PPEP-The Empty Specimen Container

A View From the Trenches

The Empty Specimen Container

I recently had an unpleasant encounter with a clinician over a problem that has undoubtedly been experienced by all pathologists in every practice setting. On a three part skin biopsy, one of the containers was missing the biopsy. A careful search of the other specimen containers and plastic bags used to transport the specimens also revealed no missing biopsy. I also inspected the bag and container, confirming the missing specimen.

The next day, when I was signing out the case, I dictated in the report that no biopsy was received in the container and instructed the secretary to call the office and notify them about the missing specimen. I also dictated a note that the physician's office was notified. Unfortunately, my secretary assumed that someone else had notified the office and never called. A few days later, I received an angry call from the physician stating that their office never received the phone call about the missing specimen, in spite of my dictated note on the report. As she recounted how her office policies are always followed to the letter, she pointedly asked me, "Don't you think you should have personally called me and notified me of the missing specimen?"

I felt as if I was kicked in the stomach. What could I say? It was our laboratory policy to always notify the physician's office of a missing specimen. However, only in exceptional cases, have I personally called the physician and informed them of the problem. I apologized and assured the physician that in the future, I would indeed call if this situation were to arise again.

There is no question that our laboratory did not follow our protocol for notifying the physician's office. Yet, I wondered whether other pathologists personally call a physician if a specimen is missing? I suppose if this was the only biopsy on the patient from a site like the brain, I may have called. But perhaps this is a cavalier approach and presumptuous on my part.

What do you think? Please email your comments. I will post them anonymously. If you would like to share your trench stories, please email them to our site. Patient and physician confidentiality will be maintained.

Paul K. Shitabata, M.D.

Comments

I think the only place the ball got dropped was that notification of the submitting physician's office by your secretary slipped through the cracks. Only in exceptional circumstances do I personally call the physician; I don't really have a rule of thumb about when to call - I just go with my gut.

I rarely make the personal call and usually only when there is something that indicates this is not a routine but a vital specimen. A lost specimen is an immediate alarm alert and everything stops until we all check what may have happened within the department first. I have the surgery department, physician office, surgery center or other location notified immediately after making certain that I have checked the specimen cap, filtered the contents, checked the bag etc. Sometimes this leads the nurse or others to remember what happened - example: a specimen was not sent as the physician changed his/her mind but the specimen bottle which was prelabeled was mistakenly sent anyway. This method allows the office or department a chance to improve their process or procedure. I too have been burnt before by my dictation of an action that I assume has been done so I have made it a rule not to dictate anything until I know it is carried out or I dictate only what I know - example: the office will be notified rather than the office was notified.