70 - Achieving Zero Specimen Error Events in Our High Reliability Organization Journey

Description: Our operating room is currently on a High-Reliability Organization (HRO) journey. HROs are organizations that operate in high-risk environments and consistently minimize adverse events by fostering a culture of safety, continuous learning, and robust systems. They emphasize a preoccupation with failure, deference to expertise, and a commitment to resilience and reliability by following Just Culture. The goal of the HRO journey is to achieve zero harm.

From January to March 2025, our operating room experienced a total of six specimen-related errors, including misplacement, missing specimens, accidentally thrown-out specimens, and unlabeled specimens (January 2025 -2, February 2025 - 1, March 2025 - 3). The patient safety goal in our operating room is zero harm. In response, we implemented a system-wide intervention in April 2025. This included the enforcement of the Just Culture algorithm to assess all specimen-related events, distinguishing between human error, at-risk behavior, and reckless conduct. Errors resulting from recklessness or consistent neglect were subject to disciplinary action.

To address the recurring specimen issues, the Operating Room Manager, Assistant Nurse Manager, and Clinical Education Coordinators formed a dedicated task force. The team collaborated to identify gaps in current practices and implement targeted interventions. The key action was the development and rollout of mandatory education on proper specimen handling. The mandatory education was introduced for all staff involved in specimen transfer, including Registered Nurses (RNs), Surgical Technologists (STs), and Support Technicians. All staff members completed the mandatory specimen training by mid-May and acknowledged the expectations and consequences related to specimen management. Staff members were also encouraged to report systemic issues and speak up about unsafe behaviors, reinforcing a culture of transparency and shared responsibility. "No specimen error since 3/31" was posted prominently on the huddle board and reinforced during monthly staff-manager meetings to sustain awareness and celebrate continued success.

A leader can hold staff members accountable while fostering Just Culture that promotes patient safety (Leadership Insights, 2025). This includes providing educational opportunities and applying progressive disciplinary actions when necessary (Leadership Insights, 2025). Following the implementation of these targeted interventions, specimen errors were reduced to zero in both April and May, highlighting the effectiveness of education, accountability, and Just Culture in supporting the organization's HRO goals.

Reference
Leadership Insights. (2025, March 27). Promoting a Patient Safety Culture. AORN Journal, 121(4), 291-294. https://doi.org/10.1002/aorn.14329