Recommended practices for the care and handling of specimens in the perioperative environment

AORN Journal,  March, 2006  

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1. Documentation should include, but not be limited to,

* type of specimen;

* patient name, age, gender, health care organization, history, and diagnosis;

* studies required;

* date and time of collection;

* information pertinent to the specimen or source;

* surgeon's name and contact number; and

* the registered nurse doing the preparation and documentation of the specimen for transport.

2. Documentation via printed tools should be used to minimize errors related to handwriting and inaccuracies. When handwritten documentation is required, it should be accurate and legible. Common reasons for pathology errors are unlabeled containers, insufficient patient identification, and incomplete or illegible information. Technology applications, such as bar coding, may be used to minimize errors. (12)

3. Specimen identification and requisition forms should accompany the specimen in a manner that protects the form and keeps it secured with the specimen.

4. Documentation should establish the chain of custody from the point of removal until pathological examination. Chain of custody is required for tissue specimens as well as material removed for forensic examination (see Recommended Practice IX).

5. Methods should be implemented to accurately record critical information such as tissue margins or orientation of the tissue as it relates to the anatomy, special tests requested, or disposition of the specimen. Requests for other than routine handling should be noted (eg, decalcification, x-ray, freezing). Delays or misdiagnosis can occur when the information is not accurately or completely communicated for the examination. (1)

6. Criteria for verbal and written specimen identification should be established to prevent misinformation. Commonly used methods include "write down, read back" verification of verbal communication. Communication should include, but not be limited to,

* physician to physician,

* physician to scrub person,

* scrub person to registered nurse circulator, and

* physician to registered nurse circulator.

7. Any communication between physicians, such as pathologist and surgeon, should be direct (ie, not through an intermediary) when it relates to diagnosis or specific diagnostic information about the specimen. A record of communication should be documented in the patient's record, such as the direct report of frozen section results to the surgeon. If communication directly between physicians is not possible, it should be written, marked with the date and time, and included in the patient's record.

8. If the patient requests to keep a removed item (eg, implanted medical device), the nurse should follow procedures for identification and standard precaution guidelines per health care organization policy.

9. Requests for specimens to be returned to the patient should follow health care organization policy after the pathology examination is complete.

10. Disposition of all removed tissue, devices, and implants should be documented on the operative record according to health care organization policy or state guidelines.