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Lost Specimens, Lost Confidence: Surgical Specimen Management a Quality
Improvement Project

T. Page 1

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Adelaide Nursing School, University of Adelaide, Australia

Background: Each year our institution undertakes more than 25,000 surgical cases with a resultant
39% of specimens referred to our pathology provider. A surgical specimen incident led to an
evaluation of three years data on surgical specimen related incidents around lost or mislabelled
specimens. Patient outcomes rely on accurate surgical specimen collection to enable the pathology
provider to offer an accurate diagnosis and the medical officer provide relevant future treatment
planning.

Objective: This quality improvement project aims to reduce surgical pathology specimen related
errors to zero. The aim was to review current processes, policies and procedures to improve patient
safety and reduce potential patient harm.

Methods: A multidisciplinary project team inclusive of medical, nursing, quality and risk managers and
a pathology provider initially undertook a process mapping exercise using the Easy Guide to Clinical
Practice Improvement as a guide. Key possible error points were determined through brainstorming
and development of an Ishikawa diagram and Pareto charts. Some key changes were then identified
and implemented.

Results: Over a three-year period 32 (0.12%) surgical specimen related errors were identified. Target
error points were identified through process mapping and subsequent improvements implemented.
Collaborating with our pathology service, changes were made to the specimen request form used
Oral Presentation Abstracts
state-wide. Other improvements included changed procedure and collection processes in several
perioperative areas. Results are favourable with the significant errors impacting on patient diagnosis
reducing in 2022 and 2023; lost specimens from 3-1 (66%) and labelling errors from 7-2 (71%).

Conclusion: The combined input of the multidisciplinary team has brought to fruition several changes
in organisational processes enabling a reduction in pathology specimen related incidents. Additional
suggested areas of concern found secondary to the aim of this project that may enable further
improvements include a review of the operating room noise and turn-around-time between cases.
These will be further investigated in 2024.

Keywords: surgical specimen, pathology, mislabelled, lost, patient safety

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Correspondence: Tamara Page, Adelaide Nursing School, University of Adelaide, Australia
E-mail: tamara.page@adelaide.edu.au

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