Archive May 2017 XVIII, No. 5

Ideas That Work: Is That Specimen Label Correct?

specimen processing PERFECT SCORE Is it possible to achieve a zero error rate for OR specimen processing?

Is That Specimen Label Correct?

A few years ago, we experienced a spike in OR specimen errors. In one month alone, we submitted 10 specimens to pathology that were missing key information: a patient label, patient identification, anatomic site or laterality. Plus, in some cases the labels didn't match electronic documentation of the specimen.

A few factors compounded the problem. First, pathology often failed to inform staff that they'd made an error. Second, our specimen documentation 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 provide 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 our specimen handling process. OR nurses are required to complete the module and pass the post-test on hire, every 2 years thereafter as a refresher and after they've made a labeling error. Subsequent errors are addressed by leadership as performance concerns.
  • Two-person checks. We now have a mandatory 2-person verification for all handwritten specimen labels to ensure we're handing off the correct specimen in the cup. We also take a 2-person "pause" when we drop the specimen off in pathology to verify the information.
  • Frequent staff reminders. OR leaders discuss specimen management frequently with the staff and praise them for their attention to detail during morning reports and staff meetings, in our weekly newsletter and via our video kiosk in the staff lounge.

Kimberly L. Hale, MSN, MBA, RN, CNOR
Mayo Clinic Hospital
Phoenix, Ariz.

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