THIS WEEK'S ARTICLES
Medication Errors in the OR - Sponsored Content
Safe Specimen Handling Every Time
Communication combined with proper transfer and handling are paramount to success.
Specimen handling is a complex process complete with many steps that healthcare providers must follow to the letter to ensure everything goes smoothly and safely. While the formal guidelines are filled with pages of minute details, there are plenty of streamlined resources OR leaders can use to doublecheck that they're dotting all their i's and crossing all their t's in this complex endeavor.
An example is AORN's Guideline Quick View: Specimen Management. Here is a closer look at what this valuable resource has to say about how to handle specimens properly.
Intraoperative team communication. According to the AORN Guideline, communication failure is among the most common factors contributing to errors in specimen management. OR staff should discuss any anticipated specimens during the pre-op briefing and use the read-back method during the handover process. During the debriefing, staff should confirm that the specimen is in the container, the patient's info is on the label and the requisition form is accurate.
They should also confirm that the indicated preservation was used (if applicable), and that all pertinent information such as document of suture tags is complete. Whenever possible, surgeons should communicate directly with pathologists; otherwise, several steps need to be taken, such as relaying all the information from pathologist-to-surgeon using read-back verification and documenting the communication in the patient's healthcare record.
Transfer from the sterile field. There are a host of specific requirements staff should follow when transferring a specimen from the sterile field. This process starts by requiring OR staff to implement measures to minimize the risk of specimen compromise (loss, contamination, crushing) on the sterile field and ends with a reminder to use a read-back method to verify the patient and specimen identification on the specimen label, pathology requisition form and patient healthcare record with the surgeon. Verifying specimen and patient identifiers before transfer minimizes opportunities for error and helps prevent misidentification.
Handling. Providers should convene an interdisciplinary team to establish a standardized process with embedded quality controls for specimen handling. Examples of effective quality controls include standardized team communication and verification processes, a review of specimen labeling and requisition forms before acceptance, clinical documentation support that alerts the user when electronic data fields are missing or incomplete, alarms that notify personnel of an issue that needs to be resolved such as a refrigerator door left open, and transport and storage logbooks with standardized fields to complete.
After forming the team and establishing the standardized process, AORN recommends providers investigate ways to reduce the number of people involved in the process, and to use automation technology and memory aids whenever possible.
Reducing Surgical Specimen Errors to Nearly Zero
Quality improvement projects can effectively eliminate the patient safety issue.
Nationwide Children's Hospital in Columbus, Ohio, averaged 10 errors per 1,000 specimens collected during approximately 34,000 surgeries annually. While the error rate was relatively low, hospital officials considered any level of preventable harm unacceptable because specimen errors can potentially lead to subsequent diagnostic errors, improper treatment selection and delays in treatment. The facility therefore launched a quality improvement effort to get the errors closer to zero.
The hospital identified multiple root causes, including suboptimal specimen request and order processes, communication gaps between departments, collection processes in need of revision, and non-standardized triage and transport practices.
The quality improvement team then devised multiple fixes and interventions, including revamping surgical specimen screens to reflect appropriate handling, adding specimen discussion to the surgical time out, standardizing the anatomic pathology embedding process, developing and implementing processes for handling OR tissue specimens, starting a plan-do-study-act process for new orders, eliminating the pre-documenting of specimens, updating labeling practices and creating a specimen request form.
"We also optimized a method of communication between consultants, surgeons, operating room staff and laboratory staff with the implementation of a Specimen Request Form within our electronic medical record system," says Jessica Holstine, MBOE, LSSBB, quality improvement service line coordinator.
Over the 46-month period of data collection, the interventions produced a reduction in the mean rate of order errors from 3.7 to 0.1 per month and the mean rate of labeling errors from 1.5 to 0.5 per month.
The stakeholders involved in the initiative say applying these methods and interventions can go a long way toward reducing surgical specimen errors and thereby reducing risks of potential patient harm.
Medication Errors in the OR
Help prevent costly errors and minimize risk with the color-coded flag system.
In a fast-paced, complex environment riddled with distractions and interruptions, the operating room remains a high-risk environment for medication errors. Responsible for delivering technically complex care, the perioperative team now faces increased risk for human error due to the additional challenges of staffing shortages, fatigue and ongoing stress.
Medication errors occur as often as 1 out of every 20 medication administrations, with nearly one-third contributing to patient harm.1 Comprehensive studies have identified the primary causes leading to these errors, which include distraction, miscommunication, fatigue and haste.
Additional environmental factors have been shown to contribute to medication errors, including increased workload and prolonged procedures with more than 20 medication administrations.2 These factors can lead to labeling errors, which result in incorrect medication administration, adverse reactions and patient harm — all of which are preventable.
The necessity of enhanced labeling
The Joint Commission's 2022 National Patient Safety Goals (NPSG) require all unlabeled medications to be labeled before a procedure begins. This includes medications in syringes, cups, and basins.3 During the complex process of administering medication in the perioperative environment, it's standard to remove medications from original containers with syringes, then place them on the sterile field.
During this preparation, proper labeling becomes critical in preventing patient harm. One study showed that almost 70 percent of medication errors in the perioperative setting occurred during preparation.4 Handwritten labels with similar looking and sounding medications can be difficult to read. Without enhanced labeling solutions in place, these scenarios can lead to devastating errors.
Over the years, because of continued education, leadership and recommendations from the Joint Commission and AORN, many facilities have moved toward more effective labeling systems designed to minimize risk for patients and avoid costly errors.
