CONTINUING EDUCATION
Back to Basics: Specimen Management 0.8 www.aorn.org/CE
SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www .aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #15518 Session: #0001 Fee: Members $6.40, Nonmembers $12.80 The contact hours for this article expire May 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to specimen management.
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict of Interest Disclosures Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.02.012 ª AORN, Inc, 2015
558 j AORN Journal
www.aornjournal.org
Back to Basics: Specimen Management 0.8 www.aorn.org/CE
SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC
ABSTRACT Specific actions for handling various types of specimens may differ; however, the management process is essentially the same. Accurate specimen management requires effective multidisciplinary communication, minimal distractions, and awareness of the opportunities for error. When advocating for patients and working with members of the health care team to provide a safe perioperative environment, perioperative nurses should adhere to best practices for specimen management and strive to prevent specimen-related errors that may lead to inaccurate or incomplete diagnoses, the need for additional procedures, and perhaps most importantly, physical and psychological injury to patients. AORN J 101 (May 2015) 559-563. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.02.012 Key words: specimen handling, specimen management, multidisciplinary communication, distractions, error.
http://dx.doi.org/10.1016/j.aorn.2015.02.012 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 559
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ppropriate specimen management requires that perioperative RNs adhere to best practices for specimen management and strive to prevent errors. Specimen-related errors may lead to inaccurate or incomplete diagnoses, the need for additional procedures, and perhaps most importantly, physical and psychological injury to patients. The following composite case study illustrates the serious consequences that may arise when specimens are mishandled.
Ms S is a 30-year-old married woman who has two children. As a teenager, Ms S was diagnosed with and treated for malignant melanoma. During a routine physical examination, Ms S’s physician detects a mass on her left kidney. Ms S is subsequently scheduled for a needle biopsy of the mass on her left kidney. The interventional radiologist who will perform the needle biopsy tells the perioperative RN that he would like the patient in left lateral position (ie, left side down) for the procedure. The RN assumes that the needle biopsy will be taken from the right side because the patient will be positioned left side down. Based on this assumption, the perioperative RN completes the documentation for a right needle biopsy procedure, including the specimen requisition and the label for the specimen container, before the patient arrives at the facility. Ms S arrives at the facility and signs a consent for a needle biopsy of a mass on the right kidney. She is positioned for the procedure with the left side down. According to the perioperative record, a time out is completed with the right side verified by all team members as being the correct site, although there is some question whether the time out was performed. During Ms S’s procedure, the perioperative RN realizes that she has made an error in the documentation because the interventional radiologist is taking the biopsy from the left side; however, she does not speak up. The perioperative RN corrects some, but not all of the documentation. The perioperative RN does not correct the specimen requisition and label identifying the specimen as a needle biopsy from a mass on the right kidney. The pathologist’s report documents that the biopsy of the mass, labeled as the right kidney, is suspicious for carcinoma. She is advised to seek consultation with a surgeon for removal of her right kidney. The surgeon reviews the pathology report discussing the suspicious characteristics of the needle biopsy specimen from the right kidney and recommends surgical removal, which Ms S undergoes. The pathology report states 560 j AORN Journal
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that her right kidney is normal. Ms Smith and her family believe she has beaten the cancer. At a later date, her physician notifies her that the suspicious mass originally diagnosed involved her left kidney and is still present. After biopsy confirmation that the left kidney mass is malignant, the surgeon removes her left kidney. Although Ms S is now cancer free, she faces treatment by dialysis until a kidney transplant can be found.
