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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.
In addition, the post-procedure debriefing should be used to verify that the surgeon collected all anticipated specimens and that required labels and requisition forms contain the correct identification information. Personnel should verify that all specimens are secured in appropriately sized containers with the required amount of fixative when needed. Personnel also should verify that no specimens remain on the sterile field.
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
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:
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:
Link T. Guidelines in Practice: Specimen Management. AORN Journal 2021; 114(5): 443-455
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
Morris AM. A Multidisciplinary Approach for Reducing Lost Surgical Specimens. AORN Journal 2020; 111(6): 691-698
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
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