Quality improvement to decrease specimen mislabeling in transfusion medicine.
BACKGROUND
Proper specimen identification and labeling is a critical preanalytic step in pretransfusion compatibility testing.


OBJECTIVE
To gather baseline data for specimen mislabeling, specifically targeting major mislabeling events, and to design and implement a plan of corrective action.


METHODS
All mislabeled specimens received by the transfusion service for a type and screen were recorded and classified into minor and major mislabeling categories. Major mislabeling events were tracked by origin of the specimen. Locations with a high proportion of major mislabeling were given timely feedback (within 1 week) of the events as they arose.


METHODS
A university hospital.


METHODS
The incidence of major mislabeling.


RESULTS
The incidence of mislabeling in the transfusion service was 0.5% (243/49 955) during 21 months of data collection. Of these mislabeling events, 47% were classified as major events (unlabeled, mismatched specimen/ requisition, ABO/Rh result on current specimen not matching historical record on file). The emergency department accounted for a high proportion of these major mislabeling events. After the intervention of providing weekly feedback to emergency department staff, their contribution to major mislabeling fell from 47% in 1 year (23/49) to 14% (4/29) in the subsequent 3 quarters.


CONCLUSIONS
Collecting and trending data on mislabeled samples with timely feedback to patient care areas can change phlebotomy practice and reduce specimen mislabeling.
Quillen
Karen
K
Department of Laboratory Medicine, Boston University Medical Center, Boston, Mass 02118, USA. kq@bu.edu
Murphy
Kate
K
D001787:Blood Group Incompatibility / Q000517:prevention & control*; D001788:Blood Grouping and Crossmatching; D001803:Blood Transfusion / Q000592:standards*; D006785:Hospitals, University; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D010355:Patient Identification Systems; D018962:Phlebotomy / Q000379:methods / Q000592:standards*; D011786:Quality Control; D013048:Specimen Handling / Q000379:methods*