SPECIMENS – COLLECTION AND HANDLING IN
Protocol
OPERATING THEATRE
CPM.S4.6
CLINICAL PRACTICE
MANUAL
STANDARD
Specimens collected at Bay of Plenty District Health Board (BOPDHB) during surgical
procedures will be handled, labelled and transported correctly and safely to ensure timely
diagnosis and clinical information for patient treatment.
OBJECTIVE
To ensure that:
Staff contact with potentially infectious specimens is avoided.
Staff contact with potentially harmful transport media such as Formalin is avoided.
All specimens reach the laboratory in an optimal condition for analysis.
All specimens are labelled with correct and complete patient information.
Specimen results are always attributed to the correct patient.
No specimens are inadvertently disposed of.
No specimens are inadvertently retained.
Specimen results are sent to Consultant Surgeon
STANDARDS TO BE MET
1. Staff Training
1.1. The Perioperative Department Nurse Manager (CNM), or their delegated
representative, is responsible for ensuring that all operating theatre nursing staff
have been taken through the requirements of this protocol and are aware of the
correct methods of handling specimens before they participate in surgical
procedures.
1.2. Each Head of Department (HOD) is responsible for ensuring that the medical
staff in their team who work in the operating theatre are aware of the
requirements of this protocol.
2. Precautions To Be Taken When Handling Formalin
2.1 The CNM (or their delegated representative) is responsible for ensuring that:
a) Formalin use is controlled according to the procedures outlined in BOPDHB’s
policies 2.1.1 Risk Management, 2.1.3 Hazard Management, and the
Formaldehyde Material Safety Data Sheet (MSDS).
b) The Formaldehyde Material Safety Data Sheet (MSDS) is kept on file in the
department along with first aid instructions in case of adverse events, and all
staff are aware of its contents and location.
c) A cool, well ventilated and regulated work area is established in the department
for Formalin handling, use and storage.
2.2 All staff who handle formalin solution must:
a) Dispense Formalin into specimen containers in the designated Formalin work
area only (Formalin is not stored or handled in the operating room).
b) Wear apron and gloves when dispensing the formalin in the fume cabinet.
c) Avoid splashing, contact with body surfaces, and breathing of the formalin
vapours.
3. Collection Of Specimens
3.1 All staff who handle specimens are responsible for ensuring that they implement
‘Standard Precautions’ as outlined in BOPDHB Infection Control protocol IC.S1.6
Standard Precautions – Specimens.
Issue Date:
Mar 2018
Page 1 of 5
NOTE: The electronic version of
Review Date:
Mar 2020
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Nurse Educator,
Authorised by: Medical Director
assumed to be the current version.
Perioperative
SPECIMENS – COLLECTION AND HANDLING IN
Protocol
OPERATING THEATRE
CPM.S4.6
CLINICAL PRACTICE
MANUAL
3.2 The scrub nurse takes responsibility for the specimen from the time it is harvested
by the surgeon, until such time as it is passed off the sterile field to the circulating
nurse. She/he is responsible for ensuring that:
a) The site from which the tissue was taken (specimen name) is checked with the
surgeon.
b) Specimens are immediately placed in a container (such as a kidney dish) to
prevent them from falling from the sterile field.
c) Once harvested, to avoid tissue disruption and staff exposure to potentially
infectious material, the specimen is handled as little as possible, and with blunt
forceps, not hands.
d) In cases of possible malignancy care is taken not to transfer cells from one
surgical site to another e.g. removal of multiple skin lesions with possibility of
malignancy. Check with the surgeon if a clean forceps and blade should be
used to harvest specimens from differing sites. If yes, the blade and forceps
should be passed off the sterile field with each specimen.
e) Specimens are promptly placed in the correct container and transport media. If
doubt exists, the surgeon is asked for confirmation.
f) If similar specimens are inadvertently mixed, under no circumstances is any
attempt made to guess which specimen came from where. The surgeon is
informed immediately.
g) The surgeon’s permission is sought before disposing of ANY tissue or foreign
bodies collected during a surgical procedure.
h) No specimen and /or specimen containers are inadvertently retained
3.3 The circulating nurse is responsible for the specimen from the time it is passed off
the sterile field until it leaves the department. She/he is responsible for ensuring
that:
a) Every specimen is contained in a leak proof container.
b) Labelling and documentation are completed correctly as described below in
Section 4.
4. Labelling Specimens / Documentation
4.1 The circulating nurse is responsible for ensuring that:
a) Checking the Consultant Surgeon’s name is on patient bradma label. Yellow
ED patient bradma labels must not be used.
b) A patient bradma label is attached to each specimen container and the
following additional information is added to the label:
c) Date of specimen collection
d) Originating source of the specimen (e.g. breast tissue, cervical tissue)
e) Every specimen is accompanied by a laboratory form, which is completed in
full and signed by the surgeon.
f) On the laboratory form where it says Copy to … document Operating
Surgeons name.
g) If the patient has requested return of the specimen this is also noted on the
laboratory form.
h) Every specimen label and its accompanying laboratory form are checked by
a registered nurse before it leaves the department.
i) All specimens sent to the laboratory (or other required destination e.g. Bay
Radiology) are recorded in the ‘Specimen Record Book’.
j) The following information is recorded in the patient’s intra-operative record:
i. The type and number of specimens collected (and if a specimen could
not be obtained).
Issue Date:
Mar 2018
Page 2 of 5
NOTE: The electronic version of
Review Date:
Mar 2020
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Nurse Educator,
Authorised by: Medical Director
assumed to be the current version.
Perioperative
SPECIMENS – COLLECTION AND HANDLING IN
Protocol
OPERATING THEATRE
CPM.S4.6
CLINICAL PRACTICE
MANUAL
ii. Confirmation that the specimen documentation is correct (label and forms
completed correctly), and signatures to that effect from both the scrub
and circulating nurse.
iii. If the patient requested return of the specimen, this is also documented
on the intra-operative record (but the patient is responsible for contacting
the laboratory to arrange return of the specimen).
5. Body Tissue Not Required For Testing Or Examination
The disposal of body tissue / parts not required for testing or examination is outlined in
policy 6.3.9 protocol 2 Disposal of Body Parts & Fluids in Perioperative Department.
6. Body Tissue Returned To Patients
The care and handling of body tissue / parts requested by the patient is outlined in
BOPDHB policy 6.3.9 Body Parts and Tissues.
8. Care & Preparation Of Specimen
DESCRIPTION
RATIONALE
1
Specimens must be put into an
Immediate attention to specimens will
appropriate sized container. Large
reduce any risk of errors being made in
specimens must be put into double plastic
labelling or handling / care of specimens.
bags before being placed in the
appropriate container for transportation,
as soon as possible. A patient bradma
label is to be place on each plastic bag.
2
Specimens should be clearly labelled with Documentation needs to be accurate so
the patient label, where the specimen is
there will be no confusion as to whose
from (specimen name) and the date.
specimen it is and where it is from. A
Patient label and specimen name to be
false diagnosis for the wrong patient can
recorded in specimen book for sign off on
result from inaccurately labelled
delivery to laboratory.
specimens.
3
Where several specimens are taken from The site of each specimen is of
the same patient, each specimen must be
significance when making a diagnosis,
labelled appropriately and individually
and for the continuing care / treatment the
numbered.
patient requires
This information must also be recorded
on the histology form and in the specimen
book
4
All specimens must have an
Documentation must be complete and
accompanying histology form filled out
accurate. The surgeon is responsible for
and signed by the surgeon.
filling out the histology form. The
information given to laboratory staff re:
the clinical finding is important for
diagnosis.
5
In Tauranga, Specimens are transported
Specimens should be sent to the
to the Laboratory twice daily.
laboratory in a timely manner to help
In Whakatane – arrange with Theatre or
reduce any risk of lost specimens and
HCA to deliver specimens to laboratory in
deterioration of specimens.
a timely manner.
Issue Date:
Mar 2018
Page 3 of 5
NOTE: The electronic version of
Review Date:
Mar 2020
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Nurse Educator,
Authorised by: Medical Director
assumed to be the current version.
