Related Experiment Video
Updated: Mar 15, 2026
Surgical Robot-Assisted Transanal Specimen Extraction Radical Sigmoidectomy Without an Auxiliary Abdominal Incision
Published on: June 13, 2025
Surgical Specimen Management: A Descriptive Study of 648 Adverse Events and Near Misses
Victoria M Steelman1, Tamara L Williams, Marilyn K Szekendi
1From the College of Nursing, University of Iowa, Iowa City (Dr Steelman); the Department of Safety Intelligence Patient Safety Organization (Ms Williams), the Research Institute (Dr Szekendi), and the Safety Intelligence Program (Dr Pavkovic), Vizient, Inc, Chicago, Illinois; the Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago (Dr Halverson); and the Department of Anatomic Pathology, University of Washington Medical Center, Seattle (Dr Dintzis). Vizient, Inc, was formerly known as University HealthSystem Consortium.
Context:
- Surgical specimen adverse events can lead to delays in treatment or diagnosis, misdiagnosis, reoperation, inappropriate treatment, and anxiety or serious patient harm.
Objectives:
- To describe the types and frequency of event reports associated with the management of surgical specimens, the contributing factors, and the level of harm associated with these events.
Design:
- A retrospective review was undertaken of surgical specimen adverse events and near misses voluntarily reported in the University HealthSystem Consortium Safety Intelligence Patient Safety Organization database by more than 50 health care facilities during a 3-year period (2011-2013). Event reports that involved surgical specimen management were reviewed for patients undergoing surgery during which tissue or fluid was sent to the pathology department.
Results:
- Six hundred forty-eight surgical specimen events were reported in all stages of the specimen management process, with the most common events reported during the prelaboratory phase and, specifically, with specimen labeling, collection/preservation, and transport. The most common contributing factors were failures in handoff communication, staff inattention, knowledge deficit, and environmental issues. Eight percent of the events (52 of 648) resulted in either the need for additional treatment or temporary or permanent harm to the patient.
Conclusions:
- All phases of specimen handling and processing are vulnerable to errors. These results provide a starting point for health care organizations to conduct proactive risk analyses of specimen handling procedures and to design safer processes. Particular attention should be paid to effective communication and handoffs, consistent processes across care areas, and staff training. In addition, organizations should consider the use of technology-based identification and tracking systems.
Insights
Surgical specimen management errors, particularly in labeling and transport, can harm patients. Improving communication, training, and technology can enhance patient safety in pathology specimen handling.
Area of Science:
- Pathology
- Patient Safety
- Healthcare Management
Background:
- Surgical specimen adverse events pose risks including diagnostic delays, misdiagnosis, and patient harm.
- These events can necessitate reoperation or lead to inappropriate treatment and significant patient anxiety.
Purpose of the Study:
- To analyze the types and frequency of adverse events in surgical specimen management.
- To identify contributing factors and the level of patient harm associated with these events.
Main Methods:
- Retrospective review of 648 voluntarily reported adverse events and near misses.
- Data collected from over 50 healthcare facilities between 2011-2013.
- Focused on events involving tissue or fluid sent to pathology post-surgery.
Main Results:
- Most events occurred pre-laboratory, specifically in specimen labeling, collection/preservation, and transport.
- Key contributing factors included communication failures, staff inattention, knowledge gaps, and environmental issues.
- Eight percent of events (52/648) led to additional treatment or patient harm.
Conclusions:
- Errors can occur at all stages of surgical specimen handling and processing.
- Healthcare organizations should proactively analyze risks and design safer processes.
- Enhancing communication, standardizing processes, improving staff training, and utilizing technology are crucial for reducing errors.
