A number of specimens had been sent to the pathology department from the operating theatre, incorrectly labeled, resulting in the specimen being returned for correct identification. Whilst there were no adverse events from the incorrect labeling, the potential to cause harm was identified. It was recognised that there was a need for a tracking process to ensure the correct labeling of multiple specimens.

A team developed a specimen register and checking system to ensure that correct patient details and specimen information is attached to the pathology container before leaving the theatre. A three month trial resulted in 100% of specimens correctly identified and recorded on the checklist prior to transport to the pathology department. As a result of these changes, the pathology results are available to the clinician in a timely manner to allow optimal ongoing patient care.

To ensure that 100% of specimens collected from patients/clients in the operating theatre are correctly labeled before transportation to the pathology department by December 2005.

There was no formal process for ensuring correct labelling of multiple specimens collected from the same patient during a procedure. The type of specimen and correct site was often not correctly identified on the container resulting in the return of the specimen for correct identification. While this caused a delay in the return of the results, no adverse events were reported in the Incident Information Management System (IIMS).

Anecdotal evidence indicates that over a period of two months approximately 25% of specimens associated with endoscopy procedures were returned for correction of labelling resulting in:

• Double handling of specimens attributing to increased transport costs of approximately $600 (5 specimens returned for identification) 
• Associated delays of up to seven days to receive pathology results
• Delayed patient diagnosis
• Potential for wrong patient diagnosis and treatment

A team consisting of representation from: The Operating Theatre: Registered Nurses and Enrolled Nurses (RN's, EN's), Pathology Department, Surgeon, RN or EN representative from Rural referral hospitals and Representative from smaller rural hospitals was formed to flow chart and review the exiting processes in place for checking and labeling of multiple pathology specimens. This showed that there was inconsistency in the process and no formal structure or process to follow. A cause and effect diagram was developed grouping the problems that were identified.

Meetings were held informally by discussion at the end of a theatre list to make use of the surgeon's time participating in the process and the pathology technician used teleconference facilities.

During these sessions it was identified, that there was a breakdown in the identification of specimens during the process of collection of multiple specimens during endoscopy procedures. Time and rushing the procedure was also identified as a contributing factor with no formal checking systems in place after specimens were collected.

Two rural referral Hospitals and six smaller rural Hospitals were interviewed via phone using a simple questionnaire to determine current processes in place at these facilities.

The following were identified as the main contributing factors:

• There were no formal processes in place for the labeling of multiple specimens at any of the facilities.
• Time constraints was an issue during the collection of specimens, with 95% of facilities surveyed having specimens returned after collection from endoscopy with incorrect identification of specimen.

Best practice was researched through literature review and consultation with Hunter Area Pathology Service, surgeons and other Operating Theatre Managers.

Operating theatre staff in consultation with the team formulated a protocol/procedure for the handling of specimens in line with the best practice guidelines. The major point in this process was that all multiple specimens be labeled and checked by two staff members, ideally one being the Surgeon. Documentation at the time the specimen was taken with each specimen numbered and exact location was considered imperative when multiple specimens were taken from the one patient.

A decision was made to develop a checklist and trial a formal process that could be standardized and used throughout the Rural Operating Theatres. The checklist was trialled for a three-month period and was readily accepted by staff.

Since the implementation of the checklist, protocol/ procedure, there has been nil adverse events and 0% of specimens returned from the pathology department incorrectly labeled.

A meeting was held to inform staff of the outcomes and those not present were informed by a written report.

100% of staff have embraced the process this is evident in the compliance of the checking system and documentation. There is increased level of awareness of the importance of correct documentation and labeling of multiple specimens at the time the specimen is collected. It was evident that there was an increased level of confidence in the staff from the surgeon and pathologist and less stress on staff working in the Operating Theatre during the collection of multiple specimens.

Specimen collection will continue to be monitored, however, it is believed that staff enthusiasm and ownership will support sustainability.

This project could be adapted for any small unit where endoscopy surgery is performed. The checklist could also be used when collecting multiple specimens during any procedures. Interest has been shown from other units contacted prior to undertaking the project.