Tracing Missing Surgical Specimens: A Quality Improvement Strategy for Adverse Events Based on Root Cause Analysis

Area of Science:

• Healthcare Systems
• Patient Safety
• Medical Error Analysis

Background:

• A 2022 incident involved a misplaced surgical specimen from a rectal prostate procedure, requiring repeat surgery.
• This critical event highlighted systemic vulnerabilities in medical specimen handling and error management.

Purpose of the Study:

• To investigate systemic vulnerabilities in healthcare specimen handling processes.
• To analyze the causes of medical errors in specimen management.
• To implement and evaluate interventions to improve patient safety.

Main Methods:

• Root Cause Analysis (RCA) was employed to identify workflow gaps and organizational factors.
• Interventions included redesigning workflows, standardizing specimen labeling with color-coding, and implementing electronic tracking.
• Staff roles were clarified, and specimen handling protocols were enhanced.

Main Results:

• Post-intervention, the visual recognition rate of sealed specimen vials improved to 100% using a dual-color system.
• No surgical pathology specimens were lost in the two years following the implementation of interventions.
• The study demonstrated a significant reduction in medical errors related to specimen handling.

Conclusions:

• Root Cause Analysis-driven reforms effectively addressed systemic flaws in specimen management.
• Targeted process redesign, ergonomic tools, and digital tracking mitigate medical error risks.
• Analyzing workflow failures within systemic contexts is crucial for resilient, patient-centered care.