Controlling Specimen Identification Errors: A Quiz
It is a well-known fact by now that most laboratory errors
occur in the pre- and post-analytic phases of testing and that these errors can
have a significant impact on patient care. Often, these activities do not occur
within the physical confines of the laboratory, but in other locations—often by
personnel not directly managed by the laboratory. There have been studies performed to assess how
to best address these issues (i.e., what are the most effective interventions
for identifying and controlling these errors?).
One such study, focusing on controlling specimen
identification errors was conducted by Elizabeth Wagar, MD, at UCLA. Not only were there statistical analyses of
how, when, where and why these errors were occurring and the resultant reports
of patient harm, but she also included quizzes of laboratory personnel to
assess “in-house” viewpoints as to the best way to address these.
Here are a couple of the quiz questions, along with some commentary
afterward. Take this quiz and see whether
your responses would have been in agreement with Wagar’s commentary.
1. Which of the following interventions is most likely to lead to a
sustained, significant decrease in mislabeling errors?
A. Quietly tell nurses and
phlebotomy staff to be more careful.
B. Loudly tell nurses and phlebotomy
staff to be more careful.
C. Place warning labels near blood
collection tubes reminding nurses to correctly match the patient with their
D. Barcode-based patient identification
and specimen collection.
2. In clinic Z, a
mislabeled specimen occurs an average of once per week, and one patient had
minor harm because of this in the last year. In the same clinic, failure to
retrieve a lab result also occurs once per week, and ten patients have been
harmed in the last year, including one seriously. What quality improvement project should the
clinic focus on first?
B. Failure to retrieve results
C. Line contamination
Question 1: The correct answer is
“D,” barcode-based patient identification and specimen collection. 91 percent of the laboratory participants chose
this answer. Warning labels (answer C) was chosen by 8 percent, and 1 percent
chose the call for enhanced vigilance, whether it be quiet (answer A) or loud (answer
B). Enhanced vigilance (whether quiet or
loud) and warning labels are weaker interventions that lead to only transitory
reduction in errors. However, this large sample of laboratory workers understands
the difference between a weak and a strong intervention. Hopefully, this
knowledge drives enhanced interventions in their workplaces.
The patient safety movement is based on implementing systems
that have error-proofing and do not rely on human vigilance. Thus, semi-automation,
in the form of barcode-based patient identification with barcoded tube labels
at the point-of-care, is the strongest intervention of those listed.
Question 2: The
correct answer is “B,” failure to retrieve lab results because, in clinic Z,
this error causes more patient harm than mislabeling—and this was chosen by 80
percent of the participants. Mislabeling
was chosen by 19 percent, and line contamination was chosen by 1 percent. The
most important errors to work on are those that harm patients. Thus, an error
that has a rate of ten cases of patient harm per year (one very serious) is a
more important focus for quality improvement than an error that causes one case
of minor patient harm per year.
Why did so many people choose mislabeling in this case even
though it was less clinically significant in Clinic Z than failure to retrieve
results? This judgment may have been based on personal experiences from their
workplaces or from all the press given to identification errors. After all,
decreasing mislabeling is a national patient safety goal and a huge focus of
quality improvement at many facilities.
Healthcare facilities differ regarding the errors most
likely to harm patients. In one facility, mislabeling may be the most
harm-causing error; in another facility, it might be phone communication
errors; and in a third, it might be failure to retrieve results. This is why it
is good for laboratory leadership to collect patient outcomes related to
laboratory errors. Knowledge of which errors are most likely to harm patients
helps the leadership focus their quality improvement efforts on the right
How did you do?
1. Decreasing Patient and Specimen Identification Errors. An
interview with Elizabeth Wagar, MD. Laboratory Errors & Patient Safety. Volume 3, Issue 5.