University of Colorado Hospital

Inpatient Laboratory
Errors


by: Becky Breidenstein RN, CVRN
The Problem
Increase in specimen errors on MS PSU
Extra labels in bag
Wrong patient label on specimen
Lack of documentation in EPIC

2
Goals

Improve and optimize patient safety and
satisfaction.
Decrease the amount of repeated specimen
collections.
Decrease the number of specimen errors on MS
PCU.




**Bottom line is to
improve patient safety


4
Number of Errors on MS PCU
8
3
5
2
4
5
6
5
June July August September October November December January
5




STEPS
1. Two patient identifiers
2. Bedside labeling
3. Limit one patient sampling
per bag
4. Place in biohazard bag
5. PTS (Pneumatic Tube
System or hand deliver to
laboratory


Specimen Integrity
The Trial
Change in Collection Process

Writing employee number on specimen label
Document collection complete in EPIC under
IV Assessment in the Doc Flowsheet

7
Where Does it Go?
Employee number
goes here
*Do not use GEL pens, they smudge
and never dry
Implementation
Who is going to be involved?
RN, CNA, ACP, AHTs
Email sent to involved staff.
One on one in-service given to all staff involved.
Collected employee numbers and signatures.
Reminder email sent to all involved staff of start date.

Follow-up
A follow up schedule was
implemented once process
began:
1 week
2 weeks
1 month and as needed
Updates provided to staff
on progress to date.

Pathway to Specimen
Error Prevention
1
st
Error
Email is sent to the staff member to inform
them of the error that has occurred.
U-Learn Laboratory Sample Handling is
assigned to the staff member.
Staff member submits completion certificate to
charge nurse within 2 weeks.



Pathway to Specimen
Error Prevention
2
nd
Error
Staff member must have all their specimens co-signed by
another RN for 30 days.
3
rd
Error
Record of conversation with manager and/or charge nurse,
plus an additional 30 days of co-signing of lab specimens.
4
th
Error
Meeting with unit manager.
Written warning is placed into employees permanent record.


Evaluation Method

Track number of SIs from the clinical lab.
Who collected the specimen?
Was it documented?
What time?
Random chart audits.
Obtain feedback from on lab labeling processes.



Post Trial Error
on MS PCU
8
3
5
2
4
5
6
5
0
2
6
Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 February
24th
Mar-14 Apr-14
Future Work
Meet with other QSA members and clinical lab
staff to collaborate ideas to improve errors.
Continue to gather information within the unit.
Keep staff informed on error rates on the unit.
Reward staff after 2months without errors.
14
Conclusion

Through this process we hope to make an impact in
reducing the amount of specimen errors on our unit. A
reduction in specimen errors will ultimately lead to
improved patient care, safety and satisfaction with the
care they receive.

Thank you for taking the time to hear this today.

~Becky Breidenstein RN, CVRN

References
Hammerling, J. A. (2012). A Review of Medical Errors in Laboratory
Diagnostics and Where We Are Today. Laboratory Medicine, 43, 41-44.
Retrieved from http://www.medscape.com/viewarticle/758467

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2009). To Err is
Human: Building a Safer Health System. [Kindle]. Retrieved from Kindle
Books

Morrison, A. P., Tanasijevic, M. J., Goonan, E. M., Lobb, M. M., Bates,
M. M., Lipsitz, S. R., ... Melanson, S. E. (2010). Reduction in Specimen
Labeling Errors After Implementation of a Positive Patient
Identification System in Phlebotomy. American Journal of Clinical
Pathology, 133, 870-877. http://dx.doi.org/10.13

References
Reducing Errors in Blood Specimen Labeling: A Multihospital
Initiative. (2011). Pennsylvania Patient Safety Advisory, 8, 47-53.
Retrieved from
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/20
11/jun8%282%29/Pages/47.aspx