AORN Guideline Gap Analysis Tool: Specimen Management Insert Facility Name Or a Header

AORN Guideline Gap Analysis Tool: Specimen Management[Insert facility name or a header]

Meets Recommendation? / Comments/Actions
Yes / No
Recommendation 1: The perioperative registered nurse (RN) should incorporate specimen management needs when developing the plan of care.
Are policies and procedures in place that address:

the need for contracting with a third party when on-site pathology, laboratory, or courier services are needed?

patients’ requests for handling specimens in a nontraditional manner?

specimen management assessment and planning among surgical team members as part of the perioperative briefing before operative or other invasive procedures?

Recommendation 2: The perioperative RN should complete a preoperative assessment that confirms the site identification of specimens to be collected.
Are strategies (such as taking photographs) in place for the identification and verification of the correct site of specimens to be collected?
Recommendation 3: Specimens should be collected and handled in a manner that protects and preserves the integrity of the specimen.
Are policies and procedures in place for collecting and handling the following types of specimens (if applicable for your facility)?

specimens of breast tissue to be examined for cancer

amputated digits to be reimplanted

amputated limbs to be reimplanted

forensic specimens

radioactive specimens

explanted orthopedic hardware and medical devices

other specimens requiring special handling

Recommendation 4: Specimens should be transferred from the sterile field in a manner that maintains the integrity of the specimen.
Are procedures in place that address specimen transfer, including when a specimen remains sequestered (secured) on the back table?
Recommendation 5: Containment of the specimen should be completed in a manner that protects and secures the specimen and prevents exposure of health care personnel to blood, body fluids, or other potentially infectious materials.
Are specimen containers selected and purchased based on the following criteria?

leak proof and puncture resistant

correct size and type (large enough to fully secure the specimen and preservative fluids)

large enough to allow the preservative solution, if used, to contact all surfaces of the specimen

accommodate labeling requirements

Recommendation 6: Specimen containers should be labeled to communicate patient, specimen, preservative, and biohazard information.
Are policy and procedures in place for:

confirmation of patient identification using two unique identifiers at the time the specimen is removed from the patient and placed into the container?

verbal confirmation between the surgeon and the perioperative RN circulator?

specimen identification that should be confirmed and documented,including:

facility or healthcare organization-defined unique patient identifiers?

the origination source of the specimen, including laterality if applicable?

type of tissue?

clinical diagnosis and additional pertinent clinical information (such as location of suture tags)?

specimen identification and labeling confirmation among surgical team members during the debriefing at the end of the procedure?

Recommendation 7: Specimens should be preserved in a manner that protects the integrity of the specimen and prevents exposure of health care personnel to chemicals, blood, body fluids, or other potentially infectious materials.
Are policies and procedures in place for:

the location where formalin is stored and used according to state and federal regulations?

personal protective equipment required when handling formalin?

disposal of chemicals used for preservation of specimens?

acceptable alternatives to formalin for tissue fixation or preservation as determined by the pathologist and surgeon?

Recommendation 8: Specimens should be transported in a manner that protects the integrity of the specimen; prevents exposure of health care personnel to chemicals, blood, body fluids, or other potentially infectious materials; and maintains the confidentiality of protected patient information.
Do policies and procedures for specimen transport include:

chain of custody from the time the specimen is removed, handed off to transport personnel, and transported to pathology lab?

storage and transport of specimens to maintain specimen integrity for examination (for example, refrigeration)?

use of clean secondary packaging or containment devices to prevent contamination of personnel and the environment during transport of specimens?

Recommendation 9: Policies and procedures for disposition of specimens should be established in accordance with local, state, and federal regulations by a multidisciplinary team that includes pathology laboratory representatives, facility or health care organization physicians, and perioperative RNs.
Do the policy and procedures for disposition of specimens include:

pathology reports generated for every specimen submitted to the pathologist?

receipt of laboratory testing or pathology reporting results to the physician?

verification that laboratory testing or pathology reporting results are added to the patient’s health record?

tissues or other specimens that require only gross identification or disposal?

Recommendation 10: Nursing activities related to specimen management should be documented in a manner consistent with facility or health care organization policies and procedures.
Does documentation related to specimen management include:

patient identification?

specimen identification?

additional information (such as location of suture tags)?

pathology examination required?

request for special handling (such as return of explanted hardware to the patient)?

physician identification and contact information?

perioperative RN identification?

Does the policy and procedure require direct communication between the pathologist and the physician related to diagnosis or specific information about the specimen (for example,frozen section)?
If this communication is not possible, is a read back verification of the information provided and documentation in the patient’s health record required?