Surgical Specimen Management

A Descriptive Study of 648 Adverse Events and Near Misses

Victoria M. Steelman, PhD; Tamara L. Williams, MSN; Marilyn K. Szekendi, PhD; Amy L. Halverson, MD;
Suzanne M. Dintzis, MD, PhD; Stephen Pavkovic, JD

 Context.Surgical specimen adverse events can lead to management process, with the most common events
delays in treatment or diagnosis, misdiagnosis, reopera- reported during the prelaboratory phase and, specifically,
tion, inappropriate treatment, and anxiety or serious with specimen labeling, collection/preservation, and trans-
patient harm. port. The most common contributing factors were failures
Objectives.To describe the types and frequency of in handoff communication, staff inattention, knowledge
event reports associated with the management of surgical deficit, and environmental issues. Eight percent of the
specimens, the contributing factors, and the level of harm events (52 of 648) resulted in either the need for additional
associated with these events. treatment or temporary or permanent harm to the patient.
Design.A retrospective review was undertaken of Conclusions.All phases of specimen handling and
surgical specimen adverse events and near misses volun- processing are vulnerable to errors. These results provide
tarily reported in the University HealthSystem Consortium a starting point for health care organizations to conduct
Safety Intelligence Patient Safety Organization database by proactive risk analyses of specimen handling procedures
more than 50 health care facilities during a 3-year period and to design safer processes. Particular attention should
(20112013). Event reports that involved surgical speci- be paid to effective communication and handoffs, consis-
men management were reviewed for patients undergoing tent processes across care areas, and staff training. In
surgery during which tissue or fluid was sent to the addition, organizations should consider the use of tech-
pathology department. nology-based identification and tracking systems.
Results.Six hundred forty-eight surgical specimen (Arch Pathol Lab Med. 2016;140:13901396; doi:
events were reported in all stages of the specimen 10.5858/arpa.2016-0021-OA)

T he management of surgical specimens, from collection

on the sterile field through communication of results,
specimen errors can lead to delays in diagnosis and
treatment, misdiagnosis, inappropriate treatment, repeat
procedures or reoperations, and emotional distress or
involves multiple providers from different disciplines.
Various preparation processes (eg, preservatives) and physical harm.1,2 In a survey of top safety issues identified
numerous handoffs (eg, from the surgeon to operating by perioperative nurses, prevention of specimen manage-
room personnel to transporting personnel and to the ment errors was identified as one of the highest-priority
issues requiring additional quality-improvement efforts.3
pathology personnel), place the process at risk for error.
Errors in the management of surgical specimens can occur
When surgical specimens are mislabeled, improperly in the prelaboratory or laboratory phases, and communica-
preserved, or lost, the consequences can be serious, tion of errors can occur during the postlaboratory
particularly when specimens are irreplaceable. Surgical phase.1,410 Studies in the prelaboratory phase have focused
on specimen identification.4,6,7 Errors can also occur during
order entry, specimen collection, specimen preservation,
Accepted for publication March 28, 2016.
Published as an Early Online Release September 9, 2016. and transport to the laboratory.11
From the College of Nursing, University of Iowa, Iowa City (Dr Studies of the laboratory phase have primarily focused on
Steelman); the Department of Safety Intelligence Patient Safety errors in specimen labeling6,8,12 and diagnostic accuracy.1319
Organization (Ms Williams), the Research Institute (Dr Szekendi), However, other errors can also occur during accessioning
and the Safety Intelligence Program (Dr Pavkovic), Vizient, Inc,
and processing, including failures in the use of equipment,
Chicago, Illinois; the Department of Surgery, Northwestern Univer-
sity Feinberg School of Medicine, Chicago (Dr Halverson); and the incorrect techniques, and cross-contamination.18,2022
Department of Anatomic Pathology, University of Washington In the postlaboratory phase, errors can occur during the
Medical Center, Seattle (Dr Dintzis). Vizient, Inc, was formerly communication of results from pathologist to treating
known as University HealthSystem Consortium. clinician. Failure may also occur when the receiving provider
The authors have no relevant financial interest in the products or fails to review the results, misinterprets the results, or fails to
companies described in this article.
