Specimen labeling by nurses is a critical piece of the laboratory testing process. Mislabeled/unlabeled specimens can result in up to nearly $280,000 per million specimens (College of American Pathologists, 2010), with repeat redraws adding to the cost. Several strategies can reduce avoidable mislabeled/unlabeled specimens. There are many interventions in the literature to reduce specimen mislabeling. The purpose of this article is to identify tips for using multiple educational interventions to reduce specimen collection errors that professional development educators can use when conducting a performance improvement project (Table 1).
Tips for Adding Multiple Educational Interventions to Reduce Specimen Collection Errors
Educational Interventions to Decrease Specimen Collection Errors
Discovering an average of 40 mis-labeled/unlabeled core laboratory specimens (e.g., chemistry, hematology, microbiology, coagulation studies, toxicity/drug screen, and unique chemistry) and blood bank specimens per month resulted in chartering a performance improvement project. Over a 1-year period, continuing to mislabel an average of 40 specimens a month would cost the organization from $134,000 to $340,000. Recognizing the costs to the organization and to patients receiving multiple unnecessary blood draws, the staff nurses and nurse leaders sought to address the labeling process for laboratory specimens. A variety of interventions were used to decrease mislabeled/unlabeled specimens.
Identifying stakeholders for a specimen mislabeling team was helpful to determine the impact of different disciplines on the process. Team members consisted of a clinical nurse specialist, staff nurses, day and night clinical managers, a master's in nursing student, and a laboratory professional staff. The team's aim was to reduce nurse specimen labeling errors, with a goal of zero errors. Rees et al. (2012) used a multipronged approach to reduce specimen labeling errors, including creating a specimen identification flowchart, providing clear staff expectations, using multi-faceted approaches to teaching staff education, posting memos and flyers by blood and urine specimen containers, posters reminding nurses to take labels into the room, and feedback to staff regarding their performance. Given that no single intervention has been deemed to be the most effective, it is important that institutions identify strategies that fit within the context of their unit or the nursing areas.
The team developed a multifaceted intervention, selected some components from the literature, and designed other interventions based upon the unit's environment. The clinical nurse specialist and the laboratory professional developed the posters and flyers and found stories from other organizations to decrease staff anxiety about errors that occurred in the organization. Unit champions have worked well in the organization to lead from within the organization. The clinical nurse specialist developed the roving in-services. The journal club was part of the shared governance structure, so the clinical nurse specialist capitalized on that meeting to provide additional reading and education about specimen collection errors.
The team developed a time line with results to let the staff know that they were paying attention to the process improvement. The team planned interventions, implemented and evaluated them, and learned from the outcomes. As more interventions were added, the results improved. Some interventions were implemented simultaneously. The goal was to improve results quickly by implementing multifaceted interventions. The project time frame was 5 months. The length of the project was based on the severity of the labeling problem and the need to prepare for an upcoming electronic health record implementation.
Although interventions were collaboratively developed in this organization, nurse educators can lead the team developing an educational intervention. The interventions included
Developing/placing a reminder checklist by the pneumatic tube stations
Displaying educational posters
Posting a bathroom flyer of “always and never” practices
Displaying the project time line with monthly labeling results
Compelling stories about dangers of labeling errors and the importance of labeling per organizational policy
Roving unit-based in-services
Real-time error notification by lab personnel to the charge nurse, with timely root cause analysis of the error and subsequent one-toone instruction (Rees et al., 2012)
A cosigning option for specimen validation by another staff nurse prior to laboratory submission
Journal club meetings discussing policies and procedures for mislabeled/unlabeled specimen articles.
Although barcode scanning during specimen collection is an effective strategy to reduce mislabeled/unlabeled specimens, multiple software applications were in use in this system, and software interfaces precluded the use of barcoding at this time.
