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Hand-over Errors Prevent Specimen Results, Timely Treatment

Publish Date: June 23, 2021


Even though you carefully manage a patient’s biopsy or other specimen in the OR, the steps taken to transport the specimen safely to the lab may not run as smoothly.

Second to labeling mishaps, specimen transport is the most common specimen error, with lost or compromised specimens frequently delaying patient treatment.  

Many specimen transport errors come down to ineffective hand-over communication. Why? Because it often requires coordinated communication with multiple personnel from multiple departments and staff, including couriers.

That’s why nurses play an important role in improving timely transport of specimens as part of an interdisciplinary team, according to Julie Cahn, DNP, RN, CNOR, RN-BC, ACNS-BC, CNS-CP, AORN Senior Perioperative Practice Specialist.

Cahn is lead author of AORN’s updated specimen management guideline published in December 2020. This updated guideline includes evidence-based recommendations that zero in on better hand-over strategies.

Standardize Your Specimen Transport Process
Section 8 in the updated specimen management guideline includes recommendations on specimen transport.

“When it’s possible, specimens should be transported to the receiving department immediately. When the specimen is received by that department, there should be confirmation of critical and time-sensitive information, such as frozen section status or when an item needs to be processed immediately,” Cahn explains.

She reminds that there are specific regulatory requirements for specimen transport that must be followed, including:

  • protecting the integrity of the specimen
  • facilitating specimen identification at each point of exchange
  • maintaining confidentiality of protected patient health information
  • protecting personnel form exposure to blood or other potentially infections materials and chemicals

“If a third party is contracted for courier services when there is not a pathology laboratory available on-site, there should be an equally strong communication and planning process with this courier, because reports show specimens can be lost during transportation through a third party,” she adds.

Use Caution with Pneumatic Tube Systems
Another potential area for specimen transport errors is when a pneumatic tube system is used to send the specimen to the lab or pathology department within a different area of the hospital.

Cahn says the updated guideline includes a “no recommendation statement” on the use of pneumatic tube systems for specimen transport because there is not enough evidence on this transport system to make a recommendation. However, potential harms with using a tube system for specimen transportation include:

  • specimen loss if the specimen is sent to the wrong location or stuck in the tube system
  • spillage of chemical or potentially infectious material inside the tube system during transport

The ECRI Institute recommends using caution when transporting specimens via a pneumatic tube system.

“When a tube system is used, the interdisciplinary team needs to follow manufacturer instructions for use including how specimens are contained and have a plan in place to confirm specimens are received,” Cahn says.

Tools to Improve Your Specimen Transport
Given the critical nature of surgical specimens being transported most expediently and safely,

“it is important that facilities perform a prospective evaluation for practice gaps and identify areas of improvement before errors occur,” Cahn stresses.

To help make this happen, AORN created a Failure Modes and Effects Analysis tool with common examples of specimen errors taken from information gathered for the guideline update.

These tools, as well as a competency verification form, policy and procedure templates, and more can be found in AORN’s Guideline Essentials for the specimen management guideline, available to AORN members only.