An intervention study to reduce the loss of pathology specimens.

Background: loss of an excised lesion can have devastating clinical and legal consequences. Previously, the incidence of pathological specimen loss was 1/1466 (0.07%) due to failure to place pathology specimens in correctly labeled containers. We theorized that a strict protocol for handling specimens would help reduce losses.

Objectives: To devise a protocol to reduce the loss of pathology specimens.

Methods: In this study, 7105 specimens excised by one plastic surgeon were sent to the pathology laboratory using a strict protocol, which included: using a carefully labeled specimen container, inserting the specimen into the container immediately after excision (not at the end of the procedure), positioning the specimen container close to the surgical field during the surgery, and both the nurse and surgeon signing their names on the container at the end of the procedure to confirm the contents and labeling.

Results: One Mohs specimen was accidentally thrown away by a pathology laboratory technician after the frozen section report was written (an incidence of 1/7105, 0.00014%). All specimens arrived at the pathology department and no lesions were lost in the operating room.

Conclusions: A strict written protocol for specimen handling significantly reduces loss of pathology specimens.