91ÊÓƵ

DEFINE

• Specimens labeled incorrectly
• Specimens missing
• Specimens placed in wrong container
• Objective: No incorrectly labeled specimen containers, no specimens placed in wrong containers, no missing specimens, 100% real-time timeout charting compliance

MEASURE

Current state:

• May 6, 2021 – Lost specimen. Specimen bag was under patient pillow and removed with linens.
• August 31, 2021 – Specimen from patient A at 11:02 am never sent to pathology. Patient B specimen collected at 2:56 pm and had several GE biopsy fragments, but only had colonoscopy.
• January 5, 2022 – Specimen F from patient A at 9:32 am was place in patient B container D at 10:27 am collection time.
• February 1, 2022 – Specimen D had fragments of gastric mucosa for a cecal polyp.
• February 28, 2022 – Specimens B and C were both labeled distal esophagus, and specimen C was supposed to be labeled proximal esophagus.

ANALYZE

• Events during procedure: Staff are being pulled from specimen collection when patient is having “airway issues,” and staff are needing to assist with that.
• Four to five specimen containers are being placed on the field for collection.
• Specimens collected during an EGD are remaining on the field while the next procedure (colonoscopy) is occurring.
• Circulators are documenting timeout ahead of time and not in real time.
• Staff continue to work and not actively participate in timeouts.
• Circulators were leaving specimens on the counter at the nurses’ station.

IMPROVE

Staff education occurred on the following process change:

• Prior to the start of a procedure, ensure specimen containers and a label printer are in the room.
• ONE specimen container on the field at a time; verify it is empty prior to use.
• Verbally clarify specimens at the time of collection with the provider; include A, B, C, etc., with the name of the specimen.
• If the circulator is pulled away from specimen collection, a huddle is completed once the patient is stable, and review of the collected specimens occurs prior to further specimen collection.
• TWO-person check occurs for correct labeling of specimens, labels printed and applied to containers, and documentation occurs in real time.
• If there are two procedures, complete a timeout after the first procedure, include a specimen check, then IMMEDIATELY move specimens to the back counter, and the snare is rinsed so no tissue remains.
• During timeout, everyone stops what they are doing and actively participates, specimens are verified that they are identified and labeled correctly.
• Specimens will be placed in a basket outside the room before the patient is moved.
• Charge nurse/float will pick up specimens, verify specimens against lab requisition and view each container for specimen, then initial with the circulator on the bag to indicate that double-check occurred.
• Charge nurse/float must initial the book, verifying the specimen was placed in the basket for lab pick-up.
• No specimens are left in the procedure room.

CONTROL

Results:

• Through random observation after process implementation, there was 100% specimen timeout compliance and 100% real-time charting compliance.

Process improvement maintenance:

• Annual competency through Net learning
• Policy updated reflecting changes
• Will continue random observation audits and follow up as needed

We hope sharing this project summary will be useful to you and your practice. Learn more about gaining honoree status in the 91ÊÓƵEndoscopy Unit Recognition Program. EURP honoree units may use the 91ÊÓƵQuality Star logo in promotions of their units, receive premium educational content bimonthly via an exclusive e-newsletter The Huddle and enjoy a range of additional benefits. Questions should be directed to eurp@ASGE.org.