14 - Procedural Specimens: Evaluating Processes using an Interdisciplinary Approach

Description: The team was comprised of an Operating Room (OR) Clinical Nurse Specialist, OR Nursing Professional Development Practitioner, OR Registered Nurse, two surgeons, a lab manager, pathology supervisor, microbiology lab scientist, Radiology Manager, Interventional Radiology Nurse, informatics nurse specialist, quality and safety support consultant, nurse consultant, and a continuous improvement consultant. Groups impacted include OR personnel, interventional radiology and endoscopy suite teams, clinical lab staff, and pathology.

Seattle Children's Hospital records numerous annual specimen processing errors, some resulting in treatment delays or requiring repeat invasive procedures. An analysis revealed that defects often occur during Epic ordering, sampling/procurement, storage, and transportation. After determining the targeted improvement area to be high risk specimen, an interdisciplinary team was assembled to create an improvement plan for collecting/processing specimen. The scope of this workgroup excluded Epic ordering and blood specimen.

The group convened for two full-day in-person sessions to review current state and identify improvement opportunities. Changes were suggested regarding clarity in timeouts, labeling, and chain of custody. To standardize timeouts, the team would use uniform descriptors for specimen (Formalin, Fresh, Frozen, Micro, Research). The term "permanent" was retired due to its ambiguity.

To improve identification, colored labels were used to indicate how specimen should be processed. Existing labeling protocols were reinforced: frozen specimen are labeled with a pink "Frozen" sticker, and fresh specimen are labeled with a green "Fresh" sticker. New labels were introduced for microbiology specimen (yellow "Micro" sticker), and for specimen shared between microbiology and pathology (orange "Shared" sticker).

It was concluded that verifying specimen receipt by the lab was more impactful than confirming that it was sent. During surgical sign-out, the OR nurse would verify that the specimen was marked "In Process," signifying receipt by the lab. Staff would transport formalin specimen after case.

Chain-of-custody documentation was revised to enhance accountability. A form was implemented requiring staff members to print their names alongside the date and time of specimen drop off and receipt. This also enabled more accurate follow-up in the event of a transport issue.

The specimen policy was updated and supporting materials developed to aid in implementation. During the second workgroup session, simulations were conducted to test and refine the proposed workflow. Once processes were confirmed, group members provided education to their teams. OR staff received education at an in-service and an email outlining the changes. Visual aids were distributed.

After implementation of changes, there was a 40% reduction in the rate of specimen defects from the OR and IR to pathology.

Feedback gathered from rounding indicates that, while specimen collection/processing remains complex, it is clearer following the changes made by this workgroup.

The multidisciplinary approach played a crucial role in reducing defects by offering comprehensive insights and highlighting the impact of OR workflows on specimen processing. The guidelines established by this group may be replicated on other units or in facilities facing specimen defect challenges. Ongoing evaluation is essential as we continue to optimize the workflow.