoba" from the date this regulation comes into force until section 79.2 of The Health System Governance and Accountability Act , as enacted by section 74 of The Regional Health Authorities Amendment Act (Health System Governance and Accountability) , S.M. 2021, c. 15, comes into force. Coming into force 8 This regulation comes into force on the same day that section 79.1 of The Health System Governance and Accountability Act , as enacted by section 74 of The Regional Health Authorities Amendment Act (Health System Governance and Accountability) , S.M. 2021, c. 15, comes into force.