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Patient Safety Tip
of the Week
January
18, 2022
AORN
on Specimen Management
Errors in specimen management can have a devastating impact to
patients. Such errors can involve mixed-up specimens and lost specimens. A lost
surgical specimen is likely irreplaceable, and a patient may be left in limbo with regard to diagnosis and management.
Our November 24, 2020 Patient Safety Tip of
the Week “Specimen
Management” discussed the AORN
“Guideline on specimen management”. A new AORN Journal article discusses
the guideline recommendations for intraoperative team communication, transfer
from the sterile field, containment, transport, and quality (Link 2021).
Multiple steps are involved in management of OR specimens. Link
notes that perioperative personnel prepare for specimen collection, review the
surgeon’s orders, and then handle, contain, label, and transport the specimen. She
further notes there are multiple specimen handovers, involving numerous individuals
(eg, surgeon, scrub person, RN circulator, relief
personnel, transporter, pathology laboratory personnel).
Intraoperative team communication plays an important role
in preventing specimen errors. Link notes that communication failures during the
handover process involving relief personnel in the OR can contribute to
specimen management errors,
One of our recommendations is echoed by the AORN guideline: during the preprocedural briefing (aka the “preop huddle”), the perioperative team discuss any specimens that the surgeon plans to obtain during the procedure. Remember, we have also recommended that your surgical booking forms include a checkbox indicating whether surgical specimens are expected.
When there is a handover (eg.
relief personnel coming on), AORN recommends the handover review specimens that
are anticipated but not yet excised, and the name, type, and location of
surgical specimens that are on the sterile field, in the room, or have been sent
to pathology laboratory. AORN suggests that read-back
be used during that handover.
While we agree discussion of specimens should be part of the
post-procedure debriefing, we think an important step may be missed. We’ve seen
cases where one or more of multiple specimens get tossed into a waste basket or
get lost in a body cavity. Hence, we recommend that a “specimen count”
be made part of the “surgical count”, just like you are counting
sponges.
Link goes on to discuss transfer and containment of
specimens. The guideline recommends that, to minimize specimen compromise on
the sterile field, the scrub person should handle the specimen as little as
possible, keep the specimen moist and contained, and place it in a safe area on
the sterile field. Link notes that specimen errors that can occur during
transfer from the sterile field include loss of integrity from lack of
moisture, contamination from airborne sources, and specimen loss from
insufficient labeling or inadequate containment before transfer.
AORN recommends that personnel transfer specimens from the
sterile field as soon as possible, using sterile technique and standard
precautions and avoiding crushing, twisting, or compacting. Personnel should
ensure that the specimen containers are large enough to fully contain the specimen
and that there is adequate fixative (when applicable) to contact all surfaces. AORN
recommends that perioperative personnel contain and label specimens
immediately upon receipt from the sterile field.
AORN recommends the specimen transport process be
standardized via input from an interdisciplinary team of personnel involved
in transporting surgical specimens to the
pathology laboratory.
AORN recommends that, when possible, personnel should
transport specimens to the receiving department immediately and the
receiving department personnel should verify receipt of the specimen. (Our
comment: if you had done a proper FMEA to see what could go wrong, you would
add to your process a contingency for what to do when specimens are collected
“after hours” when lab personnel may be absent.)
Transporting the specimen(s) immediately and not “batching” is
important in our mind. Batching, where multiple specimens are placed in one
location and taken to the lab only once a certain volume is accumulated, likely
increases the risks that a specimen will be misplaced, lost, or mixed up with
another specimen.
AORN recommends that specimen management be a regular part of
your quality management processes. Personnel should monitor the rate, type,
phase (eg, preanalytical), contributing factors, and level
of harm for specimen errors and near-miss events. These should be used to
identify trends and provide data for quality initiatives.
Link then goes on to describe a scenario at a community hospital,
where an interdisciplinary team reviewing incident reports identifies that
several specimen-related errors occurred during the preanalytical phase. The majority of the specimens come from the hospital’s multispecialty
outpatient surgery department, and all of the specimens required special
handling. Moreover, the pathology laboratory is in another building and some specimens
require transport to laboratories away from the hospital campus.
The scenario is very complicated, and we encourage you to read
it in its entirety. But it includes nuances that undoubtedly occur at other
facilities as well. Examples included:
- A relief scrub person accidentally
discarded a parathyroid specimen that she did not know was in a counted
surgical sponge on the back table.
- A specimen was lost to transport to an
outside lab because the transporter’s competing responsibilities during
between-procedure turnover interrupted the transport, and the transporter
left the specimen on the counter in the soiled utility room. When the transporter
returned to utility room, he could not locate the specimen.
- The breast tissue
specimen protocol requires personnel to send fresh specimens to the laboratory
within a one-hour time frame and notify the pathology laboratory personnel
that the specimen is in transport. However, errors occurred because the
breast specimens did not arrive at the laboratory within the specified
time frame.
The article also contains a nice table showing a sample FMEA
(failure modes and effects analysis) showing the steps involved in breast
specimen management, what could go wrong and why at each step, probabilities of
both occurrence (frequency) and detection, and potential severity of outcome of
such failures.
Our November 24, 2020 Patient Safety Tip of
the Week “Specimen
Management” also included more
detail about issues such as specimen labeling and problems with containers and preservatives.
It highlighted the excellent review of 648 surgical specimen events by Steelman
et al. (Steelman 2016). It also included some “pearls” from Temple
University Hospital (AORN 2019): One of the problems they identified was
that there was not an adequate space to collect and label specimens in the OR. So,
they created a mobile specimen table for each OR. Each table is labeled
with a brightly colored decal to identify it as the dedicated specimen table. The
decal on the table also outlines their standardized specimen management protocol.
