SHM Converge Scientific Abstract ePoster Gallery-Standardization of Endoscopic Specimen Collection With Multi-Step Verification Strategies

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This quality improvement project addressed specimen errors in an endoscopy suite, where mislabeled, misplaced, or empty biopsy containers can cause patient harm and legal risk. Two specimen error events occurred within 30 days at a Sanford endoscopy center: in one case, duodenal tissue was placed in the wrong container and the intended container was empty; in another, an esophageal biopsy container had no tissue while the other contained the expected squamous mucosa. These events highlighted how complex specimen collection is and how errors can occur at multiple steps, including patient identification, lesion identification, biopsy, container placement, labeling, and laboratory delivery.<br /><br />The project’s goal was to standardize the collection process and reduce errors by using the S.T.A.R. patient safety model: Stop, Think, Act, Review. Several verification strategies were implemented. These included a two-staff-member verification process for the six-step collection workflow, direct visualization of tissue in each specimen cup, read-back and confirmation of collected samples by the endoscopist at the end of the procedure, immediate resolution of any discrepancies, and removal of filled specimen cups from the endoscopy suite to prevent cross-contamination between cases.<br /><br />A staff stand-down was also held to reinforce communication between the person placing tissue into the cup and the endoscopist, especially regarding tissue adequacy. The team plans to track specimen error rates over the next year to evaluate the effectiveness of the standardized process and each verification step. The authors hope this approach will improve patient safety in endoscopy and may be useful in other specimen collection settings as well.

Asset Subtitle

Nikitha Sathish Kumar

Meta Tag

Author List John Bassett, Nikitha Sathish Kumar

Category Innovations

Concept Specimen Error

Concept Patient Harm

Concept Diagnostic Specimen Acquisition

Concept Specimen Labeling

Concept Endoscopy

Distinguished Non-Finalist

Presenter Organization University of North Dakota - Internal Medicine Residency Program

Presenting Author Nikitha Sathish Kumar

Track Quality Improvement

Keywords

specimen errors

endoscopy suite

biopsy containers

patient safety

specimen collection

labeling errors

S.T.A.R. model

verification process

tissue adequacy

quality improvement

Specimen Error

Patient Harm

Diagnostic Specimen Acquisition

Specimen Labeling

Endoscopy