Issue: Labeling specimens

1. Issue: Labeling specimens By: Ashley Coleman Retrieved from: Dasco Medical

2. Problem/Background • Working in the Emergency room a lot of different specimens are collected from numerous amounts of different people. When a patient is taken to their room, their labels are to be placed at the bed side, so when collecting specimens the nurse, technician or doctor can ask the patient/guardian for 2 identifiers (typically name and date of birth) and send the specimen. This is called bed side labeling, if done by everyone correctly, Emergency room visits may be faster and more cost efficient, and may even save a life. • Situation: You’re the nurse and there is a double room, both beds are filled and you have 15 people in your waiting room, you’re short staffed. When cleaning one of the beds after a patient is discharged you forget to take the labels out. A new patient is put into that room and labs are ordered. It takes you 3 tries to get blood from this patient, then your phone rings while labeling, you forget to ask the patient their name and date of birth, not realizing you just used the patient who was discharged labels. You send them to the lab and an hour passes by, you call the lab and ask where the results are, and they have no results because specimens with the correct patients labels are not down there, so now you have to redraw. Not only do you have to use more supplies (cost efficiency), but it already took 3 tries to get this patients blood (patient satisfaction) and this patient is not happy. Now he has to wait another hour in the emergency room because of one simple mistake, that would of only took a minute to correct.

3. Correct Bedside Labeling: 1. Place correct labels at bedside. 2. Draw specimen 3. Ask patient/guardian to verify name and date of birth. Once verified, time, date and initial specimen. 4. Send specimen to lab. Picture: (Beaumont Health System., Take 2) If step 3 is missed it could result in a fatal accident…

4. This could of resulted in death… “A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On the morning of surgery, the patient was awakened by the phlebotomist who drew his blood for basic laboratories and type and cross-matching. To ensure proper patient identification, the hospital had implemented a policy requiring a registered nurse or physician to verify the identity of all patients screened for blood transfusion. In practice, after verification of identity, the nurse or physician was required to initial the patient label on the vial of blood. As it was the change of nursing shift, the bedside nurse for the patient was not available and there were no physicians on the floor at the time. With another floor of patients still to see, the phlebotomist carried the labeled vial of blood out to the nurses’ station, and the label was signed by a random nurse. The sample was sent to the laboratory for analysis. Later that morning, a laboratory technician noticed a large and surprising change (compared to the previous day’s sample) in the hemoglobin value for a different patient on the same floor. She chose to investigate the discrepancy. Upon review, she realized that the vials of blood for the 54-year-old man had been mislabeled with another patient’s label by the phlebotomist. The reason the hemoglobin's were so discrepant for this other patient was that today’s value was that of the 54-year-old man, the wrong patient. On closer examination, it was determined that all the blood samples had been mislabeled, including the vial for type and cross-matching. Despite the “near miss,” the patient suffered no harm, and another blood specimen was drawn prior to surgery.” -”The Case”, (Astion & Astion) Picture: (Olson)

5. Picture: (Staff Feedback Spurs Safety Enhancements) Relevance? • Save a life • Boost patient satisfaction • Speed up hospital visits/turn around time • Improve patient safety • Save the hospital money By asking the patient their name and date of birth before sending specimens, it can…

6. The Joint Commission National Patient Safety Goal (NPSG) 1: NPSG.01.01.01 Rationale: Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-fold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Therefore, the two patient/client/resident-specific identifiers must be directly associated with the individual and the same two identifiers must be directly associated with the medications, blood products, specimen containers (such as on an attached label), other treatments or procedures. NPSG.01.01.01: Use at least two patient identifiers when providing care, treatment, and services Source: Commission National Patient Safety Goals Implementation Expectations. (Reference:"Benefiting From Bedside Specimen Labeling") Picture: The joint Commission, 2013.

