Failure to Maintain and Test

Investigate

The patient had undergone a transurethral resection of a bladder tumor after a mass was found on an abdominal CT scan. Unfortunately, rather than preserving the patient’s specimen and sending it to pathology for testing, a surgical tech threw a large portion of it out when disposing of other materials post-procedure.

The Pennsylvania Patient Safety Authority has acknowledged the potentially dire effect that a lost specimen may have on patients’ welfare, particularly in circumstances where the specimen that was lost cannot be replaced. As early as 2005, the Patient Safety Authority recommended that all hospitals implement a designated specimen collection system, requiring specimens to be placed into sterile containers and labeled immediately, as well as a chain of custody process to facilitate tracking of specimens.

Analyze

We pointed out how a breakdown in hospital procedure or failure to prevent the error from occurring harmed our client.

Synthesize

Losing the specimen and the breakdown in the chain of custody harmed the client’s welfare.