Specimen Management

AORN Guideline for
Specimen Management
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.
Developed and originally presented by
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA(E), CPSN-R, PLNC
Senior Perioperative Practice Specialist, AORN
• BSN and MSN: Middle Tennessee State University

• Membership: Phi Kappa Phi, Sigma Theta Tau Honor Society
• Certification:
– CNOR
– CRNFA (RN first assistant)
– CPSN (plastic and reconstructive surgical nursing)
– PLNC (legal nurse consultant)
• Recipient: AORN Outstanding Achievement in the Application of
Perioperative Clinical Research Award, 2005.
These slides were taken from the webinar Recommended Practices for Specimen Management, presented August 20, 2014. To listen
to the webinar, visit https://www.aorn.org/Events/Webinars/Previously_Recorded_Webinars.aspx. These slides are made available
for educational use. Slides may be personalized for your facility and presentation. HOWEVER, THE VIEWS EXPRESSED IN THESE SLIDES
ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE VIEWS OF AND SHOULD NOT BE ATTRIBUTED TO AORN.
Objectives
1. Describe the specimen management
process
2. Explain best practices for handling
surgical specimens
3. Identify alternatives to formalin for
specimen preservation
4. Discuss recommendations for
specimen disposition
Specimen Management
• The AORN guideline

depicts the actions
and role of the
perioperative RN
as the manager of
the patient’s care
• The specimen
management process
is the same for all
types of specimens
Specimen Management
• Needs assessment
• Site identification
• Collection and handling
• Transfer
• Containment
• Identification and labeling
• Preservation
• Transport
• Disposition
• Documentation
Specimen Management
• The guideline provides guidance for

management of surgical specimens in the
perioperative practice setting, including
– Breast cancer specimens
– Amputated digits and limbs
– Forensic specimens
– Radioactive specimens
– Explanted medical devices
– Explanted orthopedic hardware
Specimen Management
The guideline does not cover:

• Surgical techniques for resection of
specimens
• Clinical laboratory
specimens
– Refer to 42 CFR 493,
Laboratory Requirements
Specimen Management
Requires:
• Multidisciplinary communication
• Minimized distractions
• Awareness of opportunities for error.
Errors can lead to
– inaccurate or incomplete diagnoses
– the need for additional procedures
– physical and psychological injury
Specimen Management
• Most errors are caused by

– Slips (unintended actions)
– Lapses (omissions of intended actions)
• Errors are a result of automatic
actions, which makes them difficult to
prevent
• Redundancy has the potential to
reduce errors
Recommendations
Recommendation I
• Early assessment
– Should begin when the need for obtaining a
specimen is identified
• Assess cultural
preferences
• Preoperative briefing
Recommendation II
• Confirm the specimen site

• Display photographs that help to
identify the location of dermatologic
lesions to be removed and reduce the
risk of wrong site surgery
Recommendation III
• Collection and handling

– Breast cancer specimens
– Amputated digits and limbs
– Forensic specimens
– Radioactive specimens
– Explanted medical devices
– Explanted orthopedic hardware
Recommendation III
• Breast cancer specimens

1. Document
a. Time of excision
b. Time of fixation
2. Time from excision to

fixation should be less than
one hour
Recommendation III
• As the specimen is excised, reduction and

elimination of blood flow results in
progressive hypoxia, ischemia, and tissue
degradation
• Nucleic acid and protein changes occur
that can negatively affect accuracy of the
histological examination and biomolecular
evaluation of the sample
Recommendation III
• Nucleic acid and protein changes cease

when the fixation process begins
• Individualized chemotherapeutic agents
used to treat breast cancer are derived
from molecular and genetic signatures
found in the sample
Recommendation III
• Amputated digits and limbs

– Cool
– Handle gently
– Wrap in moist sponges
– Place in a plastic bag, then in another
plastic bag or chest filled with ice
Recommendation III
• Forensic evidence
– Establish the chain of custody
– Document informational evidence
• patient statements, bodily marks, blood stains,
unusual odors
– Take photographs
– Label each piece of evidence
– Place evidence in a sealed evidence bag or
envelope
Recommendation III
• Radioactive specimens
– Use standard precautions
– Policies and procedures should
• be developed by a multidisciplinary team
• align with local, state, and federal regulations
• define when personal shielding and exposure
monitoring is required
Recommendation III
• Explanted medical devices

– Collect and handle according to
• the health care organization’s policies and
procedures
• manufacturers’ instructions
• local, state, and federal regulations
Recommendation III
• Explanted medical devices that are subject to

medical device tracking regulation must be
reported to the manufacturer
• Serious injury related to an implanted medical

device must be reported to the device
manufacturer
• Deaths related to an implanted medical device

must be reported to both the manufacturer and
the US Food and Drug Administration
Recommendation III
• Explanted orthopedic hardware

– Follow the health care organization’s
policies
– Verify that the explanted hardware has
not been recalled by the manufacturer
– Document return of the explanted
hardware
Recommendation III
• Explanted orthopedic hardware

