Surgical Specimen Management Protocols in the Pre-analytical Phase

Purpose This quality improvement (QI) project aimed to decrease surgical specimen errors during the pre-analytical phase at the target institution by 50% by January 2025 by developing best practices for specimen labeling and documentation. Background The QI project was implemented within a level two trauma center with a 24-suite operating room (OR) in The Woodlands, Texas, which provides care across all surgical specialties except ophthalmology. Methodology The target institution changed from nurse-hand-written specimen labels and requisition sheets to electronic medical record (EMR) generated specimen labels and requisition sheets. The change was congruent with the target institution’s shift to a new EMR. The project was conducted using a Plan-Do-Study-Act approach and contained three phases. First, education of the new EMR occurred between July 2024 and September 2024. Second, implementation occurred between October 2024 and January 2025. Lastly, phase 3 included data analysis, which occurred after the project had been completed. Results From October 2023 to May 2024, the target institution’s pathology department reported 66 specimen errors from surgical services, with 74% accounting for label and documentation errors. From July 2024 to September 2024, two specimen errors occurred during the pre-implementation phase, and only one error occurred from October 2024 to January 2025 during the implementation phase. The goal of decreasing specimen errors by 50% by January 2025 was met. Implications Developing and implementing best practices for EMR-generated specimen labels and requisition sheets is vital to reducing OR surgical specimen errors. Fewer specimen errors prevent misdiagnosis, delayed treatments, and potential re-operations, leading to better patient outcomes.