Correcting Specimen Labeling Errors - Data Analysis and Management for Clinicians

Correcting Specimen Labeling Errors

Data Analysis and Management for Clinicians

Julie Zuckerman

New York University

December 1, 2016

                                Abstract:

Patient errors in labeling of specimen bottles and manual input of patient name and site when in the lab is a problem across many healthcare facilities. This problem effects the quality and reliability of the lab, clinicians and patient care. There are many studies that have shown that automatic processes and printed labeling of spacemen will help reduce the number of errors that occur. Most of the errors that occur have to do with the demographic information of the patient. There are many more advantages over disadvantages in putting a correct policy and procedure in place to reduce the risk of patient treatment errors.

Correcting Specimen Labeling Errors

The discussion of proper specimen handling for patient biopsies is one of the most important areas for concern in Dermatology. Missing specimen form a patient is not only a liability to the company but also provides great uncertainty to the patient. An analysis of clinical issues “clinical issue log” with wrong patient name, wrong specimen site or anything other information that may be missing, as well as interviews with lab staff to see what is slowing own processing time and what issues the lab sees the most must be investigated. An improvement plan and standard operating procedure for getting the right patient specimen in the right container, with the correct requisition and properly to the lab must be put in place.

        Patient errors on patient names is an issue that affects the lab, the clinician ad the patient. Removing the occurrence of these errors is essential to any provider and lab. There are many issues that can occur with a specimen being labeled such as patient name, date of birth, site, diagnosis, and even orientation of specimen on the patient’s body.

        According to the American Journal of Clinical Pathology, in an 18-month study looking at mislabeled specimen in the laboratory, almost 75% of the errors found involved the wrong patient name and 24% of the errors were because the wrong site was listed.1 This means that only less than 2% of the issues were other situations that can occur, but it also shows that if the patient name and site are checked in a multistep process, this can insure that almost 100% of the errors can be reduced. This is such a large percentage that there should be dedicated staff and time to just correcting these potential issues at the time of the patient sample being taken and on the end of the lab. While in the 18 months of research it was shown that 62% of the time it has no impact on patient case, 13% of the time a wrong therapy was given, and this is too high of a percentage of an issue that needs to be caught at the clinical and lab level.1 Also, it is shown that histotehcnicians need to be in contact communication about errors as they are most often catching the mistakes and can help stop any issues before the case is signed out by the pathologist and the report goes back to the clinician.

        As mentioned by the Dermatology Practical & Conceptual article, the true risk and number of mix ups of patient name and specimen is not really known.2 There are many cases that are not reported and therefore true data cannot be accurately given. The Dermatology Practical article states that to “prevent specimen mix-up, work processes should be standardized and automated wherever possible.”2 This really means that it should not be up to staff to have to write or decide patient names of sites, especially in the lab. Automating processes such as labeling specimen though printed labels and having the EMR pick appropriate sites will help limit the human error portion of the issue.2

        Using proper tracking systems are going to be the best way to help eliminate errors. This means that labeling the patient and giving them labeling stickers or tags that match will assure that the names and date of birth matches. An article from the American Journal of Nursing Science show that in a hospital setting, bar code tracking of spacemen and patients is really the best method to making sure to reduce errors.3 This may not be practical for subspecialty private practice however.  

Advantages of correcting this error with a proper check and balances in place and staff dedicated to correcting this mistake far outweigh any disadvantages. The advantages are that the patients will be treated appropriately and will not have the wrong therapy as shown in the American Journal of Clinical Pathology study.1 In addition, there may be less staff needed is some of the lab ad labeling systems can be automated as discussed in the Dermatology Practical journal article. With automating these systems, the staff turnover and training is less likely to affect any issues with specimen labeling and also can provide consistency.2 Another advantage is that there will not be any surgeries performed on the wrong patient or site due to clerical error. The final advantage I that the staff, clinician lab and patient will have more

Potential disadvantages of putting in these systems really are centered around cost and training. Without proper training, complex standard procedures cannot be put in place and audited. An auditing system to make sure the information put in place is being followed also needs to occur. This way the SOP can be measured for success. In addition, another disadvantage may be that a labeling system, label printers or ID tags may be costly to a practice that is not of hospital size. The cost of putting in this infrastructure will need to factor in that every room will need a label printer to assure that patient specimen are being labeled in the room. Though the cost is a disadvantage, an article by the American Journal of Nursing Science showed that when a hospital “adopted a bar code tracking system to ensure proper identification of specimens moving from bedside to the laboratory, the error rates were reduced from 108 to just 8.”3 This largest reduction in errors and possible liability may outweigh the costs of putting in a proper system.

        Though there are advantages and disadvantages, it is easy to see that advantages when dealing with affecting patient care are going to far outweigh some of these capital expenditures and training hurdles needed for proper protocols to better catch labeling errors and avoid them completely.

        In order to implement a performance improvement model uses as Plan-Do-Check-Act, a team must be assembled. The team will consist of a project manager, a lead trainer, two training coordinators and a data analyst. The project manager will be the liaison to report to the board to see how progress, costs and the entire project is going and to report road blocks. The lead trainer and training coordinators will help to implement the protocol at every site using hands on training, classroom style lecture and webinars as well as generate the materials for the new procedure roll out. The data analyst will also help measure success and how the project is going. In order to gather how big of an issue lab errors are and gather the initial data, the lab reported the log is issues they have kept. The lab was informed to log patient information for all issues found that came to the lab from the offices (see Appendix A). A tally sheet documenting which offices are making errors and how often the errors are being made will be generated to help see if the issues stem from certain staff or the lab as a whole. A tally sheet can help identify trends in errors but also is a way to report if protocols put in place are working. For example, there can be an analysis generated of a tally sheet of total wrong patient name errors that occur per office before the process improvement and after. This allows the team to measure success, change and impact.