– May be excluded from
submission to the
pathologist for
examination, provided
there is an alternative
policy in place for
documentation of
surgical removal
Questions and Answers
Recommendation IV
• Transfer of specimen from the sterile

field
– Use standard precautions and sterile
technique
– Maintain cellular structure
– Keep the specimen moist
– Don’t place on dry surfaces
• Transfer as soon as possible
• Verify identity of the specimen
– Use a “write down, read back” technique
Recommendation V
• Specimen containment
– Use leak-proof
containers
– Containers should be
large enough to
• fully contain the
specimen
• allow the preservative
to contact all surfaces
Recommendation VI
• Identification and labeling

– Confirm
• Patient identification using two unique
identifiers
• Identification of the specimen with the
surgeon using a “write down, read back”
technique
– Verify specimen identification and labeling
during debriefing
Recommendation VI
• Debriefing verification should include

– Visual confirmation that the specimen is in
the container
– Verification that
• patient information on the label and requisition
is correct
• the number and types of specimens are correct
• the specimen has been correctly fixed
– Confirmation of other pertinent information
Recommendation VI
• Discard or remove unused labels from

the procedure room at the end of
procedure.
• Affix identification labels to the
container not the lid.
• Label specimen containers to
communicate chemical preservative
and biohazard information.
Recommendation VII
• Locations where formalin is dispensed

– Posted signs warning of formaldehyde use
– Eyewash stations
available in the
immediate area
– Ventilation
requirements
Recommendation VII
• Eyewash stations
– Travel time no greater than 10 seconds
– Unobstructed access on
same level with no doors
• Store formalin outside
of the procedure room
Recommendation VII
• The volume of formalin used to fix

specimens is not agreed upon
– Varies between
2:1 and 20:1
– Volume ratio should
be determined by
the pathologist
Recommendation VII
• Formalin
– Most widely used chemical for tissue fixation
– Toxic and potential carcinogen
– May not provide the most effective
preservation of genetic and biomolecular
signatures
Recommendation VII
• Alternatives to formalin
– Under-vacuum sealing
– Honey-based fixatives
– Alcohol-based fixatives
– Ethanol
– Formalin substitutes
Recommendation VIII
• Transportation of specimens
– Must be stored in a manner that
maintains integrity of the specimen
– Must be labeled to communicate chemical
and biohazard information
– Must be transported in a manner that
protects personal health information
Recommendation IX
– Policies and procedures for disposition of

specimens should
• state that a pathologist will perform an
examination of the specimen when requested
by the physician or licensed independent
practitioner or when the pathologist determines
a pathology examination is indicated
Recommendation IX
• address the diagnostic needs of medical

personnel, including the potential for discovery
of significant findings in specimens that are
typically exempted from pathology
examination, and address the potential for
medicolegal implications
• include an alternative procedure for
documenting the removal and disposition of
any specimens or devices not submitted to the
pathologist for examination
Recommendation X
Nursing activities
related to specimen
management should be
documented in a
manner consistent with
facility or health care
organization policies
and procedures and
regulatory and
accrediting agency
requirements.
Specimen Management
Specimen Management
Specimen Management: Answers
A. There is an unlabeled
specimen in the
container on the shelf
(VI)
specimen in the
(VI)
B. The specimen container
is leaking (V.b.)
specimen in the
(VI)
is leaking (V.b.)
C. The breast biopsy
specimen is drying on
an absorbent towel
(III.a.2.)
specimen in the
(VI)
is leaking (V.b.)
an absorbent towel
(III.a.2.)
D. The breast biopsy
specimen has not been
fixed within one hour
(III.a.1.)
specimen in the
(VI)
is leaking (V.b.)
an absorbent towel
(III.a.2.)
D. The breast biopsy
specimen has not been
fixed within one hour
(III.a.1.)
E. The umbilical hernia
specimen is falling off
the sterile field (IV.b.)
References
Guideline for specimen management. In: Guidelines for Perioperative
Practice. Denver, CO: AORN, Inc.
1.Slides 11, 13, 17, 20, 23, 30, 36,

37, 38, 39, 57, 58, 59, 66:
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AORN Guideline for

• BSN and MSN: Middle Tennessee State University

• The AORN guideline

• The guideline provides guidance for

The guideline does not cover:

• Most errors are caused by

• Confirm the specimen site

• Collection and handling

• Breast cancer specimens

2. Time from excision to

• As the specimen is excised, reduction and

• Nucleic acid and protein changes cease

• Amputated digits and limbs

• Explanted medical devices

• Explanted medical devices that are subject to

• Serious injury related to an implanted medical

• Deaths related to an implanted medical device

• Explanted orthopedic hardware

• Explanted orthopedic hardware

• Transfer of specimen from the sterile

• Identification and labeling

• Debriefing verification should include

• Discard or remove unused labels from

• Locations where formalin is dispensed

• The volume of formalin used to fix

– Policies and procedures for disposition of

• address the diagnostic needs of medical

1.Slides 11, 13, 17, 20, 23, 30, 36,

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