Surgical Specimen Management Protocols in the Pre-analytical Phase

Authors

Jordan L. Hall, University of Texas Health Science Center at HoustonFollow

Author Biographical Info

Jordan Hall, BSN, RN, CNOR, RNFA is a Doctor of Nursing Practice Family Nurse Practitioner student at UTHealth Houston Cizik School of Nursing. She is a former U.S. Army nurse and has worked as an operating room nurse for nearly five years. Currently, she works at a Level II trauma center in the operating room in The Woodlands, Texas. She is actively engaged in quality improvement initiatives within surgical services, with a clinical focus on patient safety, error reduction, and interprofessional collaboration in perioperative care.

Date of Doctor of Nursing Practice Project Completion

Spring 4-24-2025

Faculty Advisor

Padmavathy Ramaswamy

Abstract

Purpose

This quality improvement (QI) project aimed to decrease surgical specimen errors during the pre-analytical phase at the target institution by 50% by January 2025 by developing best practices for specimen labeling and documentation.

Background

The QI project was implemented within a level two trauma center with a 24-suite operating room (OR) in The Woodlands, Texas, which provides care across all surgical specialties except ophthalmology.

Methodology

The target institution changed from nurse-hand-written specimen labels and requisition sheets to electronic medical record (EMR) generated specimen labels and requisition sheets. The change was congruent with the target institution’s shift to a new EMR. The project was conducted using a Plan-Do-Study-Act approach and contained three phases. First, education of the new EMR occurred between July 2024 and September 2024. Second, implementation occurred between October 2024 and January 2025. Lastly, phase 3 included data analysis, which occurred after the project had been completed.

Results

From October 2023 to May 2024, the target institution’s pathology department reported 66 specimen errors from surgical services, with 74% accounting for label and documentation errors. From July 2024 to September 2024, two specimen errors occurred during the pre-implementation phase, and only one error occurred from October 2024 to January 2025 during the implementation phase. The goal of decreasing specimen errors by 50% by January 2025 was met.

Implications

Developing and implementing best practices for EMR-generated specimen labels and requisition sheets is vital to reducing OR surgical specimen errors. Fewer specimen errors prevent misdiagnosis, delayed treatments, and potential re-operations, leading to better patient outcomes.

Keywords

surgical specimen management, surgical specimen collection, operating room specimen, electronic health record generated specimen labels, specimen labelling and documentation, specimen label, specimen documentation, surgical specimen, operating room specimen protocols

Recommended Citation

Hall, Jordan L., "Surgical Specimen Management Protocols in the Pre-analytical Phase" (2025). Doctor of Nursing Practice Final Project Abstract. 40.
https://digitalcommons.library.tmc.edu/dnp_abstract/40