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Context:
Despite accreditation requirements and a focus on JCAHO patient safety goals, significant occurrence rates and multiple causes of specimen mislabeling were identified in our institution. Defect levels were ~ 0.2% of specimens received. Occurrence rates were ~200 per month.
Objective:
To identify solutions, multidisciplinary workgroups were created to assess the impact of specimen mislabeling on process quality, resource utilization and patient safety.
Methods:
Pathology established a Steering Committee with leaders from the laboratory, administration, nursing, risk management and quality assurance to create three task forces focusing on inpatient units, ambulatory care areas and the emergency department. A group from our Innovations in Leadership (INL) program chose specimen mislabeling as their project's focus. The INL program is designed to foster professionalism among all stakeholders in medical education.
Results:
The INL workgroup compiled total charge data caused by 10 random mislabeling occurrences. After elimination of outliers, average additional charges incurred per case were $712 (n = 8) with cases from all major service areas. To raise awareness on the impact of specimen mislabeling, the INL group recommended increased use of educational techniques, marketing strategies and a bedside barcode labeling system. The Steering Committee's task forces have focused on opportunities in process and workflow. In our ED, a Failure Mode and Effects Analysis demonstrated roughly 2/3 of process risk from patient registration through specimen acquisition and order entry was associated with specimen collection and labeling. Recent improvement efforts have resulted in a 33% reduction in all mislabeled ED specimens.
Conclusions:
Early this year, the bedside barcode labeling system will be piloted and the institution will go live with a new HIS/EMR which provides computerized physician order entry. The impact of these and other changes on the status of specimen mislabeling practices continues to result in improved process quality, resource utilization and patient safety.
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See more of The 2005 Institute for Quality in Laboratory Medicine Conference