Reprints: Victoria M. Steelman, PhD, College of Nursing, The communicate the results to another provider or to the
University of Iowa, CNB 50 Newton Rd, Iowa City, IA 52242-1121 patient. In a study of frozen section reports, 2.7% (8 of 300)
(email: [email protected]). of the reports involved miscommunication of findings,
1390 Arch Pathol Lab MedVol 140, December 2016 Surgical Specimen EventsSteelman et al
including surgeons misinterpretation of nonstandard de- Table 1. Surgical Specimen Events by Category
scriptive terminology; these events were frequently associ-
ated with deferred diagnoses.9 Events,a No. (%),
Surgical Specimen Taxonomy, Level 1 n 648
A better understanding of the spectrum of surgical
specimen management errors is needed to inform the Specimen labeling 319 (49)
design of systems that are effective in preventing the Specimen transporting and/or storing 247 (38)
Specimen collecting 156 (24)
occurrence of these errors. The purpose of this analysis was Specimen processing 55 (8)
to describe the types and frequency of events (eg, Specimen quality 42 (6)
mislabeling, delays in transport), contributing factors (eg, Ordering 40 (6)
communication failure, staff inattention), and harm (eg, Reporting of results 19 (3)
additional testing or treatment) associated with the man- Analysis of specimen in the laboratory 8 (1)
agement of surgical specimens. Review of these events a
An event may appear in more than one category.
prompts discussion of interventions to reduce or eliminate Reprinted with permission from Vizient, Inc. Copyright 2015 Vizient.
surgical specimen error. All rights reserved. Surgical Specimen Events. Chicago, IL: University
HealthSystem Consortium, Safety Intelligence; 2015:111.
MATERIALS AND METHODS
This descriptive study used a retrospective review of adverse
events and near misses voluntarily reported to the University RESULTS
HealthSystem Consortium Safety Intelligence Patient Safety Our search initially yielded 1430 event reports. Of these,
Organization. Participation in a patient safety organization is 54.7% (782 of 1430) did not meet our inclusion criteria. The
voluntary, and the data submitted may not represent all reports. remaining 648 events were included in this analysis. Surgical
Surgical specimenrelated reports were obtained from more than specimen errors were reported in all stages of the surgical
50 participating health care organizations, primarily academic
hospitals and affiliates across the United States. The University of
specimen management process, with the most common
Iowa institutional review board determined that this study did not errors reported in the prelaboratory phase during specimen
meet the regulatory definition of human subjects research, and labeling (49%; n 319), specimen transport or storage (38%;
approval was not necessary. n 247), and specimen collection (24%; n 156). Some
The patient safety organization database incorporates the reports described events in more than one stage of the
Agency for Healthcare Research and Quality (Rockville, Maryland) process (Table 1).
Common Format, version 1.1, and reporting organizations use a The reporter identified his or her role in 518 of the 648
common taxonomy of event types and harm scales.23 Event types event reports (80%). Of these, more reports were completed
are depicted in Tables 1 and 2. Harm is categorized as no harm, by laboratory/pathology coordinators, supervisors, or tech-
emotional distress or inconvenience, additional treatment, perma-
nicians (39%; 202 of 518), likely because issues or errors
nent harm, severe permanent harm, or death.23 The interrater
reliability of the Common Format Harm Scale has been found to be were discovered when the specimen reached the laboratory.
moderate (j 0.51).24 Reporters described events that reached the Other disciplines included nurses (30%; n 155), managers
patient and did or did not cause harm as well as those events that (15%; n 78), physician assistants (6%; n 31), other/not
did not reach the patient (near misses). Managers (or their specified (6%; n 31), and physicians (4%; n 21). The
designees) of the reporting units (eg, operating room, pathology) clinical service involved in the event was identified in about
and safety departments reviewed the accuracy of the harm scores one-half of the surgical specimen reports (n 331). Of
and identified contributing factors (eg, communication, staff these, general surgery (28%; n 93), obstetrics/gynecology
inattention) and costs incurred (eg, delay in care, additional cost, (11%; n 36), and orthopedic surgery (9%; n 30) were
additional testing) from categories in a standardized list. Contrib-
uting factors are listed in Table 3. More information about the
most frequently involved.
Agency for Healthcare Research and Quality common formats, Prelaboratory Phase
including event types and harm scales, are available at https://
www.psoppc.org/psoppc_web/publicpages/commonFormatsV1.1. Most of the 648 event reports (93%; n 603) involved an
All event reports identifying an issue with a surgical specimen error in the prelaboratory phase, when orders were entered
sent from the operating room for pathology, cytology, or culture or transcribed, specimens were collected, containers or
from January 1, 2011, to December 31, 2013, were included. requisitions were labeled, and/or specimens were trans-
Reports that did not identify the type of specimen as a surgical ported to the laboratory (Table 2). Some event reports
specimen were excluded. A series of queries and text searches was described errors in more than one laboratory phase.
conducted to assemble a comprehensive sample. First, events
Orders and Transcriptions.Of the 648 events, 40 (6%)
meeting the following search criteria were identified: (1) adverse
laboratory event or near miss, or (2) location identified as involved orders. In some events, orders were not entered or
laboratory/pathology departments and/or operating room; and (3) were cancelled because of a software programming issue,
not including the word blood in the narrative. Next, additional and the laboratory staff did not receive the order. Other
events were selected based on the following criteria: (1) surgical errors occurred when the order was entered incorrectly or
events entered under wrong patient, wrong procedure, wrong the incorrect order was delivered to the laboratory. In a few
side/site, and other surgical events; (2) location laboratory/ reports, orders were entered into the wrong patients
pathology departments and/or operating room; (3) the narrative electronic health record, wrong encounter, or an inactive
description included the word label, report, sample, record.
specimen, and/or pathology; and (4) the narrative did not
include the word blood. Events that were an integral part of the
Specimen Collections.Nearly one-quarter of the 648
surgical procedure, such as an intraoperative parathyroid hormone errors (n 156) occurred during specimen collection. These
test, were included. errors mainly related to specimen solution (43%; n 67),
Surgical specimen events were classified by specimen type and placement into containers (33%; n 51), and collection
event type. Multiple classifications could be selected, as appropri- technique (15%; n 23). Solution/preservative errors
ate, for each event reviewed. involved not adding any solution, adding the incorrect
Arch Pathol Lab MedVol 140, December 2016 Surgical Specimen EventsSteelman et al 1391
 Table 2. Types of Surgical Specimen Issues by Stage of Specimen Management
Stage in Process,a No. (%), Events,a No. (%),
n 648 Category Issue n 648
Ordering, 40 (6) Orders not entered, cancelled by computer, not clarified 26 (4.0)
Wrong test ordered and/or delivered to laboratory 8 (1.2)
Order entered for wrong patient, encounter, inactive record, or 6 (0.9)
provider
Specimen collection, 156 (24) Not placed in specimen container, container empty, or 51 (7.9)
specimen discarded
No solution or preservative on specimen 44 (6.8)
Incorrect technique used 23 (3.5)
Incorrect solution on specimen or solution should not have 23 (3.5)
been added to specimen
More than one specimen in container 8 (1.2)
Incorrect specimen container 7 (1.1)
Specimen labeling, 319 (49) Label or requisition missing 96 (14.8)
Mislabeled: wrong or missing patient identifiers 69 (10.6)
Label or requisition inaccurate, incomplete, or illegible (eg, 67 (10.3)
date/time, diagnosis)
Mislabeled: wrong site or side 31 (4.8)
Label does not match requisition 25 (3.9)
Mislabeled: wrong tissue identified 17 (2.6)
Mislabeled: tissue not identified 14 (2.2)
Transport and/or storage of specimen, Delay 99 (15.3)
247 (38) Specimen lost or not received in laboratory or pathology 77 (11.9)
department
Delivered to or stored in wrong place 26 (4.0)
Specimen not refrigerated 13 (2.0)
Solution spilled or leaked out of container 12 (1.9)
Transported through tube system instead of hand delivery, a 8 (1.2)
pneumatic tube issue
Delivered without communicating with the laboratory or 8 (1.2)
pathology department
Breakage or compromised specimen 4 (0.6)
Specimen processing, 55 (8) Delay 31 (4.8)
Error when logging in specimen 6 (0.9)
Loss, breakage, or compromise in laboratory 6 (0.9)
Failure of laboratory to enter or clarify order 5 (0.8)
Test performed does not match order 4 (0.6)
Mislabeled 3 (0.5)
Specimen quality, 42 (6) Specimen quality compromised 27 (4.2)
Quantity not sufficient 13 (2.0)
Possible contamination 2 (0.3)
Analysis of specimen in the laboratory, Incorrect technique 6 (0.9)
8 (1) Equipment error during analysis 2 (0.3)
Reporting results, 19 (3) Delay in reporting of results 12 (1.9)
Incorrect results reported 7 (1.1)
a
An event may appear in more than one category or process stage.
