Palmetto Health Specimen MisLabeling Collaborative
Each year, more than 160,000 medical errors occur nationwide due to mislabeled specimens. And those are only the errors that we know about because something serious happened as a result of the mistake.
"We did not want to harm a patient here based on a mislabled lab," says Shelly Rorie, director of risk management at Palmetto Health in Columbia.
Lorri Gibbons, vice president of quality and patient safety at SCHA, said she often hears caregivers voicing concerns over misidentified labs and the need to address this dangerous and expensive problem.
Believing they could greatly reduce the risk of mislabeled lab specimens, Palmetto Health agreed to participate in a study of the labeling processes, related errors and ways to improve the process. For the study, Palmetto partnered with the South Carolina Hospital Association and Outcome Engenuity.
When the study began, Palmetto was one of many hospitals using the "red rule" concept to address labeling mistakes. According to Scott Griffith, COO, Outcome Engenuity, the "red rule" approach is to "whack" the employee making the mistake without adequately addressing why the mistake occurred. But if the concepts of a Just Culture are interjected into the process, the hospital can and will concentrate on designing good systems and getting employees to make the right choices that reduce the risk of error.
The key intervention developed at Palmetto Health is the implementation of a post-labeling, verbal confirmation of the last three digits of the medical record number, as read from the each specimen label and the patient’s arm band. This check, as simple as it is, is the single reason for a 98 percent reduction in mislabeled specimens where it is implemented.
Shadowing staff as they went about their duties, the researchers learned that it was not rare for a staff members to skip checking the medical record number because it was so long.
The change to checking the last three digits of the medical record number made it easy to follow procedure and safer for each patient.
Find out more about this best practice that has proven to reduce mislabeled specimens by 98 percent.