7. Patient triaged and brought back to Emergency room. Workflow analysis More resources were used (staff and supplies), patient is unhappy, and safety, efficiency, and accuracy were not upheld. Patients in ER had to wait longer, causing them to be unhappy, which could cause more issues later on in the night. Patient unhappy, patients in waiting room are waiting longer. The patient has now waited 3 hours, results are back and mononucleosis is diagnosed. Patient discharged, total ER stay over 3 hours. Nurse and physician assess patient Doctor orders a CBC, CMP, BMP and Blood Culture, as well as a rapid strep test. I hour later, Nurse calls lab. Lab states no results for that patient have been received. Nurse looks around, goes into patients room, realizes wrong patient labels are in their. At this time 90 minutes have passed, nurse has to redraw. Nurse sends the specimens without asking patient name and date of birth. Mislabeled specimen sent. Nurse draws blood and collects rapid strep. In 1 hour, results come back, patient diagnosed with Mononucleosis, patient discharged home. Total ER stay less than 2 hours. Nurse asks patient name and date of birth. Realizes wrong labels were in the room, corrects mistake and Sends the specimen Patient satisfaction, safety, accuracy, efficiency and costs were controlled.

8. The Questions is...How can we fix this? • Adding a step in documentation when sending patient specimens. • Before sending the specimen there should be a checkbox screen you have to fill out completely in the patients record. This would need to be added to the software the hospital is using (ex: Medi-tech). • This would help eliminate using the wrong patient labels, especially in double rooms or in a busy emergency room, because it is a second step that makes you double check. • The lab should not be able to run the specimen until that checkbox screen is completed. • The checkbox screen should include questions such as, the patients name, date of birth, the last 4 digits of the medical record number and the room the patient is currently in. This means the nurse has to have the specimen in her hand to complete this documentation correctly before sending to the lab. The lab then has something sent to them that the documentation is correct and they can go ahead and run the correct tests on the correct patient. • When discharging a patient from the emergency room the nurse should be responsible for removing the patient labels at the bedside for the discharged patient and place them into the shredder bin. On the discharge screen there should be a box that needs to be checked stating that the nurse did remove the labels (as a reminder) before she can fully depart the patient. • The technician, assistant or whoever is cleaning the room should double check the labels are not in there. • The secretary should be the last step in making sure the correct patient labels are in the room. The secretary is who places a sheet of labels in the room when a patient is brought back from the waiting room. She should take a glance around the room to make sure no other patient labels are in their, ask the patient their name and date of birth, (make sure correct labels)then put the labels on the whiteboard (general location = less confusion. If labels are kept in the same place in every room, there is less room for error.) Every health care professional who can collect specimens should complete a competency on bed side labeling, that way every person knows the policy, procedure and their role in the process. This should be a yearly competency.

9. Timeline for Change • Competency on bedside labeling must be completed by May 1st, 2013. On this competency it educates about the 2 identifiers (Name and date of birth) and the checkbox process, that will start on May 1st, 2013. Role of each staff member (Doctor, Nurse, Tech, Secretary) in regards to patient labels. Also, staff from the lab will be educated on an alert that will come across on their computer when the screen is completed, this will give them the okay to run the specimen. This will eliminate any mislabeled specimens being tested. • Information Services (IS) adds a check box to the nurses/physicians/technician screen so when they send a specimen they have to type in patients full name, date of birth, last 4 of medical record number and room number currently in. Also, IS adds a check box on the secretary screen to remind her to check for labels when d/c patient from computer. This will go into effect May 1st, 2013. • May 1st-8th,2013 there should be one person on each shift (7a-7p/7p-7a ) designated as a “red coat”. The red coat is only there for assistance. So, if any staff have questions about the new procedure, the red coat is there to help them and answer the questions. Also, the red coat is there for support, so any staff that is frustrated or overwhelmed with the procedure, the red coat is there. • Each staff member now has to use this checkbox alert/double checking system to prevent sending mislabeled specimens to the lab. The lab will not run specimens unless this the screen is completed. • Goal: Less than 3% errors hospital wide related to mislabeled specimens.