Reprinted with permission from Vizient, Inc. Copyright 2015 Vizient. All rights reserved. Surgical Specimen Events. Chicago, IL: University
HealthSystem Consortium, Safety Intelligence; 2015:111.

solution, or adding solution when it should not have been these 223 reports (30%), information such as date and time
added. About one-third of the collection issues involved of collection, the patients clinical information, or the
specimens that were not immediately placed into the diagnosis was missing or incorrect. In another 69 of the
specimen container, resulting in temporarily misplaced or 223 reports (31%), the label did not have the required
lost specimens. Some specimens were left on the surgical patient identifiers or the patient was incorrectly identified by
field and were, at times, accidentally discarded. Collection name or number. The label or requisition identified the
technique problems involved insufficient biopsy sample size, wrong side or site of specimen collection in 31 reports
margins, or contents or incorrect specimen handling (eg, (14%). Mislabeling, in which the specimen label did not
discarding a portion of specimen). Other collection issues match the requisition, occurred in 25 reports (11%) and
included placing the specimen in the wrong container or often misidentified the patients name. In the remainder, the
type of container. tissue was incorrectly identified (8%; 17 of 223) or not
Specimen Labeling.Almost one-half of the 648 identified on the label or requisition (6%; 14 of 223).
surgical specimen events (n 319) involved a specimen- Specimen Transport.Almost 40% of the 648 reported
labeling issue. In 96 of these events (30%), the specimen events involved issues in specimen transport to the
container was not labeled or the requisition form was not laboratory and/or storage before receipt in the laboratory
sent with the specimen. In the remaining 223 reports (70%), (n 247). Of these 247 transport errors, 99 errors (40%)
the specimen was labeled or had a requisition, but the involved delays in transporting specimens. In 77 events
information was incomplete, inaccurate, or illegible. In 67 of (31%), specimens were misplaced or lost and did not reach
1392 Arch Pathol Lab MedVol 140, December 2016 Surgical Specimen EventsSteelman et al
 Table 3. Surgical Specimen Events by Contributing specimen collection practices (27 of 42; 64%); for example,
Factor the tissue had dried because no solution or preservative had
been added, or the specimen was placed in the wrong
Events,a No. (%),
Contributing Factor n 331
solution. In other cases, the quantity was inadequate (n
13; 31%), or the specimen was compromised during
Communication issues, including 172 (52) handling; for example, the container broke and damaged
handoffs
Staff inattention 162 (49) the specimen or the specimen was contaminated.
Knowledge, training, experience 126 (38)
Environmental issues (distractions, 56 (17)
Postlaboratory Phase
interruptions, emergency, lighting) Problems surrounding the timeliness and accuracy of
Patient misidentification 36 (11) surgical specimen results were described in 3% (19 of 648)
Staffing issues (adequacy, staff mix, 26 (8)
float/agency staff) of the event reports. Delays in receiving the results were
Accuracy or availability of test results 23 (7) more common than incorrectly reported results. Some
Order entry or other documentation 20 (6) delays occurred with the patient still in the operating room;
problem for example, the reporting of frozen section results was
Policies/procedures lacking, unclear, or 20 (6) delayed.
staff unaware
Repetitive task 17 (5) Contributing Factors
a
An event may have more than one contributing factor.
