AUTHOR BIOGRAPHIES
Sara Angelilli, DNP, MS, RN, Allegheny Health Network
Sara Angelilli (sara.angelilli@ahn.org) currently serves as the director of Clinical Nursing Operations at Allegheny Health Network, providing strategic and operations support to nine hospitals. Angelilli received her doctoral degree with a specialization in nursing administration and dual master’s degrees in nursing education and leadership and industrial and organizational psychology. She is dual certified in perioperative nursing and nursing professional development.
*Corresponding author
Lisa Feathers, MT(ASCP), Allegheny Health Network
Lisa Feathers is the director of Quality in the Pathology Institute of Allegheny Health Network in Pittsburgh, Pennsylvania. She is a passionate advocate for quality and patient safety in laboratory medicine, with over 30 years of experience in the field. Feathers holds a Bachelor of Science degree in medical technology from West Virginia University (1987) and a certificate in process improvement from Intermountain Health system (2010).
Michelle McGonigal, DNP, RN, Allegheny Health Network
Michelle McGonigal is a healthcare leader dedicated to optimizing patient outcomes and fostering a culture of excellence. As network director of Quality and Patient Safety at Allegheny Health Network, she ensures the highest standards of care. Dr. McGonigal’s expertise spans nursing, quality improvement, and patient safety, and she holds multiple certifications. She earned her doctor of nursing practice degree from Waynesburg University. She is a sought-after speaker and author, sharing her insights on quality and patient safety. Dr. McGonigal’s leadership style emphasizes collaboration, empowerment, and patient-centered care, creating high-functioning teams committed to continuous improvement.
ABSTRACT
Background
Surgical specimen handling is a complex, multidisciplinary process that involves ordering, collecting, labeling, preserving, transporting, testing, and reporting results so a patient receives a diagnosis or treatment plan. A multihospital healthcare network identified specimen handling as a problem-prone process.
Methods
A project team formed to complete a failure mode and effects analysis (FMEA), identify high-risk specimen-handling steps, and implement practice changes to prevent future specimen-handling errors. The project team used the FMEA seven-step process to evaluate the practice problem and identify opportunities for improvement.
Intervention
The project team identified 82 failure modes in the FMEA. The 10 failure modes with the highest risk score were selected for a process improvement project. The perioperative project subteam and pathology laboratory project subteam initiated process improvement efforts after evaluating evidence-based practices for the 10 highest-risk process steps.
Outcomes
The project has been sustained through monthly quality monitoring and reporting. At the time of this publication, 11 months post-implementation, no serious events for surgical specimens have been reported.
Plain Language Summary
When a surgical team decides to collect a specimen for testing, this kicks off a complex process that involves many steps and many individuals across many disciplines. Specimen handling involves ordering, collecting, labeling, preserving, transporting, testing, and reporting results. The sooner this analysis is completed, the sooner the patient can be diagnosed and treated. However, such an involved, highly collaborative process is prone to problems along the way that can delay or prevent timely and appropriate treatment.
A multihospital healthcare network experienced two serious events that prevented a patient from receiving a diagnosis or treatment plan, one in which a specimen was lost and one in which a specimen was mislabeled. This network processes approximately 22,500 specimens quarterly with an error rate of 1.6 per 1,000 cases. Recognizing specimen handling as a problem-prone workflow, a quality team conducted a failure mode and effects analysis (FMEA) that identified 82 failure modes, including inconsistent workflows, workarounds, human factors, and knowledge gaps. The team focused on process improvements that would address the top 10 high-risk failure modes. Implementing and sustaining interventions guided by evidence-based practices—such as barcode tracking of specimens, use of read-backs to confirm orders and hand-offs, double checks, and education—in the operating room and gastrointestinal lab has resulted in zero reports of serious events.
