Reducing Surgical Specimen Errors Through Multidisciplinary Quality Improvement

Published:April 20, 2021DOI:


      Each year, our institution performs more than 34,000 surgical cases and obtains close to 10,000 surgical specimens. Within those procedures, we averaged 10 errors for every 1,000 surgical specimens. Any level of preventable harm is unacceptable, as it could lead to risks of treatment delay, improper therapy selection, or missed diagnoses. This quality improvement (QI) effort aimed to decrease errors in surgical specimens from 10 errors per 1,000 surgical specimens to 0 errors each month.


      Using the Institute for Healthcare Improvement Model for Improvement QI methodology, we determined the root causes of error, identified key drivers, and tested change interventions. We implemented changes in surgical specimen labeling, standardized specimen time-out and reconciliation processes, and optimized a method of communication between consultants, surgeons, operating room staff, and laboratory staff with the implementation of a Specimen Request Form.


      Over 46 months, we identified 234 specimen errors in 33,962 surgical pathology specimens. 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.


      A multidisciplinary project team implemented changes to specimen test requesting and intraoperative specimen handling with an associated reduction in errors to reduce potential patient harm involving surgical specimen errors. This article demonstrates how applying these methods and interventions can be associated with a reduction in surgical specimen errors.
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        • Steelman VM
        • et al.
        Surgical specimen management: a descriptive study of 648 adverse events and near misses.
        Arch Pathol Lab Med. 2016; 140: 1390-1396
        • Smith ML
        • Raab SS.
        Assessment of latent factors contributing to error: addressing surgical pathology error wisely.
        Arch Pathol Lab Med. 2011; 135: 1436-1440
        • Institute of Medicine
        To Err Is Human: Building a Safer Health System.
        National Academy Press, Washington, DC2000
        • Simundic A-M
        • Lippi G.
        Preanalytical phase—a continuous challenge for laboratory professionals.
        Biochem Med (Zagreb). 2012; 22: 145-149
        • Troxel DB.
        Error in surgical pathology.
        Am J Surg Pathol. 2004; 28: 1092-1095
      1. (editor)Nakhleh RE Error Reduction and Prevention in Surgical Pathology. Springer, New York2015
        • Makary MA
        • et al.
        Surgical specimen identification errors: a new measure of quality in surgical care.
        Surgery. 2007; 141: 450-455
        • Hung S-H
        • et al.
        Integration of value stream map and Healthcare Failure Mode and Effect Analysis into Six Sigma methodology to improve process of surgical specimen handling.
        J Healthc Eng. 2015; 6: 377-398
        • Scoville R
        • Little K.
        Comparing Lean and Quality Improvement.
        Insitute for Healthcare Improvement, Cambridge, MA2014 (IHI white paperAccessed Apr 25, 2021)
        • Morvay S
        • et al.
        Medication event huddles: a tool for reducing adverse drug events.
        Jt Comm J Qual Patient Saf. 2014; 40: 39-45
        • Provost LP
        • Murray SK.
        The Health Care Data Guide: Learning from Data for Improvement.
        Jossey-Bass, San Francisco2011
        • Lloyd R.
        Quality Health Care: A Guide to Developing and Using Indicators.
        2nd ed. Jones & Bartlett Learning, Burlington, MA2017
        • Slavin L
        • Best MA
        • DC Aron
        Gone but not forgotten: the search for the lost surgical specimens: application of quality improvement techniques in reducing medical error.
        Qual Manag Health Care. 2001; 10: 45-53
        • Hollensead SC
        • Lockwood WB
        • Elin RJ.
        Errors in pathology and laboratory medicine: consequences and prevention.
        J Surg Oncol. 2004 Dec 1; 88: 161-181