2 0 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J A N U A R Y 2 0 1 7
A
few years ago,
we experi-
enced a spike
in OR specimen
errors. In one month
alone, we submitted
10 specimens to
pathology that were
missing key informa-
tion: a patient label,
patient identification,
anatomic site or later-
ality. Plus, in some
cases the labels didn't
match electronic documentation of the speci-
men.
A few factors compounded the problem. First,
pathology often failed to inform staff that they'd
made an error. Second, our specimen documen-
tation process was tedious. Third, time pressures
during surgery didn't always let nurses document a specimen in "real
time" — that is, when it was removed and when the specimen label
was prepared. Here's how we smoothed out our process and virtually
eliminated specimen errors.
• Notify staff in real time about errors. Pathology agreed to pro-
vide real-time feedback regarding errors, emailing the OR details
about a specimen labeling error, typically within 24 hours.
• Staff accountability. We developed an online learning module on
Is That Specimen Label Correct?
• PERFECT SCORE Is it possible to achieve a
zero error rate for OR specimen processing?
Ideas Work
That