HOW-TO GUIDE Although the specific steps for handling various types of specimens may differ, the management process is essentially the same. For example, a frozen section specimen may be handled or preserved somewhat differently than a cytology sample; however, the management process for both specimens is essentially the same. Specimen management is a multifaceted, multidisciplinary process.1 The perioperative nurse conducts a needs assessment after the need for a specimen is identified. This assessment includes determining the personnel to be notified (eg, pathologist for frozen section), requirements for specimen collection and handling (eg, keeping the specimen moist until transfer from the sterile field), method of transfer (eg, using sterile technique), requirements for containment (eg, size of the container), method of preservation (eg, type of solution), transport needs (eg, availability of personnel), disposition of the specimen (eg, disposal, returned to the patient), and documentation required (eg, noting the location of suture tags).1 In addition to the needs assessment, the following outlines the process of specimen management. Site identification is the process of positively establishing or confirming the location of tissue, foreign objects, or body substances to be removed from the patient and sent for pathology examination.1 Collection and handling is the process of obtaining a biopsy or resecting a specimen and the act of holding, securing, moving, or manipulating a specimen.1 Transfer refers to the process of moving a specimen from the sterile field to a containment device.1 Containment involves securing the specimen by placing it in an item used for storage and transport.1 Identification and labeling is the process of affixing information that establishes or indicates the specifications or characteristics of the enclosed sample to a container.1
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May 2015, Volume 101, No. 5
Preservation is the process of protecting a specimen to preserve morphology, reduce the loss of molecular components into solution, prevent decomposition and autolysis, and prevent microbial growth.1,2 Transport refers to carrying or conveying a specimen from one location to another.1 Disposition is the process of positioning or distributing tissue, foreign bodies, explanted items, or body fluids removed from a patient for pathology examination.1 Documentation of nursing activities, such as specimen management, serves as the legal record of care delivery. Documentation of nursing activities is dictated by the facility or health care organization policy, regulatory, and accrediting agency requirements and is necessary to inform other health care professionals involved in the patient’s care.1 Accurate specimen management requires effective multidisciplinary communication, minimized distractions, and awareness of the opportunities for error.1
BENEFITS Following each step of the specimen management process confers benefits to perioperative patients and personnel. Completing an early assessment may help improve processes, increase efficiency, and decrease or even prevent errors related to specimen management.1 Confirming the specimen site and the location of tissue, foreign objects, or body substances to be removed from the patient and sent for pathology examination may help prevent wrong-site surgery.1 Implementing error prevention strategies for the identification and verification of the correct site of specimens to be collected may reduce the risk for error.1,3 Correctly collecting and handling surgical specimens may protect the specimens from compromise that could result in an inaccurate diagnosis, an incomplete diagnosis, or the need for additional procedures or unnecessary surgeries.1 Transferring specimens from the sterile field in a manner that maintains the integrity of the specimen reduces the possibility of compromising the specimen.1 Containing the specimen in a protective and secure manner prevents exposure of health care personnel to blood, body fluids, or other potentially infectious materials and may help prevent damage to the specimen, loss of the specimen, and exposure of health care personnel.1,4 Labeling specimen containers to communicate patient and specimen information can help prevent misidentification of the specimen, its margins, or other information (eg, location of suture tags) that could result in errors or delay in diagnosis or treatment or the need for additional procedures.1
www.aornjournal.org
Back to Basics: Specimen Management
Labeling specimen containers to communicate preservative and biohazard information can help prevent exposure or injury to personnel handling the contained specimen.1,4,5 Preserving specimens in a manner that protects the integrity of the specimen can help preserve specimen morphology, reduce the loss of molecular components into solution, delay decomposition and autolysis, and prevent microbial growth. Unpreserved or incorrectly preserved specimens may be compromised and lead to an inaccurate diagnosis, incomplete diagnostic information, or the need for additional procedures.1,2 Preserving specimens in a manner that prevents the exposure of health care personnel to chemicals, blood, body fluids, or other potentially infectious materials can help prevent injury to personnel handling the contained specimen.1,4,5 Transporting specimens in a manner that protects the integrity of the specimen can help avoid