Inaccurately identified specimens can lead to delayed or wrong diagnoses, missed or incorrect treatments, blood transfusion errors, and additional laboratory testing.

During a Pennsylvania Patient Safety Authority presentation, representatives of Pennsylvania hospital recognized that their facility's patient safety event report data corresponded with year 2007 statewide event data; specifically, “errors related to procedure/test/treatment” (23%) and “laboratory test problem” (41%) were the predominant event type and subcategory.

Anticipating similar experiences at neighboring hospitals, the hospital requested an Authority-sponsored effort to address this issue. At the end of the resulting multihospital collaborative, there was a 37% aggregate statistically significant decrease in specimen labeling errors.

During its multihospital collaborative improvement project, the Authority collected and analyzed 485 investigations. Facilities reported 520 different contributing factors associated with the mislabeling errors. The top three contributing factors were (1) procedures not followed (n = 256), (2) distractions and interruptions (n = 70), and (3) unplanned workload increase (n = 32).

There were six major categories of barriers to blood specimen labeling accuracy: (1) technology, (2) communication, (3) education, (4) staffing, (5) workflow, and (6) leadership.

At the facility level, the decrease in blood specimen labeling errors ranged from 57% to 84%. However, one hospital experienced a 67% increase in errors.

Figure. Collaborative Aggregate Specimen Labeling Error Rate

Overall, there was a 37% statistically significant decrease in blood specimen labeling errors in the project over the 18-month period (95% CI; p < 0.04).

Excerpted from: Reducing errors in blood specimen labeling: a multihospital initiative. Pa Patient Saf Advis 2011 Jun. http://patientsafety.pa.gov/ADVISORIES/Pages/201106_47.aspx .