Surgical Specimen Handoff to Pathology Audit

Inspection template for auditing surgical specimen labeling, requisition matching, and chain-of-custody handoff from the OR to pathology.

Audit Details

• Audit date and time recorded
• Audited location or service line identified
• Specimen type or case reviewed documented
• Inspector name and role recorded
• Applicable policy, SOP, or reference document identified

Specimen Labeling and Identification

• Specimen container label includes two patient identifiers
• Specimen label matches the requisition exactly
• Specimen source/site and laterality documented consistently
• Specimen container integrity maintained at handoff
• Unlabeled, partially labeled, or illegible specimens identified as non-conformances

Requisition Match and Documentation

• Requisition contains patient name and medical record number matching the specimen record
• Requisition includes specimen source, test requested, and collection date/time
• Collector or OR staff documentation is complete and legible
• Any special handling instructions are documented and followed
• Discrepancies between requisition and specimen are documented as a non-conformance

Chain of Custody and Handoff

• Handoff from OR to pathology is documented with date, time, and receiving party
• Specimen transfer includes sender and receiver identification or signature
• Specimen remained under controlled custody during transfer
• Transport method was appropriate for specimen type and handling requirements
• Any delay, loss, or break in custody was escalated and documented

Pathology Receipt and Non-Conformance Review

• Pathology receipt confirms specimen acceptance or rejection status
• Rejected specimens have documented reason and disposition
• Corrective action or incident report initiated for labeling or custody defects
• Audit findings reviewed with responsible department leadership