Digital Workflow Redesign Improves Intraoperative Specimen Transport and Handover Accuracy

A digital workflow redesign guided by failure mode and effects analysis significantly increased the timeliness of intraoperative frozen-section specimen transport and the accuracy of handover records, according to a service improvement study conducted at a tertiary teaching hospital in eastern China. Following the clinical implementation of the structured process, transport timeliness improved from 80.7 percent to 98.4 percent, while handover-record accuracy rose from 75.2 percent to 99.2 percent.

Intraoperative frozen-section specimen pathways routinely cross multiple professional and departmental boundaries within hospital settings, leaving them vulnerable to operational failures during specimen identification, handover, and transit. To counter these vulnerabilities, researchers evaluated a closed-loop workflow redesign structured around failure mode and effects analysis, aiming to enhance specimen traceability and diminish preventable procedural breakdowns across operating theater and laboratory interfaces.

The investigation utilized a single-center, non-randomized before-and-after study design at a tertiary teaching hospital in eastern China. The evaluation incorporated all registered intraoperative frozen-section specimens across two distinct comparative operational periods: a pre-implementation cohort comprising 238 specimens registered from October through December 2025, and a post-implementation cohort comprising 247 specimens registered from January through March 2026.

The intervention established a dedicated frozen-section pathway governed by standardized verification procedures and digital oversight. Specific technical components included a barcode-based handover protocol, a single-record register specifically designed for repeat specimen submissions, targeted role-specific staff training, and real-time monitoring designed to detect and flag workflow deviations as specimens move between surgical suites and pathology units.

Measured outcomes demonstrated substantial quantitative gains across the examined operational metrics. Specimen transport timeliness rose from 80.7 percent (192 of 238 specimens) during the pre-implementation baseline to 98.4 percent (243 of 247 specimens) post-implementation, reflecting an absolute increase of 17.7 percentage points (95% CI 12.5–23.0; risk ratio 1.22, 95% CI 1.14–1.30; p < 0.001). Concurrently, handover-record accuracy improved from 75.2 percent (179 of 238 specimens) to 99.2 percent (245 of 247 specimens), achieving an absolute increase of 24.0 percentage points (95% CI 18.4–29.6; risk ratio 1.32, 95% CI 1.23–1.42; p < 0.001).

Alongside objective process measures, staff-reported satisfaction increased descriptively from 71.0 percent (44 of 62 respondents) prior to implementation to 95.2 percent (59 of 62 respondents) following the procedural overhaul. The authors noted that the investigation was conducted as a non-randomized service evaluation at a single healthcare facility, meaning that the observed outcomes reflect single-center operational conditions and warrant careful interpretation regarding broader institutional generalizability.

Subject of Research: Intraoperative frozen-section specimen workflow redesign

Article Title: Failure mode and effects analysis-guided digital redesign of the intraoperative frozen-section specimen pathway: a before-and-after service improvement study

Article References: Liu, J., Li, X., Zhang, H., Wang, S., & Zhou, X. (2026). Failure mode and effects analysis-guided digital redesign of the intraoperative frozen-section specimen pathway: a before-and-after service improvement study. Frontiers in Medicine, 13, Article 1955216. https://doi.org/10.3389/fmed.2026.1955216

Image Credits: AI Generated

DOI: 10.3389/fmed.2026.1955216

Keywords: frozen section, failure mode and effects analysis, specimen transport, handover accuracy, intraoperative care, workflow redesign, specimen traceability, barcode verification, perioperative nursing, quality improvement, tertiary teaching hospital, real-time monitoring, transport timeliness, repeat submission registration, service improvement study, staff satisfaction