The surgeon dissected the patient’s ovary and tube and placed it in the cul-de-sac during a (laparoscopically assisted) vaginal hysterectomy. The lab reported that only one specimen was received. The specimens were sent to radiology for x-ray. The patient had a repeat biopsy performed.Ī patient had two specimens excised from her breast. It was discovered that another patient had two specimens in his bottle. The pathology lab notified radiology that the patient’s specimen bottle was empty. The specimen was a completely excised ovary mass.Ī patient underwent a liver biopsy. The cutting room called to say there was no specimen in the container. The following examples of PA-PSRS narrative descriptions reflect the scope of the problem:Īn OR specimen was transported to laboratory. 1 Furthermore, lost specimens may delay diagnosis, increase patient anxiety, or be a source of potential litigation. The loss of such specimens may result in inappropriate or unnecessary treatment. Of greater concern are specimens that cannot be replaced, such as fully excised tumors, skin lesions, or organs. However, doing so places the patient at risk from the additional procedure and imposes a greater burden on the healthcare system through additional costs, time, and labor. Some specimens can be repeated, such as a bowel biopsy to rule out inflammation or celiac disease. At least 30 reports have been submitted to PA-PSRS involving surgical pathology specimens that were lost somewhere between specimen retrieval from the patient and processing in the laboratory.
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