American Association for Clinical Chemistry
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Patient Safety Focus: How Labs Can Protect Against Specimen Loss

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 How Labs Can Protect Against Specimen Loss
 An Interview with Sky Soom

Humans are the most common agents of specimen loss in clinical labs. What can labs do to reduce human errors? In this interview, Sky Soom, director of logistics and specimen lifecycle for Pathology Associates Medical Laboratories, Spokane, Wash., discusses concepts in protecting against specimen loss, as well as the challenges faced by and strategies available to clinical labs.

Frederick Strathmann, PhD, conducted this interview.

What is the current status of protecting against specimen loss in clinical labs?

Currently, specimen loss is an unacceptable, but inevitable, occurrence without a universal solution. Many labs today use pen and paper in the form of routing slips, route sheets, and manual manifests to track outreach specimens. More sophisticated labs have deployed, or are actively deploying, computer-based mobility systems, which are usually based on barcode tracking of handoffs.

Basically, there are two problematic issues in specimen tracking that are often resolved using different strategies. The first one is long distance tracking at the level of the courier or long-distance shipper. The other is tracking specimens during movements within a lab. Over the course of its lifecycle, a specimen often has to traverse both long distances and short distances within the lab, referred to as intra-laboratory movements. The trick is to get the long distance and intra-laboratory solutions to blend well.

Effective Strategies to Protect Against Specimen Loss

  • Unique container IDs
  • Remote LIS barcode labeling at the point of care
  • Specimen labeling system that is interfaced to manifesting/tracking system inside the LIS
  • Barcode and manifest level tracking with mobile solutions
  • Monitoring every handoff electronically
  • When electronic tracking is not available, manifest each specimen and employ a controlled handoff with accountability
  • Monitor and immediately correct defects in the process
  • Report specimen loss/misplacement metrics to staff as part of continuous quality improvement

What have been the most significant gains in protecting against specimen loss in the last 10 years?

Historically, and this goes back a couple of decades, the introduction of mobile computing and barcode-based systems for specimen tracking were the biggest technical breakthroughs in decreasing specimen loss. In the last 10 years, a very important advance has been the introduction of computerized physician order entry (CPOE), combined with ability to print laboratory information system (LIS) barcodes near the point of care. This technology has enabled more accurate accounting of specimens because they can now be tracked from the point of draw. In addition, CPOE with LIS barcoding eliminates the need to label specimens inside the lab, thereby drastically reducing the number of specimens that are deemed lost due to inappropriate re-labeling in the lab. I expect a continued reduction in specimen loss as health systems further deploy electronic medical records (EMR), LIS-EMR interfaces, and CPOE with remote LIS barcode labeling.

Where do you think the greatest vulnerabilities lie for a typical lab’s specimen tracking process?

The greatest vulnerability is failing to introduce controlled handoffs with accountability for every handoff in a transportation chain. This means getting all persons who handle a specimen to appropriately handoff to the next process in line. That handshake, either electronically or manually, has to be engrained in every individual and system process. Significant mistakes will be made if institutions rely solely on batch movement of specimens.

Similarly, significant mistakes will be made if a handoff is not formalized and protected. A powerful strategy is to employ specimen manifests and take the time to ensure that each specimen is appropriately checked against a manifest list. A sophisticated laboratory will employ policies that prohibit forward movement of a shipment until a complete manifest has been verified.

What contribution might radio frequency identification technology have for protecting against specimen loss?

Radio frequency identification (RFID) holds promise but still has a long way to go (See Box, left). Proliferation of RFID throughout an outreach laboratory’s network is not only expensive but requires a tremendous amount of workflow and hardware engineering. Many institutions are implementing RFID to various degrees, but no implementation works right out of the box. In comparison to barcode-based specimen tracking, RFID offers advantages in touchless tracking, but a 100% read rate is essential. Ensuring complete interrogation of all tags is difficult with the range variability found in today’s tags. It is quite possible that the slow adoption of RFID technology may allow for the emergence of an alternative solution before RFID really gets the traction it needs to become widespread. In general, technology never has been, nor likely ever will be, a silver bullet on its own. You have to combine technology with rigorous manual processes.

A Word about RFID Technology

RFID is conceptually similar to conventional barcode technology. An RFID tag encodes a predetermined set of data that can be queried when needed to identify the specific information associated with a given specimen. The unique advantage offered by RFID over barcode scanning is the removal of a manual scanning event, as RFID tags are continuously “interrogated” by readers positioned in specific locations. Active RFID tags have an internal power source with a transmitter and can be classified as transponders that need interrogation to become active or continuous beacons. Passive RFID tags are cheaper, have no internal power source or transmitter, and have working ranges of a few inches to 30 feet.

In conclusion, what concepts are important to understand in protecting against specimen loss?

It takes a balanced blending of processes, technology, and outside-of-the-box thinking to protect against specimen loss (See Box, above). No matter the level of technology employed, a robust specimen tracking system has controlled handoffs with personal accountability. In cases of specimen loss or misplacement, the tracking system enables anyone to step back through the process and rapidly find the point of failure. Automation—such as CPOE with remote LIS barcoding, barcode-based tracking, or RFID tracking—has a role and is particularly suitable for larger institutions. Organizations of all sizes should never underestimate the impact of a well-trained staff that is held accountable for well-designed policies and procedures for manifesting, transporting, and handing off specimens.

Frederick Strathmann, PhD, is a senior fellow in the Department of Laboratory Medicine at the University of Washington, Seattle. Email:

Sponsored by ARUP Laboratories, Inc.