367 - Where's My Specimen? Implementing an Electronic Specimen Tracking System in an Academic Medical Center
Description: The retrieval of specimens for analysis during invasive procedures remains one of the most significant events that can occur within the operating suite. The process is not new; however, it continues to remain a pain point for institutions across the nation. The preventable loss of biological specimens can make it impossible for providers to make reliable clinical diagnoses which leads to severe consequences for patients including misdiagnosis and mistreatment. Surgical specimens are typically lost during collection, internal transport, or during lab processing. Standardizing specimen handling is the most effective way minimize risk and to promote positive patient outcomes and patient safety. A multidisciplinary team was established to address specimen handling issues in a large academic medical center with multiple operating room (OR) sites. The team consisted of an executive champion, risk managers, the Chair of Pathology, a cardiothoracic surgeon, nurse leaders, and analysts for the Division of Information Systems. The goal of the project was to standardize the process of specimen handling from the point of procurement to specimen accessioning. The team conducted multiple planning meetings which included walkthroughs in all of the operative and procedural areas in the institution. This assessment revealed numerous points of potential risk in the handling process. One major obstacle was that there was no formalized debriefing for procedures that included specimen management which had resulted in specimens being left on the surgical field and thrown away. There was also no process in place for misplaced specimens to be reconciled in a timely manner. Another obstacle identified was the lack of access to specimen label printers in the ORs. In order to standardize the workflows and reduce the risk for specimens to be lost in transport without detection the team implemented a specimen tracking system that was built within the organization’s electronic health record. The tracking system required the specimen to be scanned at each point of handoff in the transport process. Any specimens that were not received by the pathology department were able to be reconciled by pathology in a timely manner. In addition to this tracking system, the institution deployed a fleet of label printers in order to ensure that there was a label printer located in each operating room. These printers were mapped only to the computers located in that OR so the risk of mislabeling with the wrong patient information was reduced. A post-operative surgical debriefing was also implemented which would allow the operative team to discuss specimen management prior to the patient leaving the OR. This process allowed the team to reconcile specimens in the OR before anything could be thrown away. The outcome of this project has been an institution-wide standardization of specimen management which has resulted in a decrease in specimen-related events.