Ansell offers a comprehensive medication labeling system designed to reduce the risk of medication errors in the operating room. In addition to moisture-proof, pre-printed labels, the SANDEL® Correct Medication Labeling System™ has a patented color-coded flag system designed to maximize label visibility and match the medication container to the corresponding syringe. Medication labeling kits can also include a variety of skin and permanent markers as well as a specimen zone to help organize and label specimens on the sterile field. The system meets AORN recommendations and complies with Joint Commission's NPSG requirements.
Note: To request a sample, please visit Ansell.com/SANDEL
1. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of perioperative medication errors and ad-verse drug events. Anesthesiology. 2016;124(1):25-34
2. Factors Contributing to Perioperative Medication Errors: A systematic Literature Review. AORN Journal. January 2018
3. 2022 Hospital National Patient Safety Goals (NPSG). Joint Commission.
4. Lisa Hauk. Avoiding errors when preparing medications in the perioperative setting. AORN Journal Periop Briefing March 208
Interventions to Improve Specimen Management
Implementing replicable solutions can help reduce errors.
Without a standardized process to manage surgical specimens from generation in the OR to laboratory accession, the perioperative department at Temple University Hospital in Philadelphia experienced a series of specimen errors. These errors can threaten patient safety through delayed or incorrect diagnoses and the need for additional procedures, while also increasing costs by consuming OR and laboratory staff members' time and resources to examine errors.
To combat the problem, a nurse-led team applied novel and replicable solutions through a dedicated focus on standardization and communication. The interventions included both new ideas and practices that were adopted from other perioperative settings and tailored to fit the team's needs.
A key intervention was the implementation of a mobile specimen table. After reviewing their data on specimen errors and near misses, the team identified that perioperative nurses did not have adequate space to collect and label specimens in the OR.
Additionally, a specimen nurse manager role was established. The specimen nurse meets the transporter at the specimen refrigerator when the transporter removes specimens for delivery to the laboratory. The transporter and the specimen nurse jointly verify correct labeling on the specimen containers and laboratory requisitions.
Two months after implementing these and other improvements, the team experienced zero specimen errors, but that flawless period was followed by a series of specimen errors. However, because vigilance, auditing and continued monitoring were baked into its protocol, the team quickly identified areas where the process had broken down.
Team leaders cite staff member involvement as critical to the success of the project, with employees possessing frontline knowledge about why errors happen.
How to Handle Patient Requests for Specimens
Understand their motivations, support their needs and follow a standardized process.
Do your patients request possession of their surgical pathology specimens? A recent study examined just how prevalent the practice is, as well as patients' reasoning for their requests.
Researchers interviewed several patients of an academic medical center who made such requests and whose specimen types included products of conception, placenta and cord, costal cartilage and ribs, loop explant recorder, pacemaker, below knee amputation, cervix, uterus, Fallopian tubes and ovaries. They were asked about their motivation, what they planned to do with their specimen, the positive and negative aspects of their experience, and how patients with requests like theirs could be better supported by the pathology department.
According to the study published in Academic Pathology, the themes of the patients' answers included adversity, medical interest, souvenir, cultural beliefs and curiosity. "Subthemes included becoming whole in the afterlife, preservation, my body, restoration, honoring and regret," write the authors.
Guidelines from the Association of periOperative Registered Nurses (AORN) and the Association of Surgical Technologists (AST) address the process of receiving, retaining and releasing surgical pathology specimens to patients. The study's authors say research is limited in this area, and requests and receipts of specimens remain poorly tracked and reported. One previous study found that 61% of perinatal pathologists allow release of placentas, usually to allow patients to bury them, while another study of patients who saw their specimens found they gained a greater understanding of their clinical situation and appreciated the experience.
"Our research demonstrates a wide array of motivations," write the authors. "Patients request their specimens because of cultural beliefs and a desire to be made whole again in the afterlife. Some want to honor a lost life. Still others are curious what is inside them and feel a sense of ownership of their body parts. For many patients, their experience helped them cope with tragic life circumstances. In receiving their surgical pathology specimens, patients were better able to process what had occurred and why."
The authors urge pathologists to act as patient advocates by supporting their individual needs, motivations and goals when they request pathology specimens. "This support can take many forms, from a brief meeting with the patient to understand and support their needs, to quality improvement changes to hospital forms and processes in specimen handling," they write.
Additionally, patient requests can lead to quality improvement. "Thoughtful consideration can be given to amending pre-surgery paperwork to include information related to requesting surgical pathology specimens," write the authors. "This will not only make the process easier for the patient, but it will also make their request feel more normal and supported by the medical staff."
They add that departments of pathology should thoroughly review procedures surrounding these requests. "Consideration can be given to easing the process and putting in place measures that ensure the patients receive their specimens in a safe manner consistent with their goals," they write. "If the patient expresses interest in burying the specimen, consideration can be given to thoroughly rinsing it of formalin before transfer to the patient."
One other aspect is consent and subsequent liability. A protocol for releasing surgical pathology specimens to the custody of the patient should be developed, with release forms that require the attending pathologist's and patient's signatures as well as a process for informed consent and proper notification of any potential biohazards associated with the specimen.
"While the pathologist and clinical team have a right to examine the specimen and retain it for such purpose, we do not believe that the ultimate ownership of a surgical pathology specimen is that of the hospital," conclude the authors . "Pathologists are custodians of surgical pathology specimens, not owners. This conceptualization is in line with the encouragement of organizations such as AORN, AST and the VA."