Surgical specimen handover from the operating theatre to laboratory-Can we improve patient safety by learning from aviation and other high-risk organisations?

J Oral Pathol Med. 2018 Feb;47(2):117-120. doi: 10.1111/jop.12614. Epub 2017 Aug 20.


Essential communication between healthcare staff is considered one of the key requirements for both safety and quality care when patients are handed over from one clinical area to other. This is particularly important in environments such as the operating theatre and intensive care where mistakes can be devastating. Health care has learned from other high-risk organisations (HRO) such as aviation where the use of checklists and human factors awareness has virtually eliminated human error and mistakes. To our knowledge, little has been published around ways to improve pathology specimen handover following surgery, with pathology request forms often conveying the bare minimum of information to assist the laboratory staff. Furthermore, the request form might not warn staff about potential hazards. In this article, we provide a brief summary of the factors involved in human error and introduce a novel checklist that can be readily completed at the same time as the routine pathology request form. This additional measure enhances safety, can help to reduce processing and mislabelling errors and provides essential information in a structured way assisting both laboratory staff and pathologists when handling head and neck surgical specimens.

Keywords: aviation; checklist; handover; pathology specimen; safety.

MeSH terms

  • Aviation / methods*
  • Checklist / methods
  • Checklist / standards
  • Humans
  • Medical Errors / prevention & control
  • Patient Care Management
  • Patient Care Team
  • Patient Handoff*
  • Patient Safety*
  • Patient Transfer / standards
  • Specimen Handling*