Recommendations of the Lost Specimens Task Force

Lost and mishandled specimens are a universal problem, often with significant impact on diagnostic error and patient safety risk. At the behest of its membership, the Academic Medical Center Patient Safety Organization (AMC PSO) convened a Lost Specimen Task Force to develop a consensus-supported set of guidelines for identifying and mitigating the risks of lost and mishandled pathology specimens.

The Task Force reviewed the latest evidence, guidance, and opinion statements from relevant sources. Further insights were gathered by convening AMC PSO members’ subject matter experts across various specialties and services. These included: pathologists, surgeons, anesthesiologists, nursing leadership, information technology experts, laboratory and surgical pathology technologists, quality and safety leaders, and risk managers.


These consensus recommendations are for informational purposes only and should not be construed or relied upon as a standard of care. The AMC PSO recommends institutions review these guidelines and accept, modify, or consider alternatives based on their own institutional resources and patient populations. Institutions should review and modify these recommendations as the field continues to evolve.


Download the Guidelines



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