OCTOBER 2004, VOL 80, NO 4 Guidance Statement

AORN Guidance Statement Safe Specimen Identification,

Collection, and Handling in Perioperative Practice Settings

PREAMBLE: The purpose of this guidance state- ment is to provide a framework from which practitioners can develop and implement poli- cies and procedures for safe specimen account- ability via identification, collection, and han- dling in perioperative practice settings. These settings include traditional O h , ambulatory surgery settings, physician’s offices, cardiac catheterization suites, endoscopy suites, radiol- ogy departments, and all other areas where operative and other invasive procedures may be performed. Specimen removal is an invasive and high-risk procedure that requires cautious attention to communication and identification of the patient, specimen type, and other infor- mation specific to the specimen. Attention should be given to the patient’s cultural needs as they relate to specimen handling. Precautions and handling to protect the specimen and the individuals handling a specimen are identified.

In this document, the term OR is meant to include perioperative practice settings. The term specinien hndling is meant to include identifying, collecting, labeling, preserving, storing, prepar- ing for transport, documenting, and communi- cating. Specimens refer to blood, body fluids, tis- sue, or other specimen types removed from the patient, implanted, or reinfused, including those sent for pathological or gross examination, cul- ture, and sensitivity or other studies.

A sample protocol is presented with the understanding that it ultimately is a facility’s responsibility to develop and implement defined protocols specific to individual practice settings based on state regulations. A health care facility should establish a zero tolerance organi- zational philosophy about handling specimens outside of defined protocols from the viewpoint of the potential for systems failures and should seek systems solutions to prevent errors.

GUIDANCE STATEMENT Health care facilities should incorporate a

policy that identifies which people or job cat- egories are responsible for specimen han-

dling as well as processes required for each specimen type. A policy for safe specimen handling should identify a protocol for speci- men delivery to the location of examination or use and acceptable methods of communi- cation about the specimen before and during a procedure.

Health care facilities should develop stan- dardized procedures for safe specimen han- dling in the OR to ensure patients remain free from injuries related to handling. Elements of safe specimen handling should include, but not be limited to,

specimen containment; identification, including

patient identification that uses at least two identifiers, tissue and specimen identification, and source identification;

transferring specimens from the sterile field; transferring specimens to the point of use (eg, sterile field, person implanting); labeling specimen container(s) on and off the field; accurately identifying the chain of custody for the specimen; documenting

laboratory requisition(s), in the patient’s record, chain of custody, and verbal/written communication;

verifying correct information (eg, specimen type, patient information) before transfer- ring the specimen; storing and maintaining specimens until transfer; transferring or facilitating transfer of the specimen for examination; and using risk reduction strategies. Specimen identification, collection, and

handling are multidisciplinary tasks that require vigilant attention to detail so that each person understands the patient’s needs, com- munication needs, and information about the specimen. Misidentification or mishandling

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Guidance Statement OCTOBER 2004, VOL 80, NO 4

can lead to adverse outcomes, including inac- curate or incomplete diagnosis, incorrect han- dling of the tissue, or the need for repeated procedures. Risk reduction can occur via the following. 0 Provide personnel with appropriate and

timely education related to specimen collec- tion and handling and repeat competency validation as policies and procedures change.

0 Develop procedures for reporting and responding to specimen collection and han- dling errors and near misses, as well as reviewing trends with a focus on error reduction.

0 Modify work schedule requirements in the surgical setting to minimize the risk of fatigue-induced errors.

0 Implement constraints to minimize risks related to specimen collection and handling. Constraints might include

required audible verification (ie, read back) of patient identification, specimen type, and requirements for handling between personnel or departments at points of transfer; identified communication requirements when the pathologist is notified or a report is communicated to the periopera- tive setting; and labeling requirements for containers, req- uisition forms, and other documents.

0 Incorporate forcing functions that might

containers that eliminate exposure to formalin, supplies that improve patient identifica- tion and specimen labeling, or supplies that prevent mishandling of the specimen.

0 Simplify steps and provide easy-to-use labeling and handling processes. Steps should include accurate, complete verbal and written communication among care- givers to ensure correct specimen collection, labeling, and handling.

0 Make safe equipment and supplies readily accessible for specimen collection and handling.

include required use of

SAMPLE PROTOCOL FOR SAFE SPECIMEN HANDLING I N THE OR

1. Verify specimen or tissue collection and handling needs at the time an operative or other invasive procedure is scheduled. Verification should take place before an operative or invasive procedure to reduce time required during the procedure and to ensure appropriate notification of personnel and correct collection and handling or deliv- ery of the specimen.

2. Obtain containers, labels, requisition forms, and the preservative or fixative appropriate for the type of testing or delivery. Collection containers must be impervious and of an adequate size to easily contain a specimen. Sterile receptacles and equipment must be used for specimens when sterility must be maintained.

3. Confirm patient and specimen or tissue information by repeating the information (eg, type, location, required tests) and con- firming it with information on the patient’s record at the time a specimen is removed or implanted. The responsibility for communication should be identified to include, but not be limited to, the physi- cian(s) and the RN. Special tissue handling needs should be confirmed with the physi- cian and pathologist.

4. Contain specimens on the field by using ster- ile receptacles of an adequate size for the tis- sue, fluids, or other specimen types. Speci- mens should be handled with caution to maintain their integrity (eg, prevent crush- ing, tearing, or rupture of cells). Containment at the time of removal ensures a specimen will remain intact for examination and elimi- nates possible contamination of personnel.

5. Use standard transmission precautions and sharps precautions (eg, when fluid is removed via needle aspiration, the speci- men should be delivered to a container rather than sent for examination in a syringe with the needle intact) to protect individuals handling specimens. Labels should clearly identify the need for pre- cautions and the presence of biohazardous materials.

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OCTOBER 2004, VOL 80, NO 4 Guidance Statement

Label specimen containers immediately when a specimen is delivered to any con- tainer or contained area on or off the field. Require legible, accurate handwriting or labeling without abbreviations on containers, requisitions, and other documentation. Information might include, but is not limited to, the source or type of specimen, studies required, patient history and diagnosis, date and time of collection, specimen identifica- tion, and other pertinent information. Establish mechanisms for chain of custody to ensure accountability. Consistent commu- nication patterns should be established between personnel at change of shift or relief. Secure closed containers with 10% forma- lin solution. Open these containers only in areas designated for this purpose that have adequate ventilation to prevent inhalation of fumes and exposure to the preservative. Protective equipment must be worn by personnel handling containers with 10% formalin. Any container with formalin should be handled with the same precau- tions (eg, labeling, verifying contents) as a medication.

10.Transport specimens to the delivery location in a timely manner. If transport cannot be completed immediately, the specimen must

be stored in a location and at a temperature appropriate for the specimen type.

11.Establish direct communication methods about a specimen that ensure one-to-one communication between physicians during an operative or invasive procedure. If this is not possible, information should be written down and verified for accuracy before the message is delivered. These activities should be documented in the patient’s record. 4.

RESOURCES Hendricks, S. ”Handling cultures and speci-

mens,” in Perioperatiue Nursing Practice, ed M L Phippen, M P Wells (Philadelphia: WB Saunders

Phillips, N M. Berry & Kohn’s Operating Room Technique, 10th ed (St Louis: Mosby, 2004) 474.

”Recommended practices for standard and transmission-based precautions in the periopera tive practice setting,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004)

“Recommended practices for sur ical tissue

Guidelines (Denver: AORN, Inc, 2004) 385-395. Rothrock, J C; Smith, D. “A patient and environ-

ment,” in Alexander’s Care ofthe Patient in Surgery, 12th ed, J Rothrock, ed (St Louis: Mosby, 1999) 36.

”Sentinel event statistics,” Joint Commission on Accreditation of Healthcare Organizations, Iittp: //www.jcaho.org/accredited+organ iza t ions/ofice+basedd+ surge y/senti~~el+events/se~stats.pdf (accessed 1 June 2004).

CO, 1994) 279-295.

361-365.

banking,” in Standards, Recomrnende B Practices and

he Wound, Ostomy, and Continence Nurses T Society (WOCN) has released a new clinical guideline intended for use by health care profes- sionals who direct, provide, or specialize i n wound care for patients with lower extremity neuropathic disease, according t o an Aug 12, 2004, news release from WOCN. The guideline includes etiology; overall management goals; and information about assessment, intervention, and neuropathic wound prevention .

Lower extremity neuropathic disease occurs as a result of damage t o specific nerve structures. I n patients who are diabetic, metabolic changes tha t occur as a result of hyperglycemia and insulin defi- ciency contribute t o progressive functional and structural defects that damage peripheral nerve tis-

New Guidelines for Wound Management Available sue. This damage produces neurological deficits t ha t result in reduced or altered perception o f tem- perature, touch, and pain.

viding research-based, clinical information with a goal of producing improved, cost-effective patient outcomes. It also provides impetus for education and a framework for future research. Copies o f the guide- line can be purchased online a t http://www.wocn.org or by calling WOCN a t (888) 224-9626.

The guideline supports clinical practice by pro-

Wound, Ostomy and Continence Nurses Society Releases New Clinical Guideline for the Treatment of Lower- Extremity Neuropathic Disease (news release, Glenview, Ill: Wound, Ostomy and Continence Nurses Society, Aug 12, 2004).

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