The tables receive appropriate cleaning and can be wheeled from near the
sterile field to the computer workstation for documentation. They also created
the position of “specimen nurse” That nurse works 9AM to 3PM, when most
specimens are generated. The specimen nurse responds to the text alerts by
going into the OR when specimens are being generated to ensure proper labeling and
documentation, provide guidance to the staff members, and solicit their
feedback on the process. The specimen nurse also meets the transporter when the
transporter is removing specimens from the OR refrigerator and taking them to
the laboratory. Together, the transporter and specimen nurse verify correct
labeling on the specimen containers and laboratory requisitions.
That
column also described another quality improvement project
at the Hospital of the University of Pennsylvania (Morris 2020) which did process mapping and found there
were over 30 steps in specimen management and that there was variation depending
on the specimen type, time of day, day of the week, surgical specialty, and OR
location. Lack of interoperability between the lab IT system and the nursing IT
system precluded use of computer-generated specimen labels that could reduce
the risk for misspellings, illegibility, and transcription errors that often
occur with handwritten labels. That precluded implementation of barcode
technology for surgical specimen labeling. So perioperative nurses had to type
the specimen description into the electronic record plus handwrite the specimen’s
description on both the label used on the specimen container and the label used
in the logbook hand over to laboratory staff members.
Chain
of custody is critical in specimen management. They identified that
labeling is the first step in establishing the chain of custody. Read-back is key to confirming specimen identification
verbally and documenting it accurately, legibly, and completely. That must
include patient identifiers, source of the specimen, and laterality and avoid
using any confusing abbreviations. Read-back may also need to include spelling
out specific words to avoid errors.
One
key process change that they (and other hospitals) made was to have the specimen
handed over directly to a pathology clerk in the OR. That eliminates the
need for the RN circulator to leave the OR during the procedure to deliver the
specimen to a refrigerator. It also ensures the chain of custody is maintained and
provides the opportunity to engage the surgeon and identify any inaccuracies in
specimen description or testing requests immediately before the specimen leaves
the OR. Moreover, it eliminates the need for a logbook and the subsequent
duplication of illegible documentation. We like that idea since it potentially eliminates
at least one handoff. In our November 16, 2010 Patient Safety Tip of the Week “Lost Lab Specimens” we described how a pathology department
decided that it would take ownership of the transport process from the OR to
the lab. That effectively reduced the number of handoffs. Handoffs are always
opportunities for errors to occur so anything that reduces the number of
handoffs generally improves safety.
And we always come back to a question we ask over and over –
why can’t hospitals be more like your local supermarket or Amazon? They track
everything in detail, using a variety of tracking technologies. The postal
service and companies like UPS and FedEx scan barcodes at every step along the
way to track where your packages are at any point in time. Hospitals should be
able to do the same. Yu et al. (Yu
2019) investigated the use of
barcode technology in a Taiwanese hospital as a method to improve the accuracy
of pathology specimen labeling and patient safety. They found fewer specimen
management errors after implementation of the barcode system and found that use
of this technology significantly enhanced nurses’ satisfaction. Our June 16,
2020 Patient Safety Tip of the Week “Tracking
Technologies”
discussed multiple technologies used for tracking things.
Of course, all facilities should review any RCA’s (root cause
analyses) of incidents involving specimen mishaps. But performing a FMEA on
specimen management should be a primary focus at all facilities, regardless of
whether you have already had a specimen mishap. You’ll be surprised at the number
of potential vulnerabilities you identify.
Some of our other columns on errors related
to laboratory studies:
- October 9, 2007 “Errors in the Laboratory“
- November 16, 2010 “Lost Lab Specimens”
- October 11, 2011 “LEAN in the Lab”
- March
6, 2012 ““Lab”
Error”
- April 2012 “Specimen
Labeling Errors”
- January
22, 2013 “You
Don’t Know What You Don’t Know”
- April
15, 2014 “Specimen
Identification Mixups”
- November
25, 2014 “Misdiagnosis
Due to Lab Error”
- March
24, 2015 “Specimen
Issues in Prostate Cancer”
- May
26, 2015 “How
Safe is the Lab You Use?”
- March
29, 2016 “Inappropriate Lab Testing”
- September
27, 2016 “Lab Errors Costly”
- November
15, 2016 “Surgical Specimen Mishaps”
- March
20, 2018 “Minnesota Highlights Lost Tissue Samples”
- October
9, 2018 “More on Lab Specimen Mixups”
- March
26, 2019 “Patient Misidentification”
- May
12, 2020 “Lab Errors and COVID-19”
- November
24, 2020 “Specimen Management”
References:
Link
T. Guidelines in Practice: Specimen
Management. AORN Journal 2021; 114(5): 443-455
https://aornjournal.onlinelibrary.wiley.com/action/showCitFormats?doi=10.1002%2Faorn.13518
Steelman
VM, Williams TL, Szekendi MK, et al. Surgical
specimen management: a descriptive study of 648 adverse events and near Misses.
Arch Pathol Lab Med. 2016; 140(12): 1390-1396
AORN.
Reducing Specimen Errors. AORN Journal 2019; 109(4): 496-499
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12658
Morris
AM. A Multidisciplinary Approach for Reducing Lost Surgical Specimens. AORN
Journal 2020; 111(6): 691-698
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13061
Yu
M-H, Lee T-T, Mills ME. The Effect of Barcode Technology Use on Pathology
Specimen Labeling Errors. AORN Journal 2019; 109(2): 183-191 First Published:29
January 2019
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12585
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