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CHAPTER 19
Care of Specimens
Introduction
Many patients undergoing surgery have specimens taken to assist in establishing or confirming a diagnosis which then determines the most appropriate course of treatment (Hughes and Mardell 2009). Obtaining a specimen may be the only reason for performing the surgery (Hughes and Mardell 2009). Ensuring that the specimen is correctly handled, named, typed, labelled, dispatched and transported to the laboratory is the responsibility of both the scrub and circulating practitioners (Hughes and Mardell 2009), in collaboration with medical and laboratory staff (Phillips 2007, AfPP (Association for Perioperative Practice) 2011).
Incorrect handling, mislabelling and loss of specimens can result in the patient returning to theatre for the collection of additional specimens, a wrong diagnosis and/or inappropriate or delayed treatment (Hughes and Mardell 2009). Makary et al. (2007) reported that 4.3/1000 surgical specimens were incorrectly identified during a six-month study; 3.7/1000 of these related to theatres. In 2008, the National Patient Safety Agency (NPSA) highlighted the potential harm that could be caused through incorrect patient identification and mislabelling of specimens, and made recommendations that this be incorporated into any adaptation of the World Health Organization’s (WHO) Surgical Checklist, launched in the UK in 2009 (National Patient Safety Agency 2008, 2009).
Obtaining specimens in the UK is legislated under the Human Tissue Act 2004 (Human Tissue Authority 2004) and in Scotland, the Human Tissue (Scotland) Act 2006 (Human Tissue Authority 2006). These Acts regulate the removal, storage and use of human tissue, including from the deceased, for the purposes of transplantation, research, training and education, and further stipulate that consent should always be gained before any removal, storage or use of human body tissue, which includes for the purposes of DNA analysis (except in criminal investigations). Care and handling of specimens is regulated by the Health and Safety Executive under the Health and Safety at Work Act 1974, the Management of Health and Safety at Work Regulations 1999, the Control of Substances Hazardous to Health (COSHH) Regulations 2002 (Health and Safety Executive 2000), and local policy which should be devised in collaboration with local laboratory departments (AfPP 2011).
Table 19.1 Examples of specimen types.
| Fluids | Tissues | Non-biological |
| Amniotic fluid | Bone | Retained items, e.g. swabs/instruments |
| Blood | Breast tissue | Foreign bodies, e.g. peanuts, glass |
| Bone marrow | Brushings | Explanted prosthesis, e.g. orthopaedic screws/plates |
| Cell washings | Calculi, e.g. gallstones | Projectiles, e.g. bullets |
| Cerebrospinal fluid | Donor tissue, e.g. skin | Clothing, e.g. from crime scenes |
| Exudate | Margins of malignant lesions | |
| Semen | Muscle | |
| Urine | Organ – solid biopsy, diseased | |
| Suspicious lesions |
Types and Testing of Specimens
A sample of tissue or fluid is referred to as a biopsy (Table 19.1). By examining a biopsy histologically (tissue analysis) and cytologically (cell analysis) in a laboratory, the pathologist can determine a clinical diagnosis (Phillips 2007, Hughes and Mardell 2009). This is then verified following the removal of the whole tissue, for example, the gallbladder, referred to as the surgical specimen (Phillips 2007, Hughes and Mardell 2009). Tests performed on fluid biopsies include bacteriology, virology, cytology, cell counts and genetic studies; tests performed on tissue biopsies include histopathology, hormonal assays and tissue typing (Phillips 2007, Hughes and Mardell 2009).
Types of biopsy
Methods of taking biopsies are described in Table 19.2.
Specimen Collection
It is imperative that specimens are collected using the correct technique and equipment at the correct time and delivered to the correct laboratory without delay (Dougherty and Lister 2008). Planning for the removal of a specimen in advance can support this, for example, ensuring the pathology department is aware that a frozen section will be taken (this is the responsibility of the medical staff) (AfPP 2011).
The surgeon should identify the specimen immediately at the time it is removed (AfPP 2011). Identification includes the nature of the specimen and the site (AfPP 2011). The scrub practitioner should verify this information with the surgeon, and confirm the preparation required before relaying the same information to the circulating practitioner (AfPP 2011). This information should be ‘relayed back’ to ensure the information has been clearly understood (Hughes and Mardell 2009).
Preparation of the specimen is determined by the specimen type; for example, most histopathology specimens are fixed in a transport medium such as formalin (AfPP 2011). The integrity of the specimen should always be maintained, and unless sending dry, should be kept moist (Phillips 2007, AfPP 2011). Fresh and frozen specimens are not fixed in preservative (Phillips 2007), nor is it recommended that samples taken to confirm tuberculosis (TB) are fixed; these specimens should be sent dry (Thomas et al
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