Decreasing Surgical Specimen-Handling Errors: A Network Quality Improvement Journey

Background Surgical specimen handling is a complex, multidisciplinary process that involves ordering, collecting, labeling, preserving, transporting, testing, and reporting results so a patient receives a diagnosis or treatment plan. A multihospital healthcare network identified specimen handling as a problem-prone process. Methods A project team formed to complete a failure mode and effects analysis (FMEA), identify high-risk specimen-handling steps, and implement practice changes to prevent future specimen-handling errors. The project team used the FMEA seven-step process to evaluate the practice problem and identify opportunities for improvement. Intervention The project team identified 82 failure modes in the FMEA. The 10 failure modes with the highest risk score were selected for a process improvement project. The perioperative project subteam and pathology laboratory project subteam initiated process improvement efforts after evaluating evidence-based practices for the 10 highest-risk process steps. Outcomes The project has been sustained through monthly quality monitoring and reporting. At the time of this publication, 11 months post-implementation, no serious events for surgical specimens have been reported. Plain Language Summary When a surgical team decides to collect a specimen for testing, this kicks off a complex process that involves many steps and many individuals across many disciplines. Specimen handling involves ordering, collecting, labeling, preserving, transporting, testing, and reporting results. The sooner this analysis is completed, the sooner the patient can be diagnosed and treated. However, such an involved, highly collaborative process is prone to problems along the way that can delay or prevent timely and appropriate treatment. A multihospital healthcare network experienced two serious events that prevented a patient from receiving a diagnosis or treatment plan, one in which a specimen was lost and one in which a specimen was mislabeled. This network processes approximately 22,500 specimens quarterly with an error rate of 1.6 per 1,000 cases. Recognizing specimen handling as a problem-prone workflow, a quality team conducted a failure mode and effects analysis (FMEA) that identified 82 failure modes, including inconsistent workflows, workarounds, human factors, and knowledge gaps. The team focused on process improvements that would address the top 10 high-risk failure modes. Implementing and sustaining interventions guided by evidence-based practices—such as barcode tracking of specimens, use of read-backs to confirm orders and hand-offs, double checks, and education—in the operating room and gastrointestinal lab has resulted in zero reports of serious events.