1. Section Editor(s): Huber, Deb A. MSN, RN, ARNP, CGRN

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I was recently reviewing the Society of Gastroenterology Nurses and Associates (SGNA) Discussion Forum. There are many topics currently being addressed on the Forum. Many special interest groups are even developing by contacts on the Forum. Sometimes it is hard to pick a topic to discuss in this column!! When I was reviewing several of the topics, many addressed SGNA policies or spoke about seeing things in journal articles. This issue, I decided to pick something I hadn't seen addressed for a while, but know it has been done routinely in gastrointestinal (GI) labs daily for some time-labeling pathology specimens.


The importance of correctly labeling specimens cannot be stressed enough. People fear the word "cancer" and any time a biopsy is mentioned, they often wait on "pins and needles" until they receive the pathology report. Those who work in the field, however, often realize the acquisition of specimens is not perfect. Many of our specimens are superficial and may yield negative results when there is pathology in lower layers of tissue. Many biopsies are from random locations and one area may yield disease whereas another area with a similar presentation may not. The determination of biopsy sites is the role of the endoscopist and acquisition of that tissue is often the combined work of the endoscopist and the nurse or technician assisting in the use of the accessories to procure the specimen.


After the specimen is retrieved, the nurse or technician puts the specimen in the appropriate container or preservative to maintain its integrity until it can be processed. Often these containers are immediately labeled with the patient's name and source of the specimen. If multiple specimens are being obtained in rapid succession, they may be numbered to expedite the process. Of course, there is potential for error in using this approach. At other times, there is error in reporting biopsy location because of the scope going in or out while trying to note the biopsy area. If you were doing a colonoscopy in a tortuous bowel and a polyp was removed at 40 cm, when the colon was later straightened, the removal site might actually be at 55 cm.


What are the implications of having an incorrect site? If you noted gastric mucosa in an esophageal biopsy, you would believe the patient had Barrett esophagus, which is considered a high risk for developing esophageal cancer. What if a cancerous polyp removed from the left side of the colon was labeled as being from the right colon? Could this lead to significant consequences?


Several Forum members had asked, "Who should complete the pathology request slip?" Some responded that it is the endoscopist's responsibility to fill out the pathology slip. Some responded the nurse or technician completes the pathology slips at their practice site. Others said the nurse completes the slip, but the endoscopist signs it. Many GI units, however, have gone to electronic medical record systems which generate a pathology report from the operative report the endoscopist completes. Often, the pathology report and the operative report go to the pathology department with the specimen. What is the correct answer?


I have no legal background, but I tend to believe that if an error would occur, much of the liability would be on the shoulders of the endoscopist. Currently, in the practice setting where I work with gastroenterologists, there is a combination of ways pathology labeling is done. In one clinic/hospital setting, there is a computer-generated pathology slip generated from the endoscopist's report. In another hospital endoscopy unit, the endoscopy nurse fills out the pathology report and the endoscopist signs the report. There is also an office endoscopy unit where the endoscopy nurse fills out the pathology slip and the endoscopist does not sign it. Is one system more foolproof than another? Where is the greatest chance of error?


In computer lingo, its "GIGO," meaning "garbage in, garbage out" or, if incorrect data was put in, incorrect data will come out. If a nurse fills out a form and the endoscopist doesn't catch an error in proofreading and signs the form, is this approach any better? If the nurse fills out the form incorrectly and the endoscopist doesn't sign it, does it free him or her of liability? No system is totally error-free, but each step in the process tries to decrease the potential for errors and ensure the best results for the patient.


Hopefully none of these problems will ever come before the judicial system. If that would occur, past experience usually finds that anyone involved in the incident would be included in litigation. Many units have policies which dictate the person to complete the pathology report and these policies need to be adhered to or changed if they are not meeting current needs.


Ultimately, the best scenario is the one in which there is good communication between the endoscopist and the nurse or technician procuring the specimens. Before the age of video and monitors, we simply listened to the endoscopists as to where the specimens were taken from. If the room wasn't too dark and we were in a good position, we could see the markings on the scope to determine location. Now, we have the capabilities to visualize the area along with the endoscopist on the monitor and we still may look at the scope markings on the scope to determine specimen location. With the advances in equipment technology, the endoscopist may be able to mark on a computer-generated diagram where a specimen is taken. Confirmation of the location by the endoscopist to the nurse or technician as the specimen is taken is still, however, the best approach. And if there are many specimens, taking the extra time to make sure specimens are correctly labeled as they are obtained may save confusion or problems later. As the old saying goes, "An ounce of prevention is worth a pound of cure."