Errors in the handling of an OR specimen — for example, tissue from a biopsy to check for cancer cells — have the potential to yield devastating effects in the diagnosis, treatment, and future care of patients. Although the overall rate of specimen errors in HUP’s operating rooms is low, an initiative by the Perioperative Specimen Performance Improvement Team has brought them lower … and led to their receiving this year’s Nursing Exemplary Professional Practice Award.
Specimen errors can be attributed to many factors but the team identified “redundant documentation” as a major defect in the current system; nurses had to manually document the same information four times for each specimen in order to complete the requisition, provide documentation in the PennChart EHR and to maintain a tracking mechanism. A simple solution would be an electronic order in PennChart, but the team quickly discovered that the computer systems in the OR and Pathology and Lab Medicine did not interface.
Working in partnership with Lab Medicine and with an IS analyst, they developed a new protocol to ensure proper continuity. The team also created an electronic tutorial regarding this new process so that nurses could access these teaching materials in the moment.
When this change proved successful with a small cohort of surgeons, the project was expanded to include all HUP operating rooms, the Surgicentre, and PCAM endoscopy. Heightened awareness related to specimen handling initially resulted in a 45 percent decrease in specimen errors. The formation of this committee also created a dialogue between staff of Perioperative Nursing and Laboratory Medicine, to uncover future opportunities to work together for positive outcomes involving specimen handling.
“I am honored to have the opportunity to work collaboratively with front line nursing and laboratory team members,” said Ann Marie Morris, MSN, associate clinical director of Perioperative Services Quality and Safety. “Their diligence and support of these changes will allow us to provide a safer environment for our patients.”