Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.
BACKGROUND
Patient safety is an increasingly visible and important mission for clinical laboratories. Attention to improving processes related to patient identification and specimen labeling is being paid by accreditation and regulatory organizations because errors in these areas that jeopardize patient safety are common and avoidable through improvement in the total testing process.


OBJECTIVE
To assess patient identification and specimen labeling improvement after multiple implementation projects using longitudinal statistical tools.


METHODS
Specimen errors were categorized by a multidisciplinary health care team. Patient identification errors were grouped into 3 categories: (1) specimen/requisition mismatch, (2) unlabeled specimens, and (3) mislabeled specimens. Specimens with these types of identification errors were compared preimplementation and postimplementation for 3 patient safety projects: (1) reorganization of phlebotomy (4 months); (2) introduction of an electronic event reporting system (10 months); and (3) activation of an automated processing system (14 months) for a 24-month period, using trend analysis and Student t test statistics.


RESULTS
Of 16,632 total specimen errors, mislabeled specimens, requisition mismatches, and unlabeled specimens represented 1.0%, 6.3%, and 4.6% of errors, respectively. Student t test showed a significant decrease in the most serious error, mislabeled specimens (P < .001) when compared to before implementation of the 3 patient safety projects. Trend analysis demonstrated decreases in all 3 error types for 26 months.


CONCLUSIONS
Applying performance-improvement strategies that focus longitudinally on specimen labeling errors can significantly reduce errors, therefore improving patient safety. This is an important area in which laboratory professionals, working in interdisciplinary teams, can improve safety and outcomes of care.
Wagar
Elizabeth A
EA
University of California, Los Angeles, Clinical Laboratories, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Box 951732, AL-206 CHS 10833 Le Conte Ave, Los Angeles, CA 90095-1732, USA. ewagar@mednet.ucla.edu
Tamashiro
Lorraine
L
Yasin
Bushra
B
Hilborne
Lee
L
Bruckner
David A
DA
D019411:Clinical Laboratory Techniques; D006801:Humans; D008137:Longitudinal Studies; D019300:Medical Errors; D010338:Pathology, Clinical; D010355:Patient Identification Systems; D010361:Patients; D011785:Quality Assurance, Health Care; D017751:Safety Management; D013048:Specimen Handling