After the intervention, the average number of mislabeled/unlabeled specimens reported per month was 28. The 30% reduction in mislabeled or unlabeled specimens resulted in a cost avoidance of $8,544.00, annualized from $40,200 to $102,000. Following a structured laboratory specimen labeling process on the nursing unit is critical to patient safety. Specimen collection from the wrong patient, inappropriate specimen labeling, or lack of labeling are avoidable errors and may occur if a consistent procedure is not followed. Nurse mislabeling or failing to label laboratory specimens may cause delays in diagnosis, misdiagnosis, and omitted or inappropriate treatment. Over a 5-month period, we aimed to reduce specimen labeling errors and associated costs. We found that using a multifaceted intervention led to a substantial reduction in mislabeled/unlabeled laboratory specimens and a concomitant cost avoidance in the acuity-adaptable unit.
Our unit did not achieve its goal of zero mislabeled/unlabeled specimens in the study time frame but reduced cost and errors. Including additional laboratorians in the overall improvement of specimen collection and handling could reduce the errors even more as their expertise across the laboratory process is helpful in ensuring that opportunities for improvement continue to be recognized. Efforts for continued improvement could include further investigation into what is occurring in the unit when these errors are occurring. Important to investigate would be the nurse staffing levels, nurse expertise level, skill mix, number of admissions and discharges, nurse-to-patient ratio, and the nursing care model.
Although a clear protocol can be established, the protocol must be coupled with appropriate, ongoing education, quality metric measurement, and sharing the progress toward zero mislabeled/unlabeled specimens (Kurec, 2017). To that end, our team implemented a variety of components, including unit-based in-services, journal club meetings, one-on-one instruction, educational posters, and monthly specimen collection results. Ongoing staff education is critical to reinforce the appropriate specimen labeling procedures.
Ensuring the accuracy of patient identification is a challenge in nursing units. Nurse-collected specimens account for a portion of specimen identification errors and specimen identification errors are preventable. Given that the literature has not identified one way to fix specimen labeling errors, multiple strategies in the literature can be used with components tailored to the unit's environment. Using a collaborative team approach with multifaceted interventions, we achieved a 30% reduction in mislabeled/unlabeled specimens. Other health care organizations can develop collaborative teams and select and adopt multiple interventions to decrease specimen labeling errors. Establishing appropriate policies and protocols, developing and implementing training practices, providing continuing education, and posting results of success and areas of opportunity are essential to improving nurse specimen collection.
- College of American Pathologists. (2010). When a rose is not a rose: The problem of mislabeled specimens. http://www.cap.org/apps/portlets/contentViewer/show.do?printFriendly=true&contentReference=practice_management%2Fdirectips%2Fmislabeled_specimens.htmlpecimens
- Kurec, A. (2017). Recollecting blood specimens: Tips from the clinical experts. https://www.mlo-online.com/recollecting-blood-specimens
- Rees, S., Stevens, L., Mikelsons, D., Quam, E. & Darcy, T. (2012). Reducing specimen identification errors. Journal of Nursing Care Quality, 27(3), 253–257 doi:10.1097/NCQ.0b013e3182510303 [CrossRef] PMID:22446504
Tips for Adding Multiple Educational Interventions to Reduce Specimen Collection Errors
|1.||Identify the cost of the problem to the organization.|
|2.||Identify if the problem is on the radar for organizational leaders.|
|3.||Determine who the stakeholders are who impact the project (evidence-based interprofessional collaboration).|
|4.||If no budget, determine what educational interventions are low cost.|
|5.||Identify unit champions who can help lead the work, informally learning from peers.|
|6.||Review the current policy to determine if it is clear.|
|7.||Map the current flow for the process.|
|8.||Identify process gaps.|
|9.||Identify how effective nurse learning has occurred in the unit in the past.|
|10.||Identify relevant literature successes.|
|11.||Post time line and monthly results as numbers and percentages.|
|12.||Post compelling stories of other organization's near misses.|
|13.||Use the learning management system to track the staff's multiple education opportunities.|