Reprinted with permission from Vizient, Inc. Copyright 2015 Vizient. Managers reviewing event reports identified contributing
All rights reserved. Surgical Specimen Events. Chicago, IL: University factors in 51% (331 of 648) of the event reports. Some events
HealthSystem Consortium, Safety Intelligence; 2015:111. involved more than one contributing factor. The most
common contributing factors reported in these 331 reports
were failures in communication or handoffs (52%; n 172);
the laboratory/pathology department. Delays occurred staff inattention (49%; n 162); inadequate knowledge,
when specimens were not immediately transported to the training, and experience (38%; n 126); and environmental
appropriate area. Operating room personnel set specimens issues (17%; n 56), including distractions, interruptions,
aside or stored them temporarily on a counter, in collection emergencies, and poor lighting (Table 3). These factors
boxes, in a refrigerator, or under a stretcher, or the specimen aligned with our review of the event descriptions.
was held until the end of the case (individual or batched Specimen collection errors occurred because surgical staff
specimens) rather than taking or sending them directly to lacked knowledge, training, and experience with the
the laboratory. Other delays occurred when specimens were procedures for handling specimens or communication was
transported to the wrong location or area and had to be unclear about the preservative required. Specimens were
rerouted or were temporarily lost. lost or discarded because of improper handoffs. Factors
In some cases, the specimen was not stored properly in contributing to labeling errors included staff inattention,
the refrigerator (13 of 247; 5%). In others, the preservative/ environmental distractions, failure to follow procedures, and
solution leaked during transport when container lids were changes in staff. In some cases, the surgeon did not clearly
not sealed securely or breakage/compromise of the con- communicate about, or miscommunicated, the specimen
tainer occurred (12 of 247; 5%). type, site or side, or quantity or the nurse misunderstood the
Laboratory Phase directions.
Specimen Processing and Analysis in the Laborato- Factors contributing to delays in transporting specimens
ry.Errors in the laboratory phase were less commonly included heavy workload, interruptions, batching speci-
reported (63 of 648 reports; 10%). The most common issue mens, and staff inattention. Errors during specimen
involved delays in processing and analyzing specimens (31 transport were commonly due to lack of knowledge on
of 63; 49%). Other specimen processing errors included policies and procedures for the delivery of specimens, often
errors logging in specimens (n 6; 10%), lost or during late hours or after hours. Failures in verbal and
compromised specimens in the laboratory (n 6; 10%), physical handoffs contributed to specimens being delivered
tests that were not completed or were incorrectly completed to the wrong location or getting lost when they were
because orders were not entered or unclear orders were not delivered through the pneumatic tube system. In some
clarified (n 5; 8%), specimens in which the incorrect test cases, staff was unaware that surgical specimens were to be
was performed (n 4; 6%), and specimens that were hand-delivered to the laboratory and that delivery via the
incorrectly labeled during the analysis (n 3; 5%). pneumatic tube was in violation of policy. Often, laboratory
Only 8 reported events (13%) involved errors during staff was unaware that a specimen had been delivered
specimen analysis. In 6 of these 8 events (75%), the because it was left on the counter without notice; therefore,
laboratory/pathology staff analyzed the specimen using the the specimen sat unattended and was not processed. Delays
wrong technique; for example, the tissue was oriented in specimen analysis were caused by numerous factors,
incorrectly. In other cases, the procedure setup was incorrect including failures in order entry, indirect handoff to
because important diagnostic information was unavailable. laboratory staff, inadequate specimen quantity or quality,
Two events (25%) were associated with an equipment failures in specimen transport, miscommunication between
malfunction. the surgical staff and laboratory staff, availability of
Specimen Quality.Of the 648 cases, 42 (6%) of the laboratory/pathology staff, and shift changes. In cases in
specimen quality issues were identified through the which the specimens were lost in the laboratory, there was
narrative descriptions and were typically reported by the often more than one specimen and/or different sizes of
laboratory. Most often, these were a result of improper specimens in the same container.
Arch Pathol Lab MedVol 140, December 2016 Surgical Specimen EventsSteelman et al 1393
 Harm not available, we were unable to calculate the incidence rate
Most surgical specimen errors were discovered before the of reported events.
patient was significantly harmed. Of the 648 surgical However, the results provide a rich source of information
specimen reports, most were either near miss events on the types of errors that occur and the factors contributing
(43%; n 279) or events that reached the patient and did to those errors. These events can have significant impact on
not result in harm or only caused emotional distress or patient care and outcome, including the need for additional
inconvenience (49%; n 318). About 8% (n 52) of all testing, treatment, and patient monitoring, as well as an
surgical specimen events resulted in either the need for increased length of stay, a higher level of care, admission, or
additional treatment (7%; n 45) or temporary or additional surgery. Although it is beyond the scope of this
permanent harm to the patient (1%; n 7). article to measure the cost of this additional care, it may be
significant and is worthy of additional study.
Some errors resulted in delays, either intraoperatively or
Misidentification and specimen labeling errors are com-
during processing and reporting. In cases in which a delay
mon and represent an important priority for quality-
affected intraoperative interpretation, the error extended the
improvement efforts. Although most labeling errors were
duration of surgery and anesthesia. For example, when
near misses, the potential consequences can be severe when
orders were not identified as rapid for intraoperative
specimens are misidentified or labeled with the incorrect
parathyroid hormone, delays occurred in obtaining results.
patients name or clinical information, which can be critical
When orders were entered into the wrong patients
for correct interpretation of the specimen by the pathologist.
electronic health record, wrong encounter, or an inactive
Other problem-prone processes in the prelaboratory
record, orders were not seen by the laboratory staff and a
phase were specimen collection, preservation, and trans-
delay in processing occurred.
port. Of particular concern are the many specimens that
In many of the events, operating room or laboratory
were compromised when prepared with incorrect transport
personnel identified the error and took corrective action.
medium, fixative, or technique. Policies and procedures
About 54% of the identification/labeling errors (172 of 319)
should be readily accessible for staff at the point of use.
were caught after transport to the laboratory. Errors were
Discussion of planned specimens and their management
also caught when laboratory staff discovered that labeled during the presurgical briefing and verification of specimens
containers were empty or requisitions indicated that not all during the postoperative debriefing adds additional layers of
specimens were in the container, and the specimens were safety.
retrieved. In some of these cases, specimens were found in Commonly, reports indicated that specimens were not
the operating room and/or garbage after staff conducted a received in the laboratory, having been either temporarily or
search. Rarely, lost specimens resulted in additional surgery permanently lost. Lost and compromised specimens can
when it was necessary and possible; however, in some cases, have serious implications for diagnosis and treatment,
the specimen could not be replaced. particularly when they are irreplaceable. Technology-based
Costs Incurred solutions, such as wireless bar code tracking systems and
radiofrequency identification, have been proven to reduce
Overall, managers reviewing reports indicated that the identification errors during all phases of the laboratory
financial cost for surgical specimen-related events was low. process2528 and should be explored for potential benefit.
Of the 648 events reported, the reporter categorized the Less than 10% of reports described issues in processing
costs incurred in 316 cases (49%), and most (212 of 315; and analysis in the laboratory. These results are consistent
67%) reported no or minimal additional cost to the with previous studies reporting errors in the laboratory
organization. Of the 316 reports, 70 (22%) indicated that ranging from 0.1% to 7.44% of the overall total errors.5 It is
the event caused delays in care, and 60 (19%) reported that possible that errors occurring in these phases are reported in
the event caused pain, anxiety, or inconvenience to the other venues, such as internal laboratory quality commit-
patient. Additional laboratory or diagnostic testing or tees, and may be underreported in our data set.
treatment (eg, ambulatory visits or drug therapy) was In our analysis, 43% (279 of 648) of the reports were near
required in 13% (41 of 316) of the events; additional patient misses, suggesting that the processes for managing speci-
monitoring was needed in 5% (n 16); extended length of mens catch many errors before causing clinical consequence
stay, a higher level of care, or an admission was required in to the patient. However, in 18% (117 of 648) of events
3% (n 9); and additional surgery was indicated in 1% (n reviewed by managers, surgical specimen errors resulted in
3) of the cases. the need for additional patient monitoring or treatment,
including ambulatory visits. Four percent (12 of 316) of the
DISCUSSION events involved higher costs associated with hospitalization
This analysis examines a large, generalizable sample of and reoperation. Our analysis did not quantify the cost of
errors reported in the management of surgical specimens litigation, which can be substantial.