inaccurate or incomplete diagnoses or the need for additional procedures.1 Transporting specimens in a manner that avoids exposing health care personnel to chemicals, blood, body fluids, or other potentially infectious materials can help prevent injury to personnel transporting the contained specimen.1,4,5 Transporting specimens in a manner that maintains the confidentiality of protected patient information prevents violating the confidentiality of personal health information.1,6 Correctly documenting nursing activities related to specimen management according to the policies and procedures of the facility or health care organization and in a manner consistent with regulatory and accrediting agency requirements provides reliable data. This information is necessary to chronicle patients’ responses to nursing interventions and to demonstrate the facility or health care organization’s progress toward quality care outcomes.7
STRATEGIES FOR SUCCESS Reducing errors in specimen management requires a careful review of previous errors, input from those involved in the specimen management process, a careful examination of system flaws and failures that may have contributed to the errors, and to be responsive to analysis and correction.1 The simple application of redundancy to various portions of the specimen management cycle (ie, double-checking the steps of the process) may significantly reduce errors.8,9 Keep the following strategies in mind after viewing the What’s Wrong With This Picture? related to specimen management (Figure 1). In addition to the patient and specimen identification information that must be included on the label, specimens must be labeled to communicate preservative and biohazard information.1 AORN Journal j 561
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Figure 1. This depiction of specimen care and handling is wrong because (A) there is an unlabeled specimen in the container on the shelf, (B) the specimen container is leaking, (C) the breast biopsy specimen is drying on an absorbent towel, (D) the breast biopsy specimen has not been fixed within one hour, and (E) the umbilical hernia specimen is falling off the sterile field.
Specimen containers must be leak proof and puncture resistant. This is a regulatory requirement.1,4 Air exposure can desiccate the tissue.10 Dry surfaces may adhere to the tissue, and this can result in loss of portions of the resection margins when the specimen is removed from the dry surface.1,10 Breast cancer specimens should be handled in a manner that preserves the molecular and genetic signatures of
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the specimen.1 Delays in fixation can result in a decreased ability to detect breast biomarkers in the sample. 11 Careful monitoring of specimens that must remain on the sterile field reduces the possibility for the specimen to be lost or compromised.1 Passing specimens off the sterile field as soon as possible reduces the possibility for the specimen to be lost or compromised.1
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May 2015, Volume 101, No. 5
Back to Basics: Specimen Management
WRAP-UP Perioperative nurses play an important role in advocating for patients and working together with members of the health care team to provide a safe perioperative environment.12 The mission of AORN is to promote safety and optimal outcomes for patients undergoing operative and other invasive procedures.13 One basic element of advocating for patients and promoting a safe perioperative environment is to adhere to best practices for specimen management and to do everything possible to prevent specimen-related errors. These errors may lead to inaccurate or incomplete diagnoses, the need for additional procedures, and perhaps most importantly, physical and psychological injury to patients.
References 1. Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:389-418. 2. Bell WC, Young ES, Billings PE, Grizzle WE. The efficient operation of the surgical pathology gross room. Biotechnic Histochem. 2008; 83(2):71-82. 3. AORN Position Statement: Preventing Wrong-Patient, Wrong-Site, Wrong-Procedure Events. http://www.aorn.org/Clinical_Practice/ Position_Statements/Position_Statements.aspx. AORN, Inc. Accessed January 19, 2015. 4. x29 CFR 1910.1030. Hazardous substances. Bloodborne pathogens. 2013. Occupational Safety and Health Administration. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id¼ 10051&p_table¼STANDARDS. Accessed January 19, 2015. 5. Hazardous substances. Formaldehyde. Occupational Safety and Health Administration. xCFR 1910.1048. https://www.osha.gov/ pls/oshaweb/owadisp.show_document?p_id¼10075&p_table¼ STANDARDS. Accessed January 19, 2015. 6. Modifications to the HIPAA privacy, security, enforcement, and breach notification rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; other modifications to the HIPAA rules. Fed Regist. 2013;78(17, Pt 2):5566-5702. http://www.gpo.gov/ fdsys/pkg/ FR-2013-01-25/pdf/2013-01073.pdf. Accessed January 19, 2015. 7. Guideline for information management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:491-512. 8. Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clin Lab Med. 2004;24(4):979-996. vii. 9. Novis DA. Detecting and preventing the occurrence of errors in the practices of laboratory medicine and anatomic pathology: 15 years’ experience with the College of American Pathologists’ Q-PROBES and Q-TRACKS programs. Clin Lab Med. 2004;24(4):965-978.
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10. Lagios MD. Pathology procedures for evaluation of the specimen with potential or documented ductal carcinoma in situ. Semin Breast Dis. 2000;3:42-49. 11. Yaziji H, Taylor CR, Goldstein NS, et al. Consensus recommendations on estrogen receptor testing in breast cancer by immunohistochemistry. Appl Immunohistochem Mol Morphol. 2008; 16(6):513-520. 12. Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2015:67-96. 13. AORN mission and vision. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:2.
Resources Clinical FAQs: Specimens. http://www.aorn.org/clinicalfaqs/specimens/ Webinars-Previously Recorded: Recommended Practices for Specimen Management http://www.aorn.org/Events/Webinars/Previously_ Recorded_Webinars.aspx#RPSpecimen. Graybill-D’Ercole P. RP implementation: specimen management. AORN J. 2014;100(6):625-636. RP summary: recommended practices for specimen management. AORN J. 2014;100(6):637-640. Policy and Procedure Templates [CD-ROM]. 4th ed. Denver, CO: AORN, Inc; 2015. http://www.aorn.org/PolicyandProcedureTemplates/. Perioperative Competency Verification Tools and Job Descriptions [CD-ROM]. Denver, CO: AORN, Inc; 2014. http://www.aorn.org/ CompetencyTools/.
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC is a perioperative nursing specialist, AORN, Inc, Denver, CO. Ms Van Wicklin has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Check back in July 2015 for the next “Back to Basics” topic: Skin Antisepsis.
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EXAMINATION
Continuing Education: Back to Basics: Specimen Management 0.8
www.aorn.org/CE
PURPOSE/GOAL To provide the learner with knowledge of best practices related to specimen management.
OBJECTIVES 1. 2. 3.
Discuss common areas of concern that relate to perioperative best practices. Discuss best practices that could enhance safety in the perioperative area. Describe implementation of evidence-based practice in relation to perioperative nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
2.
To advocate for patients, perioperative RNs 1. adhere to best practices for specimen management. 2. strive to prevent specimen-related errors that may lead to inaccurate or incomplete diagnoses. 3. reduce the risk of the need for additional procedures. 4. prevent physical and psychological injury to patients. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 The nurse conducts a needs assessment when he or she 1. identifies that obtaining a specimen is planned. 2. determines the personnel to be notified. 3. identifies the requirements for specimen collection and handling, transfer, containment, and preservation. 4. determines the required documentation. 5. questions the physician about how the patient should be positioned. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
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3.
Accurate specimen management requires effective multidisciplinary communication, minimized distractions, and awareness of the potential opportunities for error a. true b. false
4.
Confirming the specimen site and the location of tissue, foreign objects, or body substances to be removed from the patient and sent for pathology examination is a best practice but does not affect the occurrence of wrong-site surgery. a. true b. false
5.
Failure to label specimen containers accurately could result in 1. the need for cancelling the procedure. 2. the need for additional procedures. 3. errors or delay in diagnosis or treatment. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3
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LEARNER EVALUATION
Continuing Education: Back to Basics: Specimen Management 0.8
www.aorn.org/CE
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.
PURPOSE/GOAL
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
8.
Our accrediting body requires that we verify the time you needed to complete the 0.8 continuing education contact hour (48-minute) program:__________________________________
To provide the learner with knowledge of best practices related to specimen management.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2.
3.
Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
5.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
www.aornjournal.org
AORN Journal j 565
Back to Basics: Specimen Management 0.8 www.aorn.org/CE
SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Learner Evaluation at http://www .aorn.org/CE. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements.
Event: #15518 Session: #0001 Fee: Members $6.40, Nonmembers $12.80 The contact hours for this article expire May 31, 2018. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to specimen management.
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict of Interest Disclosures Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC, has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.02.012 ª AORN, Inc, 2015
558 j AORN Journal
www.aornjournal.org
Back to Basics: Specimen Management 0.8 www.aorn.org/CE
SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC
ABSTRACT Specific actions for handling various types of specimens may differ; however, the management process is essentially the same. Accurate specimen management requires effective multidisciplinary communication, minimal distractions, and awareness of the opportunities for error. When advocating for patients and working with members of the health care team to provide a safe perioperative environment, perioperative nurses should adhere to best practices for specimen management and strive to prevent specimen-related errors that may lead to inaccurate or incomplete diagnoses, the need for additional procedures, and perhaps most importantly, physical and psychological injury to patients. AORN J 101 (May 2015) 559-563. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.02.012 Key words: specimen handling, specimen management, multidisciplinary communication, distractions, error.
http://dx.doi.org/10.1016/j.aorn.2015.02.012 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 559
Van Wicklin
A
ppropriate specimen management requires that perioperative RNs adhere to best practices for specimen management and strive to prevent errors. Specimen-related errors may lead to inaccurate or incomplete diagnoses, the need for additional procedures, and perhaps most importantly, physical and psychological injury to patients. The following composite case study illustrates the serious consequences that may arise when specimens are mishandled.
Ms S is a 30-year-old married woman who has two children. As a teenager, Ms S was diagnosed with and treated for malignant melanoma. During a routine physical examination, Ms S’s physician detects a mass on her left kidney. Ms S is subsequently scheduled for a needle biopsy of the mass on her left kidney. The interventional radiologist who will perform the needle biopsy tells the perioperative RN that he would like the patient in left lateral position (ie, left side down) for the procedure. The RN assumes that the needle biopsy will be taken from the right side because the patient will be positioned left side down. Based on this assumption, the perioperative RN completes the documentation for a right needle biopsy procedure, including the specimen requisition and the label for the specimen container, before the patient arrives at the facility. Ms S arrives at the facility and signs a consent for a needle biopsy of a mass on the right kidney. She is positioned for the procedure with the left side down. According to the perioperative record, a time out is completed with the right side verified by all team members as being the correct site, although there is some question whether the time out was performed. During Ms S’s procedure, the perioperative RN realizes that she has made an error in the documentation because the interventional radiologist is taking the biopsy from the left side; however, she does not speak up. The perioperative RN corrects some, but not all of the documentation. The perioperative RN does not correct the specimen requisition and label identifying the specimen as a needle biopsy from a mass on the right kidney. The pathologist’s report documents that the biopsy of the mass, labeled as the right kidney, is suspicious for carcinoma. She is advised to seek consultation with a surgeon for removal of her right kidney. The surgeon reviews the pathology report discussing the suspicious characteristics of the needle biopsy specimen from the right kidney and recommends surgical removal, which Ms S undergoes. The pathology report states 560 j AORN Journal
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that her right kidney is normal. Ms Smith and her family believe she has beaten the cancer. At a later date, her physician notifies her that the suspicious mass originally diagnosed involved her left kidney and is still present. After biopsy confirmation that the left kidney mass is malignant, the surgeon removes her left kidney. Although Ms S is now cancer free, she faces treatment by dialysis until a kidney transplant can be found.
HOW-TO GUIDE Although the specific steps for handling various types of specimens may differ, the management process is essentially the same. For example, a frozen section specimen may be handled or preserved somewhat differently than a cytology sample; however, the management process for both specimens is essentially the same. Specimen management is a multifaceted, multidisciplinary process.1 The perioperative nurse conducts a needs assessment after the need for a specimen is identified. This assessment includes determining the personnel to be notified (eg, pathologist for frozen section), requirements for specimen collection and handling (eg, keeping the specimen moist until transfer from the sterile field), method of transfer (eg, using sterile technique), requirements for containment (eg, size of the container), method of preservation (eg, type of solution), transport needs (eg, availability of personnel), disposition of the specimen (eg, disposal, returned to the patient), and documentation required (eg, noting the location of suture tags).1 In addition to the needs assessment, the following outlines the process of specimen management. Site identification is the process of positively establishing or confirming the location of tissue, foreign objects, or body substances to be removed from the patient and sent for pathology examination.1 Collection and handling is the process of obtaining a biopsy or resecting a specimen and the act of holding, securing, moving, or manipulating a specimen.1 Transfer refers to the process of moving a specimen from the sterile field to a containment device.1 Containment involves securing the specimen by placing it in an item used for storage and transport.1 Identification and labeling is the process of affixing information that establishes or indicates the specifications or characteristics of the enclosed sample to a container.1
www.aornjournal.org
May 2015, Volume 101, No. 5
Preservation is the process of protecting a specimen to preserve morphology, reduce the loss of molecular components into solution, prevent decomposition and autolysis, and prevent microbial growth.1,2 Transport refers to carrying or conveying a specimen from one location to another.1 Disposition is the process of positioning or distributing tissue, foreign bodies, explanted items, or body fluids removed from a patient for pathology examination.1 Documentation of nursing activities, such as specimen management, serves as the legal record of care delivery. Documentation of nursing activities is dictated by the facility or health care organization policy, regulatory, and accrediting agency requirements and is necessary to inform other health care professionals involved in the patient’s care.1 Accurate specimen management requires effective multidisciplinary communication, minimized distractions, and awareness of the opportunities for error.1
BENEFITS Following each step of the specimen management process confers benefits to perioperative patients and personnel. Completing an early assessment may help improve processes, increase efficiency, and decrease or even prevent errors related to specimen management.1 Confirming the specimen site and the location of tissue, foreign objects, or body substances to be removed from the patient and sent for pathology examination may help prevent wrong-site surgery.1 Implementing error prevention strategies for the identification and verification of the correct site of specimens to be collected may reduce the risk for error.1,3 Correctly collecting and handling surgical specimens may protect the specimens from compromise that could result in an inaccurate diagnosis, an incomplete diagnosis, or the need for additional procedures or unnecessary surgeries.1 Transferring specimens from the sterile field in a manner that maintains the integrity of the specimen reduces the possibility of compromising the specimen.1 Containing the specimen in a protective and secure manner prevents exposure of health care personnel to blood, body fluids, or other potentially infectious materials and may help prevent damage to the specimen, loss of the specimen, and exposure of health care personnel.1,4 Labeling specimen containers to communicate patient and specimen information can help prevent misidentification of the specimen, its margins, or other information (eg, location of suture tags) that could result in errors or delay in diagnosis or treatment or the need for additional procedures.1
www.aornjournal.org
Back to Basics: Specimen Management
Labeling specimen containers to communicate preservative and biohazard information can help prevent exposure or injury to personnel handling the contained specimen.1,4,5 Preserving specimens in a manner that protects the integrity of the specimen can help preserve specimen morphology, reduce the loss of molecular components into solution, delay decomposition and autolysis, and prevent microbial growth. Unpreserved or incorrectly preserved specimens may be compromised and lead to an inaccurate diagnosis, incomplete diagnostic information, or the need for additional procedures.1,2 Preserving specimens in a manner that prevents the exposure of health care personnel to chemicals, blood, body fluids, or other potentially infectious materials can help prevent injury to personnel handling the contained specimen.1,4,5 Transporting specimens in a manner that protects the integrity of the specimen can help avoid inaccurate or incomplete diagnoses or the need for additional procedures.1 Transporting specimens in a manner that avoids exposing health care personnel to chemicals, blood, body fluids, or other potentially infectious materials can help prevent injury to personnel transporting the contained specimen.1,4,5 Transporting specimens in a manner that maintains the confidentiality of protected patient information prevents violating the confidentiality of personal health information.1,6 Correctly documenting nursing activities related to specimen management according to the policies and procedures of the facility or health care organization and in a manner consistent with regulatory and accrediting agency requirements provides reliable data. This information is necessary to chronicle patients’ responses to nursing interventions and to demonstrate the facility or health care organization’s progress toward quality care outcomes.7
STRATEGIES FOR SUCCESS Reducing errors in specimen management requires a careful review of previous errors, input from those involved in the specimen management process, a careful examination of system flaws and failures that may have contributed to the errors, and to be responsive to analysis and correction.1 The simple application of redundancy to various portions of the specimen management cycle (ie, double-checking the steps of the process) may significantly reduce errors.8,9 Keep the following strategies in mind after viewing the What’s Wrong With This Picture? related to specimen management (Figure 1). In addition to the patient and specimen identification information that must be included on the label, specimens must be labeled to communicate preservative and biohazard information.1 AORN Journal j 561
Van Wicklin
May 2015, Volume 101, No. 5
Figure 1. This depiction of specimen care and handling is wrong because (A) there is an unlabeled specimen in the container on the shelf, (B) the specimen container is leaking, (C) the breast biopsy specimen is drying on an absorbent towel, (D) the breast biopsy specimen has not been fixed within one hour, and (E) the umbilical hernia specimen is falling off the sterile field.
Specimen containers must be leak proof and puncture resistant. This is a regulatory requirement.1,4 Air exposure can desiccate the tissue.10 Dry surfaces may adhere to the tissue, and this can result in loss of portions of the resection margins when the specimen is removed from the dry surface.1,10 Breast cancer specimens should be handled in a manner that preserves the molecular and genetic signatures of
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the specimen.1 Delays in fixation can result in a decreased ability to detect breast biomarkers in the sample. 11 Careful monitoring of specimens that must remain on the sterile field reduces the possibility for the specimen to be lost or compromised.1 Passing specimens off the sterile field as soon as possible reduces the possibility for the specimen to be lost or compromised.1
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May 2015, Volume 101, No. 5
Back to Basics: Specimen Management
WRAP-UP Perioperative nurses play an important role in advocating for patients and working together with members of the health care team to provide a safe perioperative environment.12 The mission of AORN is to promote safety and optimal outcomes for patients undergoing operative and other invasive procedures.13 One basic element of advocating for patients and promoting a safe perioperative environment is to adhere to best practices for specimen management and to do everything possible to prevent specimen-related errors. These errors may lead to inaccurate or incomplete diagnoses, the need for additional procedures, and perhaps most importantly, physical and psychological injury to patients.
References 1. Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:389-418. 2. Bell WC, Young ES, Billings PE, Grizzle WE. The efficient operation of the surgical pathology gross room. Biotechnic Histochem. 2008; 83(2):71-82. 3. AORN Position Statement: Preventing Wrong-Patient, Wrong-Site, Wrong-Procedure Events. http://www.aorn.org/Clinical_Practice/ Position_Statements/Position_Statements.aspx. AORN, Inc. Accessed January 19, 2015. 4. x29 CFR 1910.1030. Hazardous substances. Bloodborne pathogens. 2013. Occupational Safety and Health Administration. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id¼ 10051&p_table¼STANDARDS. Accessed January 19, 2015. 5. Hazardous substances. Formaldehyde. Occupational Safety and Health Administration. xCFR 1910.1048. https://www.osha.gov/ pls/oshaweb/owadisp.show_document?p_id¼10075&p_table¼ STANDARDS. Accessed January 19, 2015. 6. Modifications to the HIPAA privacy, security, enforcement, and breach notification rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; other modifications to the HIPAA rules. Fed Regist. 2013;78(17, Pt 2):5566-5702. http://www.gpo.gov/ fdsys/pkg/ FR-2013-01-25/pdf/2013-01073.pdf. Accessed January 19, 2015. 7. Guideline for information management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:491-512. 8. Valenstein PN, Sirota RL. Identification errors in pathology and laboratory medicine. Clin Lab Med. 2004;24(4):979-996. vii. 9. Novis DA. Detecting and preventing the occurrence of errors in the practices of laboratory medicine and anatomic pathology: 15 years’ experience with the College of American Pathologists’ Q-PROBES and Q-TRACKS programs. Clin Lab Med. 2004;24(4):965-978.
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10. Lagios MD. Pathology procedures for evaluation of the specimen with potential or documented ductal carcinoma in situ. Semin Breast Dis. 2000;3:42-49. 11. Yaziji H, Taylor CR, Goldstein NS, et al. Consensus recommendations on estrogen receptor testing in breast cancer by immunohistochemistry. Appl Immunohistochem Mol Morphol. 2008; 16(6):513-520. 12. Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2015:67-96. 13. AORN mission and vision. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:2.
Resources Clinical FAQs: Specimens. http://www.aorn.org/clinicalfaqs/specimens/ Webinars-Previously Recorded: Recommended Practices for Specimen Management http://www.aorn.org/Events/Webinars/Previously_ Recorded_Webinars.aspx#RPSpecimen. Graybill-D’Ercole P. RP implementation: specimen management. AORN J. 2014;100(6):625-636. RP summary: recommended practices for specimen management. AORN J. 2014;100(6):637-640. Policy and Procedure Templates [CD-ROM]. 4th ed. Denver, CO: AORN, Inc; 2015. http://www.aorn.org/PolicyandProcedureTemplates/. Perioperative Competency Verification Tools and Job Descriptions [CD-ROM]. Denver, CO: AORN, Inc; 2014. http://www.aorn.org/ CompetencyTools/.
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC is a perioperative nursing specialist, AORN, Inc, Denver, CO. Ms Van Wicklin has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Check back in July 2015 for the next “Back to Basics” topic: Skin Antisepsis.
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EXAMINATION
Continuing Education: Back to Basics: Specimen Management 0.8
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PURPOSE/GOAL To provide the learner with knowledge of best practices related to specimen management.
OBJECTIVES 1. 2. 3.
Discuss common areas of concern that relate to perioperative best practices. Discuss best practices that could enhance safety in the perioperative area. Describe implementation of evidence-based practice in relation to perioperative nursing care.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
2.
To advocate for patients, perioperative RNs 1. adhere to best practices for specimen management. 2. strive to prevent specimen-related errors that may lead to inaccurate or incomplete diagnoses. 3. reduce the risk of the need for additional procedures. 4. prevent physical and psychological injury to patients. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 The nurse conducts a needs assessment when he or she 1. identifies that obtaining a specimen is planned. 2. determines the personnel to be notified. 3. identifies the requirements for specimen collection and handling, transfer, containment, and preservation. 4. determines the required documentation. 5. questions the physician about how the patient should be positioned. a. 4 and 5 b. 1, 2, and 3 c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5
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3.
Accurate specimen management requires effective multidisciplinary communication, minimized distractions, and awareness of the potential opportunities for error a. true b. false
4.
Confirming the specimen site and the location of tissue, foreign objects, or body substances to be removed from the patient and sent for pathology examination is a best practice but does not affect the occurrence of wrong-site surgery. a. true b. false
5.
Failure to label specimen containers accurately could result in 1. the need for cancelling the procedure. 2. the need for additional procedures. 3. errors or delay in diagnosis or treatment. a. 1 and 2 b. 1 and 3 c. 2 and 3 d. 1, 2, and 3
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LEARNER EVALUATION
Continuing Education: Back to Basics: Specimen Management 0.8
www.aorn.org/CE
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.
PURPOSE/GOAL
6.
Will you be able to use the information from this article in your work setting? 1. Yes 2. No
7.
Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.)
7A.
How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: __________________________________
7B.
If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: __________________________________
8.
Our accrediting body requires that we verify the time you needed to complete the 0.8 continuing education contact hour (48-minute) program:__________________________________
To provide the learner with knowledge of best practices related to specimen management.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2.
3.
Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High
CONTENT 4.
5.
To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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