SPECIMEN MANAGEMENT
Case Study
Unintentional Disposal of a Tissue Specimen
Is a process in place at your facility to secure specimens on the sterile field when required?
In the hand over of care during a surgical procedure, are specimen handling and
disposition discussed?
Is there a process in place to ensure specimens are not lost?
A 40-year-old woman was scheduled to undergo a total parathyroidectomy (ie, removal of all
four parathyroid glands) with heterotopic autotransplantation to treat hyperparathyroidism.
The anesthesia professional drew the patient’s blood for a baseline calcium level after the
induction of anesthesia. The surgeon exposed and excised tissue that was presumed to be
parathyroid gland tissue. The surgeon handed the tissue specimen to the scrub person to secure
on the back table.
The scrub person placed the tissue specimen in a counted surgical sponge moistened with
sterile normal saline and placed it in a kidney basin. The anesthesia professional again drew
blood from the patient to determine the patient’s blood calcium level and to compare it with
the preoperative blood calcium level. Surgical protocol requires obtaining calcium levels
immediately before removal of the glands and 10 minutes after removal of the glands. An
immediate drop in calcium verifies the parathyroid glands have been removed.
The surgical plan included reimplantation of a portion of a parathyroid gland in the patient’s
left forearm. While the team was waiting for the results of the calcium blood level, the scrub
person was relieved for a lunch break. The scrub person did not communicate to his relief that
the specimen was secured on the back table in a moist sponge in a kidney basin. The surgeon
proceeded to close the incision while awaiting the blood test results. The relief scrub person
prepared for a closing surgical count and discarded all counted, used surgical sponges from the
back table, including the sponge containing the tissue specimen.
When the primary scrub person returned from his break, the surgeon requested the tissue
specimen for implantation. The scrub person could not locate the specimen, and it was
discovered in the sponge that was discarded off the sterile field. The tissue was no longer sterile
and could not be used for autotransplantation. As a result, the patient will require lifetime
calcium supplements.
TAKEAWAY The specimen location and plan for disposition should be documented and
communicated in the hand over of care to ensure specimens are maintained
and preserved until needed.
Copyright © 2016 AORN, Inc. All rights reserved. The facility and events depicted in this case study are fictitious. Similarity to any event, organization, or person living or
Used with permission. dead is merely coincidental.
SPECIMEN MANAGEMENT
Case Study
Forgotten and Discarded Specimen
Are policies and procedures in place at your facility for documentation of the chain
of custody from the time a specimen is removed from the patient until it reaches the
pathology lab?
A 54-year-old woman presented to the surgery center for a right breast lumpectomy for cancer.
After excision of the breast lesion, the circulating nurse placed the specimen in a container
without fixative or solution and called a surgical aide to transport the fresh specimen to the
laboratory. The surgical aide was in the midst of cleaning an OR between procedures. He
informed his colleagues of the request to transport the specimen to the lab and went to pick up
the specimen.
After the specimen was handed off to the aide and he was en route to the pathology lab, he
received a call on his hospital-issued phone-pager asking him to return immediately to the OR
he had been cleaning to verify instruments for the next procedure. On his return to the OR, the
aide placed the specimen on the counter in the workroom with the intention of returning to
transport the specimen to the lab.
When he returned to the workroom, the specimen was no longer on the counter. The aide
immediately reported the missing specimen to his supervisor. They conducted a search but
could not locate the specimen. The surgical aide decided it must have been discarded.
The surgeon was informed of the lost specimen after the procedure was completed. Because
he was not able to confirm that the margins of the breast specimen were clear, the surgeon
informed the patient that she may need additional surgery in the future.
TAKEAWAY Having procedures in place to ensure specimens arrive at the lab in a timely
manner and are not left unattended in an undesignated place may prevent
errors related to lost specimens. In addition, delays in transport may delay
placement of the tissue specimen in fixative, which could affect the integrity of
the specimen.
Copyright © 2016 AORN, Inc. All rights reserved. The facility and events depicted in this case study are fictitious. Similarity to any event, organization, or person living or
Used with permission. dead is merely coincidental.
