A Scoping Review of Interventions to Prevent Lost Surgical Specimens in the Preanalytical Phase

Specimen management is inherently complex. Although rare, lost surgical specimens indicate failure to meet patient safety expectations. Thirteen pieces of evidence were examined through a scoping review to investigate lost surgical specimens during the preanalytical phase. Lost specimens should be recognized as sentinel events. Organizations are encouraged to establish interdisciplinary teams, process-map specimen management according to policies and procedures, use event-reporting systems, and explore systems-level safeguards to minimize opportunities for lost specimens. Intraoperatively, specimens should be placed into containers immediately after collection and confirmed using callout/read-back techniques. Confirming the specimen in the container is essential. Specimen confirmation and review of labeling should take place during the surgical debriefing. Preventing specimen loss necessitates leadership, interdisciplinary collaboration, and proactive adoption of technology-driven systems.