Description of team: The team includes operating room (OR) nurses, surgical technologist (ST), informatics resource nurses (IRN), and a nurse manager. Preparation and planning: Between September 2018 and May 2019, it was found that there was an average of 30.9 specimen events per month. Specimen events include incorrect specimen name, laterality, orientation or special instruction, missing specimen, and missing pathology requisition. With a high number of pathology specimen events, an interdisciplinary team was formed to look at the issue and propose solutions that can decrease these events.
Assessment: The team reviewed the data collected by the IRN to identify what caused the increase in specimen events. After brainstorming ideas, the team created a fish-bone diagram and process map and found that hand-off communication (SBAR), and specimen handling process were the main issues that led to mishandling and mislabeling of specimens. Another finding that impacted specimen events was that nurses were utilizing the electronic health record (EHR), while the pathology department uses a different system to track specimens. The team also observed that surgical staff attitude potentially played a role in specimen events. Some of these observations included distraction of the staff and personality conflicts between staff members. Lastly, a general survey was given to the OR staff to understand their practice of specimen handling. The team did not focus on missing pathology requisitions, as this process will be changed during the EHR update. Implementation: The interventions implemented included distributing a monthly specimen error report, requiring the attending surgeon to sign-off on requisition, and improving the specimen SBAR hand-off. The error report included information on type of specimen events that occurred the previous month as well as reminders and tips for the nurses to avoid these issues. The team reintroduced the process of the surgeons being required to sign the pathology requisition prior to the pathology department receiving the specimen. This process allowed the surgical team to review and verify the names and special instructions of specimens submitted. The lack of communication regarding specimens during shift change was addressed by updating the SBAR to include specimen issues. Outcome: The team started sending the monthly error reports in May 2019. By looking at the included specimen events within the first three months of implementation, the average number of errors dropped from 30.9 to 18 events per month. Looking closely at the incorrect specimen names, there was a drop from 3.55 to 0.67 errors per month. Implications: Proper specimen handling is important, as it is vital to the patient’s treatment and diagnosis. If improperly handled, it could cause harm to the patient. It is important to provide the best possible care for our patients in the operating room.