AHRQ PDSA form

Reducing Surgical Specimen Collection Errors

Name

Institution

Professor

Course

Submission Date

Description of the Problem

In the healthcare practice, the collection of surgical specimen is a routine process that may sometimes results to common errors during the specimen management process. Tabatabaee et al. (2023) claim, specimen management process is a three-stage process (pre-analysis, analysis and post-analysis), and in each of the three stages, an error may occur. However, surgical specimen errors are more likely to occur in the pre-analysis stage. Specimen collection jeopardized patient safety, which negatively impacts patient outcomes.

The Big Picture to the Issue and Problem’s Significance

According to Holstine & Samora (2021), an average of 10 surgical specimen collection errors in every 1000 surgical specimen are likely to occur within surgical procedures. These errors mostly occur in the pre-analytical stage as a result of unlabeled specimens, mismatch of specimen form, missing specimen, incorrect order entry, incorrect specimen identification, incorrect destination, and incorrect fixator or holder. A problem analysis identifies patient identification as the most crucial and most errors associated with labelling of test tubes and analysis or request sheets. The impacts of surgical specimen collection errors are detrimental to patients and the overall institution. According to Tabatabaee et al. (2023), specimen collection errors are associated with reduced patient safety as it increased the risk for delayed treatment, misdiagnosis and incorrect treatment collections which ate detrimental to the quality of patient care. In addition, the errors are associated with increased healthcare costs. In their study, Tran & Liu (2020), established that in an institution, the average cost associated with lost specimen was estimated at $548 and when cumulated over three-month period, the cost increased to approximately $20,430. As such, organizations must implement quality improvement initiatives that aim to address the errors, ultimately enhancing patient safety and reducing healthcare costs.

Where the Problem Exists

This is an acute care facility with over 900 beds that is committed to providing safe and quality patient care. The hospital services include inpatient and outpatient care, emergency care, counseling, mental care, surgical care among others. The hospital has a team of professionals including doctors, nurses, psychiatrists, among other staff members. Due to its large capacity, it performs an average of 100 scheduled surgeries Monday through Friday and an about 10 to 15 unscheduled surgical cases on the weekends.

Approximately 75% of surgical specimen collection errors occurs in the pre-analytical phase, with most happening before the specimen arrives in the laboratory (Tran & Liu (2020)

Mislabeled specimens are the most common errors in the pre-analytical phase, caused by patient misidentification, mislabeled specimen, mix-ups before collection, collection of specimens in wrong containers, use of handwritten labels and mislabels at the laboratory. In addition, other factors such as staff inattention, handoff miscommunication problems and environmental issues are also known to cause the errors (Tran & Liu 2020). As such, organizations must implement best practices that focus on addressing the common sources of specimen collection errors.

The problem statement

Surgical specimen collection errors, such as mislabeling, mishandling, and improper transport, pose a serious risk to patient safety by leading to diagnostic inaccuracies, delayed treatments, and increased healthcare costs.

References

Holstine, J. B., & Samora, J. B. (2021). Reducing Surgical Specimen Errors Through Multidisciplinary Quality Improvement. The Joint Commission Journal on Quality and Patient Safety, 47(9), 563–571. https://doi.org/10.1016/j.jcjq.2021.04.003

Tabatabaee, S. S., Ghavami, V., Kalhor, R., Amerzadeh, M., & Zomorrodi-Niat, H. (2023). Evaluation of Errors Related to Surgical Pathology Specimens of Different Hospital Departments with a Patient Safety Approach: A Case Study in Iran. Patient Safety in Surgery, 17(1). https://doi.org/10.1186/s13037-023-00360-1

Tran NK, Liu Y. Pre-Analytical Pitfalls: Missing and Mislabeled Specimens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens

Reducing Surgical Specimen Collection Errors

Name

Institution

Professor

Course

Submission Date

Description of the Problem

In the healthcare practice, the collection of surgical specimen is a routine process that may sometimes results to common errors during the specimen management process. Tabatabaee et al. (2023) claim, specimen management process is a three-stage process (pre-analysis, analysis and post-analysis), and in each of the three stages, an error may occur. However, surgical specimen errors are more likely to occur in the pre-analysis stage. Specimen collection jeopardized patient safety, which negatively impacts patient outcomes.

The Big Picture to the Issue and Problem’s Significance

According to Holstine & Samora (2021), an average of 10 surgical specimen collection errors in every 1000 surgical specimen are likely to occur within surgical procedures. These errors mostly occur in the pre-analytical stage as a result of unlabeled specimens, mismatch of specimen form, missing specimen, incorrect order entry, incorrect specimen identification, incorrect destination, and incorrect fixator or holder. A problem analysis identifies patient identification as the most crucial and most errors associated with labelling of test tubes and analysis or request sheets. The impacts of surgical specimen collection errors are detrimental to patients and the overall institution. According to Tabatabaee et al. (2023), specimen collection errors are associated with reduced patient safety as it increased the risk for delayed treatment, misdiagnosis and incorrect treatment collections which ate detrimental to the quality of patient care. In addition, the errors are associated with increased healthcare costs. In their study, Tran & Liu (2020), established that in an institution, the average cost associated with lost specimen was estimated at $548 and when cumulated over three-month period, the cost increased to approximately $20,430. As such, organizations must implement quality improvement initiatives that aim to address the errors, ultimately enhancing patient safety and reducing healthcare costs.

Where the Problem Exists

This is an acute care facility with over 900 beds that is committed to providing safe and quality patient care. The hospital services include inpatient and outpatient care, emergency care, counseling, mental care, surgical care among others. The hospital has a team of professionals including doctors, nurses, psychiatrists, among other staff members. Due to its large capacity, it performs an average of 100 scheduled surgeries Monday through Friday and an about 10 to 15 unscheduled surgical cases on the weekends.

Approximately 75% of surgical specimen collection errors occurs in the pre-analytical phase, with most happening before the specimen arrives in the laboratory (Tran & Liu (2020)

Mislabeled specimens are the most common errors in the pre-analytical phase, caused by patient misidentification, mislabeled specimen, mix-ups before collection, collection of specimens in wrong containers, use of handwritten labels and mislabels at the laboratory. In addition, other factors such as staff inattention, handoff miscommunication problems and environmental issues are also known to cause the errors (Tran & Liu 2020). As such, organizations must implement best practices that focus on addressing the common sources of specimen collection errors.

The problem statement

Surgical specimen collection errors, such as mislabeling, mishandling, and improper transport, pose a serious risk to patient safety by leading to diagnostic inaccuracies, delayed treatments, and increased healthcare costs.

References

Holstine, J. B., & Samora, J. B. (2021). Reducing Surgical Specimen Errors Through Multidisciplinary Quality Improvement. The Joint Commission Journal on Quality and Patient Safety, 47(9), 563–571. https://doi.org/10.1016/j.jcjq.2021.04.003

Tabatabaee, S. S., Ghavami, V., Kalhor, R., Amerzadeh, M., & Zomorrodi-Niat, H. (2023). Evaluation of Errors Related to Surgical Pathology Specimens of Different Hospital Departments with a Patient Safety Approach: A Case Study in Iran. Patient Safety in Surgery, 17(1). https://doi.org/10.1186/s13037-023-00360-1

Tran NK, Liu Y. Pre-Analytical Pitfalls: Missing and Mislabeled Specimens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens