Raising the bar for safety in the handling of surgical specimens Is this specimen fresh or frozen? Is it routine, or does it require a lung protocol?

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1 Patient safety Raising the bar for safety in the handling of surgical specimens Is this specimen fresh or frozen? Is it routine, or does it require a lung protocol? Does it go to the frozen section lab or the microbiology department? Proper labeling and handling of surgical specimens are critical to reduce the risk of misdiagnosis and the need for repeat surgery. Decreasing specimen-handling defects is one goal of the Michigan Health and Hospital Association (MHA) Keystone: Surgery collaborative, which aims to reduce surgical complications and mortality by 5%. The collaborative has made a difference: The defect rate declined by more than 50% from 3.18% to 0.46% from 2010 to Keystone: Surgery members from 3 hospital systems described their efforts to improve specimen handling. Ensuring a specimen chain of custody Sparrow Hospital in Lansing, Michigan, had begun improving specimen safety before joining Keystone: Surgery in Using failure mode and effects analysis (FMEA), a team had identified what needed to be fixed or improved. Becoming part of Keystone has enhanced our process even further, says Lynn Raynor, MSN, RN, CNOR, clinical nurse specialist, surgical services at Sparrow. One improvement is a process to ensure the chain of custody for a specimen: The chain begins when the surgeon hands a specimen to the surgical technologist (ST) and tells the ST what the specimen is and what process is needed in the lab. The ST hands off the specimen to the circulating nurse, repeating what the surgeon said. The nurse labels the specimen container and places the specimen in the container. The nurse completes the tissue requisition and initials it. The requisition is also initialed by the transporter and the lab person who accepts the specimen. During the debriefing at the end of the case, the circulating nurse announces all specimens obtained; if no specimens were obtained, that is also announced. A copy of the lab requisition is filed by date in a binder at the OR front desk, in a step suggested by an OR secretary. This helps ensure that all specimens intended to be delivered to the lab actually were delivered. The OR secretary makes sure the transporter brings a copy of each requisition back from the lab. The lab requisition was revised to include an extra copy for the binder. This has been helpful on a couple of occasions to clarify questions, notes Raynor. Tracking specimen data The Sparrow OR in collaboration with the lab tracks specimen data so the number and types of errors can be identified using a tool developed by Keystone: Surgery. If we see any trends, we can hone in on what s happening and correct it, says Raynor. Early in the collaborative, Raynor says the OR saw process errors decline to zero over a 6-month period because of improvements identified through the tracking information. 1

2 We have learned we have to keep our finger on the pulse to spot and correct any errors, she says. It s also necessary to reinforce the new process with the staff and physicians. A safety board in the OR reports a running count of days without specimen errors and communicates any safety information and lessons learned from errors. Learning from defects A learning-from-defects tool has been instrumental in preventing errors, says Mary Pride, BSN, RN, department manager. The tool is part of the Comprehensive Unit- Based Safety Program (CUSP) and is provided by Keystone. The tool guides caregivers and leaders through a defect analysis to identify what contributed to the defect and how to prevent it from recurring. This tool helped identify a potential source of errors by the OR assistant who transports specimens to the lab. He noted that he often was distracted by a phone call to pick up a frozen section that must be delivered to the lab immediately while he was reconciling routine specimens in the specimen room to take to the lab. The solution was to declare a no-distraction zone when the OR assistant is reconciling specimens, says Pride. Before entering the specimen room, the assistant gives up his phone to focus on ensuring consistency between the specimen requisitions and the tissue log. He then takes those specimens to the lab and does not pick up his phone until he returns to the OR. Another OR assistant covers the phone while he is gone. The learning-from-defects tool has been super-helpful, says Pride. She notes that in discussing a defect, we make sure everyone understands that it s absolutely nonpunitive and is for our learning to prevent further errors. Standardizing processes At the Henry Ford Health System in Detroit, Michigan, the OR, pathology, and laboratory medicine have worked together to standardize processes, notes Rita D Angelo, MS, CQE, SSBB, manager, Quality Systems Division, Pathology and Laboratory Medicine. D Angelo is managing 2 teams of nurses, pathologist assistants, and quality specialists with the goal to create one standard approach to collect, label, and deliver specimens to the lab. Henry Ford had begun looking at specimen defects long before it joined Keystone: Surgery and realized the pathology lab received a considerable amount of inaccurate or incomplete information from other departments, says D Angelo. We realized we didn t have a clearly defined standard of work or training on either side. We had defective processes, she says. In starting to working with Keystone: Surgery, We already had a good idea of what was missing and what was needed. Videos aid communication In their work, the Henry Ford teams learned surgeons and nurses did not necessarily communicate complete information about specimens. The surgeon identified the specimen as it was taken from the patient, but the nurse didn t always hear the surgeon or know how to spell the name of the specimen. To illustrate the correct process, D Angelo filmed a training video for the nurses on how to collect and label the specimens. The nurses were thrilled with it, but they suggested the surgeons also needed to see it, she says. She made a second video in which a surgeon spoke to the surgeons about what 2

3 SURGICAL SPECIMEN SUBMISSION ROUTINE PROTOCOL SECTION LYMPHOMA WORK-UP LUNG PROTOCOL MICROBIOLOGY SPECIMEN ROUTINE LYMPHOMA LUNG MICRO MICROBIOLOGY DEPARTMENT Mon-Fri, 8am-5pm: leave at frozen section window Off-hours and weekends: leave in frozen section refrigerator notify Pathology before Monday-Friday, 8am-5pm CALL Off-hours and weekends PAGE On-call staff: 3300 (Resident) or 2281 (Pathologist) Generic label for additional requests for assistance Mon-Fri, 8am-5pm: CALL Off-hours and weekends: PAGE On-call staff at 3300 (Resident) or 2281 (Pathologist) The specimens are labeled with a color-coded sticker for timesensitive or special-handling specimen streams A color-coded specimen submission form created by the Henry Ford Health System. was required in handing off a specimen to make sure the circulating nurse knew the correct information. The surgeons pointed out that after they call out the specimen, they move on to another part of the procedure and may not have time to make sure the nurse heard the specimen information correctly. The nurses noted that they and the surgeons did not use the same nomenclature for specimens, leading to the realization that the pathology department had not provided a list of specimen types for reference. Training the surgeons and getting them involved were milestones, but we re realizing other things we still have to do, says D Angelo. Developing standard work To develop standard work, 3 teams of nurses and pathology personnel are observing processes in both departments. The teams will then develop a standardized process to handle specimens in the OR and hand them off to the lab. At that point, they will include the surgeons. All will vote on the process to adopt. The physician steering committee will roll out the process to the rest of the clinicians and staff. The standardized process will be included in the OR s new Epic software, which will automate the requisition and submit it to the lab electronically. When the lab receives the specimen, the requisition will be waiting. 3

4 Meanwhile, the IT department is creating a site using Microsoft s Sharepoint software. Circulating nurses will document their frozen sections, and the information will be viewed in the frozen section room so lab personnel know what specimens are coming out of each OR. As part of standard work, the OR has introduced a color-coded labeling system to denote the tissue type and test (illustration, p 10). When the lab receives the specimen, it knows what test is needed and where the specimen needs to go. Each OR has a poster of the color-coding system. Standardizing the process requires time and effort, D Angelo notes, but it has lowered the specimen defect rate to about 2 a week from about 40 a month before the Keystone project began. Steps to guide handoffs Marquette General Hospital in Michigan s Upper Peninsula has revised its specimen handoff communication protocol based on its involvement with Keystone, says Patricia Wills, BSN, RN, CNOR, director of clinical education for perioperative services. Although there had been a policy on handoff communication for specimens, it wasn t necessarily followed, Wills notes. She and team members educated the staff about the process and developed these steps: The surgeon calls out the name of the specimen; the ST repeats the name to the circulating nurse; the nurse repeats back the specimen name and receives verification from the surgeon. Music is to be turned down and conversation held to a minimum during specimen collection. If circulating nurses are gathering multiple specimens for frozen sections, they must call the OR desk to send help, which could be a floating RN, an ST, a manager, or an educator. Communicating with pathologists As the pathologists have begun requiring new tissue-handling processes for certain specimens, communication and education with the pathologists are doubly important, says Wills. An example is requiring certain specimens, such as lung tissue, to be transferred in a sterile manner, which had not been done before. The head of the pathology department gave an in-service session for the OR staff about the new processes. The OR had to determine which sterile containers to use to transfer specimens because some of the lung tissue samples were large. At the beginning, bone jars intended for large bone flaps were used, but the $10 cost was prohibitive. Instead, the staff decided to use a sterile basin covered with a sterile adhesive drape. Another staff idea was color-coded specimen requisitions. Bright yellow requisitions are now used for specimens that require special handling, such as frozen sections and breast specimens sent fresh that need to be processed within an hour. The requisition for routine specimens is white. Included on the special-handling requisition are: reason for evaluation OR number name of circulating nurse name of surgeon who requested special handling time placed on dumbwaiter lift to the lab test requested. 4

5 The goal is to decrease requisition errors to 0 to 1 per month, a goal that is being met in most months. Judith M. Mathias, MA, RN More on Keystone: Surgery is at Have a question on the OR revenue cycle? Keith Siddel will respond to questions in the column. Send your questions to editor@ormanager.com You can also reach Siddel at ksiddel@hrmlc.com. Copyright Access Intelligence. All rights reserved. 888/