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Patient Safety Tip of the Week

November 24, 2020   Specimen Management



Our multiple previous columns on errors in specimen management have highlighted the devastating impact of mixed-up specimens and lost specimens. In this month’s AORN Journal, Lisa Croke (Croke 2020) provides a preview of the pending update of AORN’s Guideline for Specimen Management, expected out in December. Topics in the update included transferring specimens off the sterile field, handling, containing, labeling, requisition forms, preserving, transporting, temporarily storing them, policies and procedures, documentation, quality, and education.


We’re glad to see they included a point we have long been making: your preop huddle or preprocedure briefing should specifically include discussion of anticipated specimens. (Likewise, we recommend your post-procedure debriefing should include note of any specimens taken and sent.) And many organizations include anticipated specimens as an item on their Surgical Safety Checklist.


The guideline stresses the importance of using the read-back method for communication between OR staff members to review the specimens that are anticipated, but not yet excised; and the name, type, and location of specimens on the sterile field, in the OR, or that have been sent to the pathology laboratory. The guideline also says the pathologist should communicate directly with the physicians regarding the diagnosis or other information about the specimen.


There is a discussion on the vacuum sealing method of containment and refrigeration issues, including processes for cleaning and disinfecting the vacuum sealing containment device. A new section on highly infectious specimens, such as from patients with COVID-19 or Ebola, has been added to the guideline. It also contains a new section on handling specimens from patients with known or suspected prion disease, including Creutzfeldt-Jakob disease. It stresses the critical importance of communication among all parties when handling such specimens that might pose a risk to the healthcare workers.


That same issue of AORN Journal also provides a graphic example of proper labeling for specimen containers (AORN 2020b).


One of the biggest impediments we see to safe specimen management is lack of error reporting that is available to all who need to know. You can’t fix what you don’t know about! Your quality improvement/patient safety dashboard should specifically track and report specimen errors.


Another barrier to safe specimen management is that, in many healthcare organizations, there are different IT systems in the OR and the pathology lab. That was mentioned in the Lim (Lim 2020) study and the Temple University Hospital (AORN 2019) and the Hospital of the University of Pennsylvania (Morris 2020) that we discuss below. The Temple article describes how special computer script was written to get info from both systems to create a specimen tracking capability.


Steelman et al. (Steelman 2016) reviewed 648 surgical specimen events. Though events were reported at all stages of the lab process (pre-analytic, analytic, and post-analytic), events most commonly occurred during the pre-analytic phase and, specifically, with specimen labeling, collection/preservation, and transport. The most common contributing factors were failures in handoff communication, staff inattention, knowledge deficit, and environmental issues. Eight percent of the events resulted in either the need for additional treatment or temporary or permanent harm to the patient. That study served as a call to attention for healthcare organizations to conduct proactive risk analyses of specimen handling procedures and to design safer processes. It recommended particular attention should be paid to effective communication and handoffs, consistent processes across care areas, and staff training. It also recommended organizations consider the use of technology-based identification and tracking systems.


In the Steelman study (Steelman 2016) almost one-half of the surgical specimen events involved a specimen labeling issue. In 30% of those, the specimen container was not labeled, or the requisition form was not sent with the specimen. In the other 70%, the specimen was labeled or had a requisition, but the information was incomplete, inaccurate, or illegible.


Nearly one-quarter of the errors occurred during specimen collection. Issues were related to specimen solution (43%), placement into containers (33%), and collection technique (15%). Solution/preservative errors involved not adding any solution, adding the incorrect, solution, or adding solution when it should not have been added. Often specimens were not immediately placed into the specimen container, resulting in temporarily misplaced or lost specimens. Some specimens were left on the surgical field or were accidentally discarded. There were also issues with collection technique (eg. insufficient biopsy sample size, margins, or contents) or incorrect specimen handling (eg, discarding a portion of specimen). Other collection issues included placing the specimen in the wrong container or type of container.


Almost 40% of the reported events involved issues in specimen transport to the laboratory and/or storage before receipt in the laboratory. 40% of these involved delays in transporting specimens and in 31% specimens were misplaced or lost and did not reach the lab or pathology department. Sometimes, OR personnel set specimens aside or stored them temporarily on a counter, in collection boxes, in a refrigerator, or under a stretcher, or the specimen was held until the end of the case (individual or batched specimens) rather than taking or sending them directly to the laboratory. Sometimes specimens were transported to the wrong location or area and had to be rerouted or were temporarily lost. In some cases, the specimen was not stored properly in the refrigerator and, in others, the preservative/solution leaked during transport when container lids were not sealed securely, or breakage/compromise of the container occurred.


6% of the specimen events involved orders. In some events, orders were not entered or were cancelled because of a software programming issue and the laboratory staff did not receive the order. Other errors occurred when the order was entered incorrectly, or the incorrect order was delivered to the laboratory. Rarely, orders were entered into the wrong patient’s electronic health record, wrong encounter, or an inactive record.


