Surgical specimen handover from the operating theatre to laboratory—Can we improve patient safety by learning from aviation and other high‐risk organisations?

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During a hospital episode or admission, patients will often need the expertise of many different hospital departments and specialties and pass from one high‐risk “sector” to another. This commonly occurs in the surgical treatment of head and neck cancer, where following complex ablative and reconstructive surgery, patients are transferred to the intensive care or high dependency unit. A thorough handover is essential to ensure that vital information is communicated between clinical teams. Evidence suggests that a structured approach using a checklist will reduce communication failures and the risk of potential patient harm.1
Where possible, a checklist should be as simple to use as possible both to ensure staff engagement and improve quality of care provided.2
While the WHO checklist has significantly reduced near miss and never events (as their name implies, they should never happen and include retained instruments or swabs and wrong site surgery), these incidents still continue to occur.3 Towards the end of a surgical procedure, the WHO checklist is used to aid ongoing patient safety, such as the need for possible thromboembolic prophylaxis.
Compliance with the WHO checklist can also reduce the chance of errors with labelling of pathology specimens during this sign out period.4 It is perhaps not surprising that errors completing pathology forms and mislabelling of specimens may occur after a long operation, where surgeons and junior staff may be tired and finish tasks in a rush. In our own practice, we advocate taking breaks at regular intervals to minimise fatigue and possible error.6
However, it is not just in the operating theatre environment where error and safety issues occur. The use of pins and needles to orientate neck dissection specimens on boards enabling lymph node levels to be analysed with precision can result in needle stick injuries for pathology laboratory staff, and this has occurred in our own unit. As a result, the use of rubber bands has been advocated for specimen orientation,7 but these are not universally used and injuries will undoubtedly continue to occur. Additionally, although rare, processing errors occur once the specimen has arrived in the laboratory,8 which can have potentially disastrous consequences for a patient, particularly if a wrong diagnosis is made as a result.
Human error can be categorised broadly into four main domains or levels9 (with examples relevant to pathology specimen handling):
These four levels are well known in aviation and other high‐risk organisations (HRO) such as air traffic services and motor racing. The first three levels of error are termed active failures, representing the decisions, attitudes or actions of individuals or teams, while latent failures result from errors occurring in an organisation itself.9 The familiar Swiss cheese model occurs when deficiencies (holes in the cheese) occur across all four levels and align to cause an error or adverse incident to occur.11
Latent failures contributing to error in pathology are well known and include failures of appropriate transfer of knowledge, poor safety culture and a lack of standardised protocols.

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