Reducing Surgical Specimen Errors Through Multidisciplinary Quality Improvement.

Abstract

Each year, our institution performs more than 34,000 surgical cases and obtains close to 10,000 surgical specimens. Within those procedures, we averaged 10 errors for every 1,000 surgical specimens. Any level of preventable harm is unacceptable, as it could lead to risks of treatment delay, improper therapy selection, or missed diagnoses. This quality improvement (QI) effort aimed to decrease errors in surgical specimens from 10 errors per 1,000 surgical specimens to 0 errors each month. Using the Institute for Healthcare Improvement Model for Improvement QI methodology, we determined the root causes of error, identified key drivers, and tested change interventions. We implemented changes in surgical specimen labeling, standardized specimen time-out and reconciliation processes, and optimized a method of communication between consultants, surgeons, operating room staff, and laboratory staff with the implementation of a Specimen Request Form. Over 46 months, we identified 234 specimen errors in 33,962 surgical pathology specimens. The error rate was reduced from 10 to 2.31 errors per 1,000 specimens. The mean rate of order errors decreased from 3.66 to 0.13 per month, and the mean rate of labeling-related errors decreased from 1.5 to 0.5 per month. A multidisciplinary project team implemented changes to specimen test requesting and intraoperative specimen handling with an associated reduction in errors to reduce potential patient harm involving surgical specimen errors. This article demonstrates how applying these methods and interventions can be associated with a reduction in surgical specimen errors.