Operating Room Specimen Errors can be devastating as it can affect the patient diagnosis, treatment and outcome. Imagine having the correct diagnosis given to the wrong patient, or a diagnosis that never makes it to the patient because the specimen is lost! How about those mislabeled specimens, labeled left when it should be right or right when it should be left? Worse than that, how about the retained specimen that never makes it to the lab because it was “forgotten” to be removed?
Specimens are considered precious and cannot be replaced. The National Quality Forum has listed specimen error as a care practice serious reportable event. The Joint Commission has implemented a national patient safety goal designed to eliminate the specimen error problem. “Goal 1: Improve the accuracy of patient identification” (Joint Commission National Patient Safety Goal, 2017). Specimen management is a multifaceted, multidisciplinary process for the interoperative team.
Specimen management is a process that consists of accurate site identification, specimen collection, handling, transfer, containment, patient identification, labeling, preservation, transport, and documentation. Each member of the surgical team plays a crucial role in ensuring that the specimen has been processed safely. Unfortunately, even when a specimen process plan is implemented, errors still happen. Bulbuloglu S, Eti Aslan F, van Giersbergen MY(2018) found that communication errors, staff carelessness, lack of information, lack of policies and protocols, order and documentation, and poor staff awareness make up most of the specimen errors in the operating room even though there is a clear process. Just like a cough is a symptom of a cold, a specimen error is a symptom that is the result of a bigger problem. To decrease the rate of specimen error, the root cause must be identified. Once that cause is identified an evidence-based plan can be put into place along with leadership support to help sustain the initiative.
Miscommunication has been identified as a root cause in specimen error. The OR can be a hectic environment in which a surgeon’s verbal orders, for the lab and specimen, are given while they are standing at the sterile field. Those orders need to be interpreted and transcribed into the electronic medical record by the circulating room nurse. Many times, those specimen orders are given during closing when surgical counts are taking place, suture and dressings are being dispensed, and other end of the surgery tasks are being completed. This multitasking makes it difficult for the circulating room nurse to ensure that the correct order has been inputted, the correct label has been generated and the specimen has been collected from the sterile field. One way to improve communication and ensure specimen orders are correctly entered, is to conduct a surgical debriefing.
AORN describes the debriefing process in the Team Communication guideline as, an active process with engagement from all members of the perioperative team focusing on specific events and applying what they learned to their practice. Debriefings allow the perioperative team to identify opportunities to improve efficiency and patient safety, identify any defects in care, and discuss the plan for the transition of patient care from the OR to another team. Verbalizing the specimen order during the debrief gets the team on the same page and ensures accuracy.
Specimen handling is as important as safe patient handling, maintaining a sterile field and surgical counts. By creating a multidisciplinary standardization of specimen collection process which include improved communication strategies, lab errors will decrease and patient outcomes will improve.
Bulbuloglu S, Eti Aslan F, van Giersbergen MY(2018) The Surgical Pathology Specimen Safety Study: Management Errors in the Operating Room. Surgery Curr Res 8: 305. doi: 10.4172/2161-1076.1000305
National Patient Safety Goals Effective January 2017. (2017). Retrieved from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_AHC_November 2020
