The Final Check: Some Is Not a Number, Soon Is Not a Time

Modern Healthcare features an ad promoting the Outcome Engenuity/Palmetto Health Richland/SCHA blood specimen mislabeling initiative.


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 mislabeled 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 heard caregivers voice 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 Dallas-based Outcome Engenuity – a company that focuses on helping high consequence industries become safer.

Outcome Engenuity CEO David Marx said the challenge was to design a better system. “Could we go into an area of health care, and demonstrate the power of different ideas? In 90 days let’s try to reduce that rate by 90%. That’s what we set out to do.”

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 error occurred. “All of us will make mistakes,” Griffith said. “The task for an organization is to be intellectually honest with themselves around which types of procedures are actually doable.”

The key intervention developed at Palmetto Health was the implementation of a post-labeling, verbal confirmation of the last three digits of the medical record number, as read from each specimen label and the patient’s arm band. This check, as simple as it is, was the single reason for a subsequent 98 percent reduction in mislabeled specimens.

Shadowing staff as they went about their duties, the researchers learned that it was not rare for a staff member to skip checking the medical record number because it was so long. The change to checking only the last three digits made it easy to follow procedure and safer for each patient. “One small step can make such a huge difference”, Gibbons said.

Five additional South and North Carolina hospitals have now put The Final Check into practice, with equally impressive results.

Presenting at the fifth annual SCHA Patient Safety Symposium, Marx explained, “By identifying the right intervention and holding people accountable in the right way, we can produce better outcomes.”

Due to the initiative’s broad success in the Carolinas, the company plans to introduce the program to hospitals on a nationwide level.

The Final Check toolkit is free and available for download here.