It is a well-known fact by now that most laboratory errors occur in the pre- and post-analytic phases of testing and that these errors can have a significant impact on patient care. Often, these activities do not occur within the physical confines of the laboratory, but in other locations—often by personnel not directly managed by the laboratory. There have been studies performed to assess how to best address these issues (i.e., what are the most effective interventions for identifying and controlling these errors?).
One such study, focusing on controlling specimen identification errors was conducted by Elizabeth Wagar, MD, at UCLA. Not only were there statistical analyses of how, when, where and why these errors were occurring and the resultant reports of patient harm, but she also included quizzes of laboratory personnel to assess “in-house” viewpoints as to the best way to address these.
Here are a couple of the quiz questions, along with some commentary afterward. Take this quiz and see whether your responses would have been in agreement with Wagar’s commentary.
Questions:
- Which of the following interventions is most likely to lead to a sustained, significant decrease in mislabeling errors?
a. Quietly tell nurses and phlebotomy staff to be more careful
b. Loudly tell nurses and phlebotomy staff to be more careful.
c. Place warning labels near blood collection tubes reminding nurses to correctly match the patient with their labels.
d. Barcode-based patient identification and specimen collection. - In clinic Z, a mislabeled specimen occurs an average of once per week, and one patient had minor harm because of this in the last year. In the same clinic, failure to retrieve a lab result also occurs once per week, and ten patients have been harmed in the last year, including one seriously. What quality improvement project should the clinic focus on first?
a. Mislabeling
b. Failure to retrieve results
c. Line contamination
Answers:
Question 1: The correct answer is “D,” barcode-based patient identification and specimen collection. 91 percent of the laboratory participants chose this answer. Warning labels (answer C) was chosen by 8 percent, and 1 percent chose the call for enhanced vigilance, whether it be quiet (answer A) or loud (answer B). Enhanced vigilance (whether quiet or loud) and warning labels are weaker interventions that lead to only transitory reduction in errors. However, this large sample of laboratory workers understands the difference between a weak and a strong intervention. Hopefully, this knowledge drives enhanced interventions in their workplaces.
The patient safety movement is based on implementing systems that have error-proofing and do not rely on human vigilance. Thus, semi-automation, in the form of barcode-based patient identification with barcoded tube labels at the point-of-care, is the strongest intervention of those listed.
Question 2: The correct answer is “B,” failure to retrieve lab results because, in clinic Z, this error causes more patient harm than mislabeling—and this was chosen by 80 percent of the participants. Mislabeling was chosen by 19 percent, and line contamination was chosen by 1 percent. The most important errors to work on are those that harm patients. Thus, an error that has a rate of ten cases of patient harm per year (one very serious) is a more important focus for quality improvement than an error that causes one case of minor patient harm per year.
Why did so many people choose mislabeling in this case even though it was less clinically significant in Clinic Z than failure to retrieve results? This judgment may have been based on personal experiences from their workplaces or from all the press given to identification errors. After all, decreasing mislabeling is a national patient safety goal and a huge focus of quality improvement at many facilities.
Healthcare facilities differ regarding the errors most likely to harm patients. In one facility, mislabeling may be the most harm-causing error; in another facility, it might be phone communication errors; and in a third, it might be failure to retrieve results. This is why it is good for laboratory leadership to collect patient outcomes related to laboratory errors. Knowledge of which errors are most likely to harm patients helps the leadership focus their quality improvement efforts on the right approach.
How did you do?
References:
Decreasing Patient and Specimen Identification Errors. An interview with Elizabeth Wagar, MD. Laboratory Errors & Patient Safety. Volume 3, Issue 5. https://www.pathology.med.umich.edu/intra/LabSafetyRept/March.April2007.pdf
Originally published by ADVANCE for Administrators of the Laboratory Lab Quality Advisor Blog