[Counter-measures against patient misidentification and specimen mismanagement with blood collection].
My theme for this symposium is counter-measures against patient misidentification and specimen mismanagement with blood collection due to the lack of using authentication systems. What is applicable to our laboratory is patient misidentification counter-measures for specimen management at the time of inpatient ward blood collection and specimen examination (mistakes in appending bar code labels and entering specimen numbers). During the period from January 2008 to July 2012 at our laboratory, there were 9 cases of patient misidentification for hospital ward blood collection and specimen management. There were 2 cases in 2008 (1 for blood collection, 1 for specimen management), no cases in 2009, 3 cases in 2010 involving blood collection, 1 case in 2011 involving specimen management, and 3 cases in 2012 (1 for blood collection, 2 for specimen management). All patient misidentifications involving hospital ward blood collection arose from bedside blood collection. As a counter-measure, training slides were created at a medical safety management review session, repeated training in attention and patient check procedures was conducted with staff members, and hands-on training in pointing and naming was carried out. With these training slides, the goal was the execution of verification duties by encouraging conversations that include the patient's name, such as "Mr./Ms. XXXX, today we'll be collecting 3 tubes of blood," as a link to patient verification duties. With specimen management, 3 of the 4 cases occurred during overtime for day-shift work. As counter measures: 1) adherence to 1 patient, 1 tray, and signing when matching; 2) as a counter-measure against mistaking specimens for blood gas hemolysis, confirmation as other specimens, separating approximately 3 drops of blood that cannot be used for sampling, confirming hemolysis, and preventing misidentification.
Department of Clinical Pathology, Tenri Hospital, Tenri 632-8552, Japan. ohgoe@tenriyorozu.jp
Kazuhiko
K
Ohgoe
D001800:Blood Specimen Collection / Q000379:methods*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D010355:Patient Identification Systems