Healthcare facilities in northeast Pennsylvania have come together to reduce and eliminate laboratory errors due to specimen mislabeling. Pocono Medical Center helped to spearhead the effort when they noticed they were reporting a large number of mislabeled lab specimens at their facility that coincided with data delivered in a presentation by the Pennsylvania Patient Safety Authority.
"The Authority spoke at an event for Pocono Medical Center in January and gave a presentation about Pennsylvania hospital data," Fran Charney, director of educational programs for the Pennsylvania Patient Safety Authority, said. "The Authority's specimen mislabeling data sparked a particular interest in Pocono and they approached the Authority to help improve patient safety in this area. The Authority agreed to facilitate a collaborative of area facilities to work on the issue."
Charney oversees the Authority's Patient Safety Liaison (PSL) program that has Authority representatives going into Pennsylvania's facilities to help them implement Pennsylvania Patient Safety Advisory guidance and improve patient safety processes. Pocono Medical Center's Patient Safety Officer (PSO) worked with the Northeast PSL, Megan Shetterly, to develop the collaboration.
Charney said analysis of Authority data shows that mislabeling events occur more often in the Emergency Department (ED) than other care areas, which is consistent with findings reported in literature that show laboratory samples drawn in the ED were 10 times more likely to be mislabeled. Specific to the northeast region, Authority analysis shows there is one mislabeling event reported per facility per month. Unfortunately, the Authority believes there are probably more mislabeling events that go unreported.
"Pocono Medical Center uses their laboratory information system to specifically track mislabeling errors," Charney said. "Many events are most likely missed, especially near-miss events, in other facilities if they do not have a process to track these specific events. Existing processes within facilities need to be examined and changed, if necessary, to be able to track these events more thoroughly."
Charney added that the collaboration will help facilities track these events more carefully and then more process changes will occur to reduce the chances of a healthcare provider mislabeling a patient's lab specimen. Ten hospitals and one rehabilitation facility are participating in the collaborative. To ensure participating facilities will collect the correct events for analysis, they were encouraged to compare specimen mislabeling events submitted to the Authority to other data, such as the number of redraws per month and the number of specimens wasted per month.
Two key elements were identified by the participants for this purpose: 1) the definition of phlebotomy specimen mislabeling and 2) the list of questions (taxonomy) under which these events will be reported to the Authority.
"It is so important for facilities to work together to solve problems, particularly in regard to this project," Charney said. "We must ensure that the data we are collecting for the project is standardized so we can analyze the loopholes in processes that are causing the mislabeling to occur and thereby provide guidance to prevent any future mislabeling of lab specimens."
Charney said the Authority will provide education, technical assistance, tools, resources and an interactive forum to facilitate participants' efforts to improve patient safety with phlebotomy specimen mislabeling prevention. She added that success of the project depends upon a high level of commitment from patient safety officers, laboratory directors, information technology personnel, nursing leaders, physician champions, senior leaders and frontline staff.
A list of the anticipated benefits of the collaboration include a learning network for facilities in the northeast of Pennsylvania to help reduce and eliminate phlebotomy specimen mislabeling and new educational processes designed to eliminate common human behaviors that might cause an error to occur.
A complete list of the anticipated benefits is included in the 2009 September Pennsylvania Patient Safety Advisory article "Collaborative Patient Safety Effort: Addressing Phlebotomy Specimen Mislabeling." Future Advisory articles will also give updates on best practices identified within the collaboration.
The Authority's quarterly September Advisory contains other articles developed from data submitted about real events that have occurred in Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights include: