QI Project Aims to Reduce Surgical Specimen Collection Errors

The collection of surgical specimens is a routine process that occurs daily in hospitals across the US. If those specimens are handled improperly, preventable harm, such as delays in treatment or missed diagnoses, can occur.*

Specimen collection is a manual process that can be complicated by several challenges, such as:

  • Unclear communication
  • Lack of ownership
  • Difficult to understand electronic systems

In a study published in the September 2021 issue of The Joint Commission Journal on Quality and Patient Safety, Jessica B. Holstine, MBOE, and Julie Balch Samora, MD, PhD, MPH, chronicled their work in creating an interdisciplinary quality improvement (QI) task force to decrease errors in surgical specimen collection in operating rooms (ORs) and interventional radiology suites from 10 errors per 1,000 surgical specimens to zero by December 31, 2019.

“At our pediatric institution, we obtain close to 10,000 surgical specimens each year, with a baseline error rate of 10 errors per 1,000 surgical specimens each month, including errors in identification along with mishandling, incorrect test ordering, and other events,” the authors wrote. “A previously published rate of 0.4 errors per 1,000 specimens focused on errors in the surgical specimen identification process steps, including labeling, laterality, site, and patient identifiers.

“In addition to the potential adverse clinical outcomes, previous studies indicate that the cost of surgical specimen error can be high.”

The study authors formed a team of representatives from staff across nursing, surgery, radiology, medical consultation, laboratory, pathology, information technology, and QI services to review all documented errors from January 2017 to May 2018. The team identified 648 errors over that period of time.

Using the Institute for Healthcare Improvement Model for Improvement QI methodology, the study authors determined the root causes of the errors and identified the key solutions:

  • Optimized specimen request/order process
  • Effective communication between services
  • Updated standard work for specimen collection processes
  • Standard specimen triage and transport practices
  • Optimized anatomic pathology process for surgical specimens

Study Results

The group then tested the change interventions. Over the course of 46 months, the team identified 234 specimen errors in 33,962 surgical pathology specimens, and the error rate was reduced from 10 to 2.31 errors per 1,000 specimens. The mean rate of order errors decreased from 3.66 to 0.13 per month, and the mean rate of labeling-related errors decreased from 1.5 to 0.5 per month.

“Through this collaborative QI effort, we were able to reduce our rate of surgical specimen error by nearly 80%,” the authors wrote. “Through these interventions, we have reduced the risk for preventable harm for our patients, such as avoiding potential diagnostic delay or error, and preventing returns to the OR for repeat procedures to obtain more specimen.”

The study—“Reducing Surgical Specimen Errors through Multidisciplinary Quality Improvement”—is available here.


The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

*Steelman VM, Williams TL, Szekendi MK, Halverson AL, Dintzis SM, Pavkovkic S. Surgical specimen management: A descriptive study of 648 adverse events and near misses. Arch Pathol Lab Med. 2016;140(12):1390-1396.

Holstine JB, Samora JB. Reducing surgical specimen errors through multidisciplinary quality improvement. Jt Comm J Qual Patient Saf. 2021;47(9):563-571. Available at: https://www.jointcommissionjournal. com/article/S1553-7250(21)00096-9/ fulltext. Accessed January 7, 2022.

Tagged as: , ,

Notify of
Inline Feedbacks
View all comments


Bulletin of the American College of Surgeons
633 N. Saint Clair St.
Chicago, IL 60611


Download the Bulletin App

Apple Store
Get it on Google Play
Amazon store