Safety Issues – Patient “Handoff” (part 1)

In 2013, there was a report published by NASA’s top toxicologist that estimated there are between 210,000 and 440,000 patient deaths due to medical errors.  This was further supported by other publications which described the large number of significant errors seen in the US healthcare system.

In his article in the Wall Street Journal, James B. Lieber, author of “Killer Care: How Medical Error Became America’s Third Largest Cause of Death and What Can Be Done About It”, describes several sources of significant medical error.  Interestingly the first that he mentions are the errors that occur during patient “hand-offs”.

While the majority of these issues are by clinicians during the “shift change” period, there are other important times when hand-off’s occur, yet may not be obvious.  One of these is the hand-off of specimens between various health care providers, starting at the time when the specimen is first obtained proceeding through the various stages until the specimen is successfully “grossed-in” within the anatomic pathology laboratory and placed into it’s appropriate tissue processing cassette.

Hand-offs are everywhere

Let’s look at the areas where hand offs occur during the course of a typical specimen, from the time it is obtained to when it is handled in the pathology laboratory, and how the Safety-Spec lab tray can potentially help reduce the incidence of hand off errors.

  1. In the procedure room.  By using the Safety-Spec lab tray, starting in the procedure room, such as a GI endoscopy suite, the incidence of specimen mix ups both between patients (inter-patient err0r) and within a patient biopsy set (intra-patient labeling) errors may be reduced.  By using a unique tray in the procedure area, each biopsy can be properly transferred into the appropriate formalin vial, which is held in order securely, helping prevent mix of of different parts during the patient procedure (intra-patient mislabeling).  At the end of the procedure the surgeon / operator can visually confirm the specimen(s) in the Safety-Spec tray  and ensure they are labeled properly and are all present.  They can then be transported, with the appropriate paperwork, to the laboratory in a sealed plastic bag, with each specimen being held securely.  This also helps prevent mislabeling between patients (inter-patient mislabeling).  
  2. Reduced potential for specimen loss.  Although rare, the chance of a specimen loss from spillage of the formalin vial due to being “knocked over” in the procedure room is substantially reduced by the secure holding of the specimen jars within the Safety-Spec tray.  Having a specimen fall on the floor or counter can result in the loss of the specimen, spoilage due to non-fixation or drying, or mix up with other particles on the floor (dirt).  This can also help in the reduction of the negative impact of a formalin spill would have in a procedure room and the required clean up and ventilation time that would have a deleterious effect on the procedure schedule in the room.

In our next post…we will continue on with 4 more signifiant areas of patient hand-offs.