In a pilot program, mislabeling of blood specimens was reduced by 90% in less than three months.
by Larry Beresford
South Carolina hospitals have succeeded in reducing the incidence of mislabeled blood specimens, an error that occurs in 1 of every 1,000 blood draws in U.S. hospitals and carries potentially life-threatening consequences. The South Carolina Hospital Association has released a toolkit from the project, aimed at helping hospitals prevent specimens that are drawn at a hospitalized patient’s bedside from being labeled with another patient’s name.1 In initial pilots at Palmetto Health Richland Hospital in Columbia starting in May 2011, then expanding to five other South Carolina hospitals, mislabeling of blood specimens was reduced by 90% in less than three months.
Under the “final check,” which follows a hospital’s normal identification verification procedures, the last three digits of the medical record number from the patient’s armband are read aloud by a nurse at the bedside in front of the patient and reconciled with the last three digits on the blood specimen container. This final check was found to require only a small change in the specimen-collecting process, with no additional money or staff time required. The use of only three digits and the vocal confirmation were considered keys to success, as was emphasizing a “just” culture—providers were not punished for systemic failures.
At Regional Medical Center in Orangeburg, a final check was piloted in an ED nursing unit, according to Gary Ferguson, BSMT, MHA, director of pathology and laboratory medicine. “Several unique features of the final check immediately interested me as a laboratory director—the first being its low cost and low impact to existing procedures,” Dr. Ferguson says.
For hospitalists, an erroneous lab result can mean redundant or unnecessary testing, even mismanagement of the patient, Dr. Ferguson says. On the piloted unit, mislabeled blood samples decreased to zero from 3.5 per month over the first three months of the project. It will next be rolled out in intensive- and coronary-care units.
Larry Beresford is a freelance writer in Oakland, Calif.
The Hospitalist newsmagazine reports on issues and trends in hospital medicine. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.