Why Are Specimens Mislabeled?
In 2004, Sinai Hospital in Baltimore had 499 unlabeled specimens reach the lab. A multidisciplinary team reduced these errors 50%. Children’s Hospitals and Clinics of Minnesota reduced labeling errors 75% with a zero tolerance (“Any Is Too Many” is their motto -- love it!!) policy with a Failure Mode and Effects Analysis (FMEA) team approach. A College of American Pathologists Q-Probe study estimates a mislabeling rate of about 1 in 1000 extrapolated to more than 160,000 adverse events caused by labeling errors annually.
It’s expensive, too: a Loyola University Health System study estimates $712 per error.
Why are specimens mislabeled, anyway? How is this not top priority? If it’s my specimen or that of a loved one, it had better be labeled correctly. How does everyone not think that way?
I puzzled over this, sitting in a manager’s office as we discussed a specimen with the wrong patient label rejected by the lab.
“For the lab, specimen collection is a focused task,” I said. “In a way, this makes it easier for us to avoid mistakes. We have the labels in hand, draw the sample, and label the tube right at the bedside.”
“That’s right,” said the nurse. “But in a trauma situation or when the nurse can’t leave the patient, that’s much harder to do. We may not have labels or may be distracted. Collecting a specimen is one of many tasks all done at once. That nurse is worried about the whole patient.”
She’s correct. Specimen labeling often happens in less controlled settings for nursing. It may even be a lower priority than another problem at hand. I agree.
But the lab labels specimens at bedside because training, label printers, bedside scanning, order verification,and other system elements are deliberately designed to make it happen every time, not because phlebotomists aren’t busy but precisely because they are.
The problem is system design, not workload. People need to worker smarter, not harder, and they can’t in a stupid system. It’s that simple.
Do we all just see this problem differently?