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Patient Safety and Quality

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Applying strategies that focus on laboratory specimen labeling errors can significantly reduce specimen identification errors

A typical hospital clinical laboratory receives thousands of specimens to analyze daily. A mislabeled clinical laboratory specimen, a common and avoidable problem, can lead to devastating consequences for patients. Applying strategies that focus on laboratory specimen labeling errors can significantly reduce specimen identification errors, according to a new study supported in part by the Agency for Healthcare Research and Quality (HS11512).

Researchers used a clinical laboratory database to analyze three blood specimen/patient identification errors: unlabeled specimens, mislabeled specimens, and specimen/requisition mismatch (specimen received with a requisition that did not match the request or patient identified on the tube or container). Error trends were followed over a 2-year period both before and after implementation of three patient safety projects.

These included: reorganization of phlebotomy services to 24-hour service and intensive care unit nursing in-service phlebotomy education; implementation of an online electronic adverse event reporting system; and installation of an automated specimen processing system. Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1 percent, 6.3 percent, and 4.6 percent of errors, respectively.

The most serious errors, mislabeled specimens, declined significantly after implementation of the three patient safety projects compared to before their implementation. Trend analysis also revealed decreases in all three clinical specimen error types for 26 months.

More details are in "Patient safety in the clinical laboratory: A longitudinal analysis of specimen identification errors," by Elizabeth A. Wagar, M.D., Lorraine Tamashiro, B.S., Bushra Yasin, Ph.D., and others, in the November 2006 Archives of Pathology and Laboratory Medicine 130, pp. 1662-1668.

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