The loss of pathological specimens: incidence and causes.

Background: Tissue biopsy loss can have devastating clinical and legal consequences.

Objective: To evaluate the incidence and cause of tissue biopsy loss.

Methods & Materials: The study followed biopsy specimens taken by one plastic surgeon in an outpatient clinic between October 2001 and April 2005. Four thousand two hundred minor surgical procedures were performed, and 4,400 biopsy specimens were sent to pathology. In case of specimen loss, a formal investigation was performed.

Results: Five specimens were reported as lost during the period. Two were retrieved, two were lost probably because of failure to insert the pathology specimen into the container, and one was lost in the pathology laboratory during processing. Overall incidence of specimen loss was 1 in 1,466 (0.068%).

Conclusions: In this study, we identified the critical point of specimen loss to be noninsertion of the specimen into the container by medical staff. To prevent future errors at this critical point, strict guidelines such as immediate insertion of the specimen into the container and signing on the container confirming that the specimen is in the correct labeled container at the end of the procedure are recommended.