and communication of results by more than 50 health care Results of this analysis serve as a starting point for
organizations nationally. Event reporting is voluntary, and identification of systems weaknesses within the context of
the data do not represent all surgical specimen management the individual organization. Key recommendations for
events. In addition, the types of event reports submitted to improving the safety of specimen management are listed
the patient safety organization may vary across organiza- in Table 4.
tions and may not represent all reports. Most reported surgical specimen errors occur in the
Lack of documentation of specimen type did not allow prelaboratory phase. This is consistent with other published
inclusion of some potential events. Reports were reviewed studies.21 In addition to mistakes in labeling and identifi-
by managers within facilities, and inconsistencies in the cation, errors occurred during specimen collection, preser-
completion of reports may exist. Because data on the vation, and transportation. Common contributing factors
number of specimens accessioned at each organization were involved failures in handoff communication, knowledge
1394 Arch Pathol Lab MedVol 140, December 2016 Surgical Specimen EventsSteelman et al
 Table 4. Key Recommendations
Recommendation Details
1. Conduct a proactive risk assessment  Establish an interdisciplinary team.
 Conduct a proactive risk assessment (eg, health care failure mode and effect
analysis),29 and identify processes that are at high risk of failure and in need
of control.
 Use results to improve specimen handling processes.
2. Enhance communication and handoffs  Discuss anticipated specimens during the preoperative briefing, and verify all
information during the postoperative debriefing.
 Include verbal communication and read-back verification of the specimen
type, location, and other relevant information during handoffs of specimens
among the surgeon, scrub nurse, and circulating nurse.2,30
3. Develop effective policies and procedures  Establish policies and procedures for the safe handling of surgical specimens.
The AORN, with input from the ACS, provides a framework for these
documents.2
 Place specimens in containers as soon as possible after they are obtained.
 Label each container with 2 unique patient identifiers, specimen type, and
specimen site.2
 Conduct double-checks and cross-checks of the labeling of containers,
requisitions, and logs before transport of specimens.2
 Establish safe processes for chain of custody, and ensure the specimens are
physically delivered to laboratory personnel, and critical information is
communicated.2
4. Educate staff  Provide training on handling surgical specimens during orientation, annually
and when policies and procedures are updated.
 Discuss policies and procedures for specimen labeling, adding solutions/
preservatives, handoffs, transport of specimens (including delivery during off-
hours), and management of rarely collected specimens.
 Provide documentation and rapid reference guides at the point of use.
5. Explore technology  Consider developing electronic order sets specific to specimens collected in
the operating room.27
 Explore technology-based solutions, such as wireless bar codebased tracking
systems and radiofrequency identification to reduce identification errors
during all phases of the process.2528
Abbreviations: ACS, American College of Surgeons; AORN, Association of Perioperative Registered Nurses.

deficits, and the work environment. Multidisciplinary teams 12. Schmidt RL, Messinger BL, Layfield LJ. Internal labeling errors in a surgical
pathology department: a root cause analysis. Lab Med. 2013;44(2):176185.
should evaluate and take action to improve their identified 13. Coffin CM, Spilker K, Zhou H, Lowichik A, Pysher TJ. Frozen section
error-prone processes. diagnosis in pediatric surgical pathology: a decades experience in a childrens
hospital. Arch Pathol Lab Med. 2005;129(12):16191625.
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Prepare Submissions Now

for the CAP17 Abstract Program
Abstract and case study submissions to the College of American Pathologists (CAP) 2017 Abstract
Program will be accepted beginning on Monday, January 9 through 5 p.m. Central time Friday, March
10, 2017.

Accepted submissions will appear on the Archives of Pathology & Laboratory Medicine Web site as a
Web-only supplement to the September 2017 issue. Awards will be presented to the winners of the Top
5 Junior Member Abstract Program.

The CAP17 meeting will be held October 811 in National Harbor, Maryland. Visit the CAP17 Web
site (www.cap.org/cap17) and the Archives Web site (www.archivesofpathology.org) for additional
abstract program information as it becomes available.

1396 Arch Pathol Lab MedVol 140, December 2016 Surgical Specimen EventsSteelman et al