Preventing Surgical Pathology Specimen Loss

Abstract

Problem & Purpose: Though rare, surgical pathology specimen (SPS) loss is a ‘never event’ that can lead to significant adverse outcomes. From November 2020 to April 2022, operating rooms (OR) at an urban academic center experienced 1 lost SPS and 1 near miss. Electronic health record (EHR) data revealed issues with SPSs being collected but not documented as sent to the lab; collected but not resulted; and missing handoff documentation. The purpose of this quality improvement project was to implement SPS barcode scanning to improve chain of custody and tracking in the OR. Methods: The Translating Evidence into Practice Model facilitated the SPS scanning implementation. Staff were trained to scan the barcoded labels of all SPSs collected in the OR at different checkpoints. The physical location and chain of custody for the SPS was automatically recorded in the EHR. For SPSs transported directly to Pathology from the room, handoff documentation is manually recorded. Adverse event reporting system and EHR reports provided data on scanning compliance, handoff documentation, SPS lab accessioning, and lost SPSs. Results: Hardware installation, software updates, visual reminder posting, and report modifications were completed. At go live, 73% of staff were trained. Of the 1,508 SPSs collected, 100% were accessioned by lab, and none were lost. Over the 15 weeks of the project, scanning compliance for the OR Room checkpoint averaged 89% and for the Surg Path Refrigerator or Staff Picked Up checkpoints the mean was 94%. On average, 49% of SPSs scanned to the Staff Picked Up checkpoint contained handoff documentation. Conclusions: Scanning of SPSs can be used to track physical location, support accessioning by lab; and was associated with improved documentation of handoff in the EHR. Scanning of SPSs may help prevent SPS loss.