Contributing factors were identified in 51% of the event reports, the most common being failures in communication or handoffs (52%), staff inattention (49%), inadequate knowledge, training, or experience (38%), and environmental issues (17%), including distractions, interruptions, emergencies, and poor lighting.


Steelman et al. also noted errors in the laboratory and post-laboratory phases of specimen management, but those are not the focus of today’s column.


Several published quality improvement projects have highlighted the importance of communication issues and handoffs as factors contributing to specimen errors. After finding over 30 specimen error issues per month at their facility, Lim and colleagues (Lim 2020) undertook a quality improvement project in which they did fishbone diagrams and process mapping. They found that handoff communication and specimen handling processes were the main issues that led to mishandling and mislabeling of specimens. They also found that, while nurses were utilizing the electronic health record (EHR), the pathology department was using a different system to track specimens. Other issues noted related to shift changes, staff attitude, personality conflicts, and distractions.


Interventions developed and implemented included distributing a monthly specimen error report, requiring the attending surgeon to sign-off on requisition, and improving the specimen SBAR handoff. Within the first three months of implementation, the average number of errors dropped from 30.9 to 18 events per month.


The article from Temple University Hospital (AORN 2019) noted that many individuals were looking at specimen management errors on single cases and there was no overall coordinated effort. So the Temple group put together a multidisciplinary team to look at the big picture. One of the first 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. (Another hospital (Liston 2018) standardized specimen carts for each OR. When nurses move from room to room, they know that the cart is stocked and has everything they need to collect a specimen. The carts are positioned in the same spot in each OR — near the sub-sterile door so when the surgeon breaks scrub, he can look at the specimen and sign the order.)


Temple 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.


They also got their computer programmers to create from the 2 different IT systems a run-time report that would show location and status of each specimen confirm when it was received in the lab.


They also, as we recommended above, began to incorporate discussion of specimens in their post-op debriefing. And they used TeamSTEPPS® and Just Culture principles to facilitate communication amongst all staff.


They reported that, as a result of these efforts, their rate of “high risk” specimen errors was reduced by 50%.


An IHI Improvement Story highlighted a project done at the Carle Foundation Hospital and Carle Clinic Association (Urbana, Illinois) to improve specimen management that resulted in a significant reduction in specimen errors (IHI 2020). Their multidisciplinary team developed standardized processes for specimen handling and labeling and transport and actions to be taken by the Histology lab when a specimen arrives with any errors or deficiencies. Order entry screens and requisitions were standardized. It required the proceduralist to verify correct specimen(s) is/are in the correct container(s) and information on label and requisition are complete and correct prior to leaving procedure area. Second person double-checks all of the information. Specimens cannot be sent without these verifications. Label printers were installed in all relevant locations, with barcode capability. They created secure holding areas for specimens while waiting for transport. They adopted regular reporting of specimen errors for review by all levels of the organization and instituted educational programs for all impacted parities on the topic of specimen management.


Another quality improvement project at the Hospital of the University of Pennsylvania (Morris 2020) 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.


One other interesting feature is used at Geisinger, where OR nurses suggested that when they were doing the count, that would be a perfect time to have a conversation about specimens before they go out to pathology. That led to development of the "Specimen Safety Pause" (Neufer 2019).  As the surgeon begins to close, they all review with the surgeon the specimens they've obtained and read the label back to the surgeon. And that leads right into the count, which is another time where everybody needs to be participating.


Steelman et al. (Steelman 2016) also recommended organizations consider the use of technology-based identification and tracking systems. 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. 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. Conceivably you could use RFID technology for tracking specimens as well.



Specimen management errors often result in devastating consequences for patients. Every organization needs to be monitoring the occurrence of such errors and sharing them with all stakeholders. Pay careful attention to the recommendations in that AORN guideline expected out this December.



Some of our other columns on errors related to laboratory studies:






Croke L. Guideline for specimen management. AORN Journal 2020; 112(5): P8-P10



AORN (Association of periOperative Registered Nurses), Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2021. In press



AORN (Association of periOperative Registered Nurses), Correctly labeling surgical specimen containers. AORN Journal 2020; 112(5): P25-P25



Lim, K., Maghanoy, E., Juarez, A., Garay, R., Jacob, R. and Segal, C. (2020), Eliminating Mistakes One Specimen at a Time. AORN Journal 2020; 112(5): 545-545



AORN. Reducing Specimen Errors. AORN Journal 2019; 109(4): 496-499



Morris AM. Reducing Lost Surgical Specimens. AORN Journal 2020; 111(6): 691-698



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



Liston J. Ideas That Work: Pathology. Standardize Your Specimen Management Carts. Outpatient Surgery 2018; XIX(11): November 2018



IHI (Institute for Healthcare Improvement). Eliminating Pathology Specimen Handling and Labeling Errors/Deficiencies. IHI Accessed November 19, 2020



Neufer L. Ideas That Work: Doing Zero Harm. Take a Specimen Safety Pause. Outpatient Surgery 2019; XX(7): July 2019



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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