How It All Began
During a January 2009 Pennsylvania Patient Safety Authority presentation, a hospital located in the northeast region of Pennsylvania recognized that its patient safety event report data corresponded with year 2007 statewide event data from the Pennsylvania Patient Safety Authority Reporting System (PA-PSRS); specifically, “errors related to procedure/test/treatment” (23%) and “laboratory test problem” (41%) were the predominant event type and subcategory.1 Anticipating similar experiences at neighboring hospitals, the hospital requested an Authority-sponsored effort to address this issue. The Authority facilitated a blood specimen labeling collaborative among nine hospitals with the goal of decreasing blood specimen mislabeling events by 50%.
Clinical laboratory services play a vital role in the delivery of healthcare. Seventy percent of all information used by clinicians to diagnose conditions and treat patients comes from the laboratory.2 Adverse events due to mislabeling of blood specimens can result in physical, financial, and emotional costs for patients, their families, and the clinicians who care for them.
Pennsylvania healthcare facilities that are interested in more information about this collaborative may contact Megan Shetterly through the Pennsylvania Patient Safety Authority at firstname.lastname@example.org or 717-346-0469.
On the Cutting Edge
A literature search yielded little information related to blood specimen mislabeling. However, the Centers for Disease Control and Prevention previously commissioned a panel of laboratory experts to investigate laboratory medicine best practices. As the Authority’s patient safety liaison for the labeling collaborative, I had the opportunity to meet one of the experts and his colleagues during an educational offering in Pennsylvania about process improvement in the laboratory. At this time, I learned more about the national effort, a three-phase project (2006 through 2010). This interaction gave me the opportunity to extract valuable information that I introduced into the collaborative.
After obtaining senior leadership approval to commit to the time and effort involved with the Authority collaborative (e.g., reporting, conference calls, workshops), each participating hospital assigned a project manager, formed a core team, and selected an applicable care area. With the 50% reduction in mind, the collaborative mantra was, “The right blood specimen is correctly labeled for the right patient every time.”
For consistent measurement, the collaborative participants defined mislabeled blood specimen as “the collection of any blood specimen that is not consistent with the policy of each respective hospital,” including missing, partial, illegible, or wrong labels and excluding point-of-care testing. Consistent measurement required the participating hospital to decide who was going to collect the data, review the data for accuracy, and ensure timely receipt and timely reporting. Each event was reported through PA-PSRS.
One challenge during the collaborative was an apparent lack of buy-in from staff about reporting near-miss events. In most of these situations, there was a lack of communication between nursing and laboratory personnel. For a project of this magnitude to work, all disciplines have to work together in a culture that promotes effective communication and learning. It should be considered not a “lab project” but rather a facilitywide patient safety endeavor. Addressing these issues requires leadership support and a commitment from the project manager to be an agent for change within the organization.
During the collaborative, the participants learned that blood mislabeling was encountered by more than just their respective organizations. They were given an example of a real-life situation in which a mislabeling event resulted in the death of a patient from the transfusion of an incompatible blood type. It was an eye-opening experience for the participants to learn that Serious Events such as these do occur.
Furthermore, the participants did not believe all incidents were being reported through PA-PSRS. They recognized early on that getting their staff to report near-miss events would be critical to the success of this program. How to do this? An eagerness to learn and to use skills would be necessary to achieve the desired results.
Workshops and conference calls were well attended. But the true collaboration developed over time as sharing of experiences among the group helped to forge professional relationships, growth, and learning. Structure and laboratory processes may have varied between each organization, but there were some commonalities. On most teams, either the laboratory supervisor or the director was the project manager. They were well versed in laboratory medicine standards, but some professed little exposure to some of the relevant knowledge and principles involved with mapping of processes: the influence of human factors; the Just Culture™ model; and how to conduct an event investigation.
To help meet participants’ needs, the Authority provided education and guidance. On-site observations were offered to those who wanted a fresh set of objective eyes to look at their processes. Reviewed items included the categories of standardization, functionality, activity flow, availability of equipment and supplies, communication, distractions, and work assignments. Changes or interventions were instituted according to findings and included decluttering of work spaces and reeducation of staff about identification practices.
Planned redundancy was seen as a key element to integrate into hospital processes. The Authority invited participants to develop a patient identification slogan. One of the project managers came up with a creative idea that was adopted by the collaborative (see Figure). The slogan “Did You ID Me” became useful for identification not only of blood specimens but for other tests and treatments throughout organizations.Figure. Patient Identification Slogan
Almost every participant in this collaborative expanded the project to include either other types of specimens (e.g., pathology, urine) or other care areas. Most of the collaborative project managers now serve as consultants for the expanded projects at their hospitals. They have also made their hospitals available as mentor hospitals. (For more information, see the accompanying article in this issue, “Reducing Errors in Blood Specimen Labeling: A Multihospital Initiative.”)
One of the most important lessons learned during this collaborative involved culture, which plays a key role and is influenced greatly by leadership. Recently, a nurse manager from a nonparticipating hospital asked, “Can you give me examples of how these collaborative members were able to get staff involved in the process?” He was looking for concrete examples of implementation measures. But the answer that best reflects the participants’ work is in their passion for patient safety, the drive to be a change agent, the persistence to see it through, and a “we can” mentality. It was a worthwhile if not easy task. In the end, the group saw a statistically significant 37% decrease in mislabeling of blood specimens and, albeit small, a notable change in the culture at some facilities.
Dock B. Improving the accuracy of specimen labeling. Clin Lab Sci 2005 Fall;18(4):210-2.