10. “Benefitting From Bedside Specimen Labeling" 5.8% of phlebotomy samples are mislabeled. Redrawing and retesting specimens related to labeling errors cost hospitals $200-$400 million a year. “One of the root causes of wrong site Surgery is the switching, mislabeling or incorrect display of test specimens or results, which accounts for 12 percent of wrong site surgeries annually “ 1 in 18 sample errors leads to an adverse event. • “Labeling blood and other samples at the time they are collected improves patient safety and helps prevent a host of problems related to misidentification—including many of the estimated 160,900 adverse events that occur in U.S. hospitals annually because of sample identification errors.” • http://www.zebra.com/content/dam/zebra/virtual-tours/en-us/ebook/pdfs/bedside-specimen-en-us.pdf Statistics from “Benefitting From Bedside Specimen Labeling”

11. Linda McDougal Case • 2003, “NEW YORK (CNN) -- Linda McDougal was told she was suffering from an aggressive form of breast cancer. Her breasts, she was told, would have to be removed. She was told wrong” • “A paperwork mistake cost Linda McDougal both her breasts and left her suffering infections, facing more surgeries and trying to rebuild her life.” • View article at: http://www.cnn.com/2003/HEALTH/01/20/medical.mistake/ • 48 hours after a double mastectomy, McDougal was told she never had cancer, and her breasts had been removed unnecessarily. • This nightmare started in the lab at United Hospital in St. Paul, Minnesota where her biopsy slides for mixed with another patients due to them being on the same tray. • 6 months after her surgery, she was still fighting off infection. • “McDougal survived a medical mistake, but thousands of others aren't as fortunate. Between 44,000 and 98,000 patients die every year because of medical errors, the Institute of Medicine reported in 1999.’” -(CNN, 2003)

12. Research shows.. • A experiment before scanning patient labels “Barcoding” and after implementation. • October, November, December of 2006 was before “barcoding” was added in addition to 2 patient identifiers (Name and date of birth). Ranging from 3-9 mislabeled specimens. • After implementing barcoding (Jan., 07-Dec., 07) a unanimous 0 across the board for mislabeled specimens. At the bedside: Ask patient name and date of birth. In addition most hospitals have implemented “barcoding” Where they scan the patient in addition to asking them 2 patient identifiers, this has decreased errors tremendously. (Tournas Estelle)

13. In conclusion: It is a priority that every health care staff is properly educated on bed side labeling and it is being used. It is our duty as nurses to make sure we are doing it and everyone else is too. If you see someone who is not labeling at the bedside or asking the patient their name and date of birth upon collection of the specimen politely remind them of the correct procedure, as it may save a life.

14. Working together saves lives!! Picture: (Brown)

15. References • Astion, M., & Astion, M. (n.d.). ”The Case”. Retrieved from http://www.webmm.ahrq.gov/case.aspx?caseID=142 • Beaumont Health System. (Photographer). (2013). Take [Print Photo]. Retrieved from http://dr.beaumontphysician.com/News/Pages/Take-2-RO.aspx • "Benefiting From Bedside Specimen Labeling." . Zebra Technologies, n.d. Web. 25 Apr 2013. http://www.zebra.com/content/dam/zebra/virtual-tours/en-us/ebook/pdfs/bedside-specimen-en-us.pdf • Brown, T. . Retrieved from http://opinionator.blogs.nytimes.com/2013/03/16/healing-the-hospital-hierarchy/ • CNN. (2003, January 21). Breasts removed by mistake; paperwork slip-up blamed. CNN. Retrieved from http://www.cnn.com/2003/HEALTH/01/20/medical.mistake/ • Olson, John D. Label the Specimen. 2004. Photograph. n.p. Web. 25 Apr 2013. <https://labs.uhstx.com>. • Patient Bedside. 2012. Photograph. DascoMedicalWeb. 25 Apr 2013. <www.dascomedical.com >. • Staff Feedback Spurs Safety Enhancements. 2005. Photograph. n.p. Web. 25 Apr 2013. <http://www.brighamandwomens.org/about_bwh/publicaffairs/news/publications/DisplayBulletin.aspx?articleid=3030>. • The joint commission. (2013). DOI: www.qualitycheck.org • Tournas Estelle. (n.d.). Retrieved from http://laboratorian.advanceweb.com/Features/Articles/Barcoding-Improving-Patient-Safety.aspx