Perioperative
SPECIMENS – COLLECTION AND HANDLING IN
Protocol
OPERATING THEATRE
CPM.S4.6
CLINICAL PRACTICE
MANUAL
DESCRIPTION
RATIONALE
6
Biopsy Specimens:
a) Special fixatives are recommended for
If special histological examinations are
certain types of biopsy e.g. renal, muscle,
required the laboratory staff must be
cervical smear. (Contact the laboratory
consulted beforehand, as special fixatives
staff if you have any doubts as to what to
or collection precautions may be
do with specific tissue.)
necessary.
b) If bacteriological investigations are also
required from the specimen e.g. TB
Keep all staff informed as to the progress
culture, the biopsy specimen should be
of preparations for transport and
divided and one part sent to the
documentation, so no errors occur and
laboratory without a fixative agent.
there is a double check system is place.
c)
Frozen Section Biopsy:
Is arranged with the pathologist at
Pathlab.
d)
Hook Wire Specimens:
Hook wire specimens are sent fresh to
Medex or Bay Radiology. In Tauranga
the taxi collects the specimen from SAU
reception. In Whakatane a hospital driver
collects the specimen from SAU
reception. This must be prearranged
prior to commencement of surgery.
- Check with patient if he / she requires
the return of the biopsy post
examination and document as
appropriate;
- Ring taxi or transport department to
transport it directly to either Medex or
Bay Radiology (as appropriate)
- Ensure biopsy correctly labelled and
in appropriate container.
- In a large brown paper bag place :
- The lab form the surgeon has signed
prior to the procedure.
- 1x labelled specimen container with
specimen labelled FRESH.
- 1x specimen container with formalin in
a plastic bag.
- 6 extra patient bradma labels.
- Write on bag Urgent specimen along
with the destination – depending
where the films were performed.
- Take to SAU reception for the taxi to
collect.
7
Fluids for culture must be sent to the
Discharging the fluid into a jar aerates it
laboratory immediately.
and may kill oxygen sensitive organisms.
If aspirated into a syringe attach a sterile
cap and transport in the syringe.
Issue Date:
Mar 2018
Page 4 of 5
NOTE: The electronic version of
Review Date:
Mar 2020
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Nurse Educator,
Authorised by: Medical Director
assumed to be the current version.
Perioperative
SPECIMENS – COLLECTION AND HANDLING IN
Protocol
OPERATING THEATRE
CPM.S4.6
CLINICAL PRACTICE
MANUAL
DESCRIPTION
RATIONALE
8
For specimens from drains, the specimen
should be taken from the tubing not from
the drainage bottle.
9
Swabs for routine culture and sensitivity
Swabs for culture must not be left to dry
must be received in the appropriate
out.
transport medium.
Organisms need a moist environment in
Anaerobic culture of swab specimens is
which to grow, and if swabs reach the
done at the discretion of the laboratory
laboratory dry, they can’t gain a true
staff based on the clinical details available
culture.
on the request form.
10 Urine – MSU, catheter or bladder
specimens are suitable.
If laboratory staff are unavailable,
specimen is to be placed in the laboratory
refrigerator.
11 If the patient has expressed a wish for the This is an important cultural issue with a
return of the tissue / fluids taken as
wide variety of patients. Please ensure
specimens this should be documented on
their wishes are respected.
the histology form and in the patient’s
health record (Refer to Policy 6.3.9
Protocol 1
Body Parts and Tissues –
Standards to be Met)
REFERENCES
AORN Perioperative Standards and Recommended Practices, Current Edition
J.C. Alexander, Alexander's Care of the Patient in Surgery, 14th edition, St Louis, 2010,
Mosby Inc. Missouri
Report of a Ministerial Inquiry into the Management of Certain Hazardous Substances in
Workplaces, July 2003. Accessed Aug 2010
ASSOCIATED DOCUMENTS
Bay of Plenty District Health Board policy 2.1.1 Risk Management
Bay of Plenty District Health Board policy 2.1.3 Hazard Management
Bay of Plenty District Health Board policy 6.3.9 Body Parts and Tissues
Bay of Plenty District Health Board Infection Control protocol IC.S1.6 Standard
Precautions – Specimens
Bay of Plenty District Health Board policy 6.3.9 protocol 2 Disposal of Body Parts and
Fluids in Perioperative Department
Bay of Plenty District Health Board policy 6.3.9 protocol 3 Donor Tissue, Organs
Handling and Storage in Operating Theatre
Bay of Plenty District Health Board Hazardous Substances Material Safety Data Sheets
(MSDS)
Issue Date:
Mar 2018
Page 5 of 5
NOTE: The electronic version of
Review Date:
Mar 2020
Version No: 6
this document is the most current.
Any printed copy cannot be
Protocol Steward: Nurse Educator,
Authorised by: Medical Director
assumed to be the current version.
Perioperative
