Laboratory Specimen Errors in a
Hospital Emergency Department

THE PROBLEM:

When a mislabeled specimen reaches the laboratory for testing, there are two possible outcomes that could occur. The best-case scenario would be a lab technician noticing the mistake and taking the appropriate steps to resolve the issue which would essentially cost time, money, and harmful delays in treatment. The worst-case scenario involves a lab technician that does not catch the error and the patient may receive incorrect care that could possibly lead to severe injury or even death. Studies have found rates for such errors ranging from 0.039% to 1.12% of all specimens collected for medical testing with almost 13 billion tests conducted in American medical laboratories every year. This translates to millions of similar errors across the country, costing billions of dollars and impacting thousands of lives.

THE MODEL:

A Trajectories Company advisory team partnered with a hospital to build a Trajectories model of such errors in an emergency department (ED) setting. After the initial assessment, the team recognized that specimen labeling errors are not merely a matter of getting the correct label on the specimen after collection, but involve the interaction of multiple processes which consists of:the correct patient must be identified, the correct tests ordered, specimens collected from the correct patient and transported to the laboratory, and the laboratory must test the correct specimens and report accurate results back to the correct patient’s record. Therefore, the team chose to model the entire process from the patient’s arrival in the ED to the provider receiving the results of the ordered laboratory tests. Then, analyzing the Trajectories of any error which would lead to problems with accurate patient care.

This Trajectories model identified all potential errors, mistakes, and other failures at each point in this process which could lead to an adverse patient care event and then assessed the robustness and efficacy of existing controls to prevent these failures from resulting in adverse patient care events in the future.

THE FINDINGS:

The Trajectories® model uncovered three key insights around the ED’s current systems for ensuring accurate specimen collection and testing:

  • For specimens drawn in response to a provider ordering laboratory test, there was relatively little risk of a mislabeled specimen being tested and associated with the incorrect patient’s medical record. The ED had an effective process in place for checking specimen labels against requisition orders before transporting them to the laboratory and the accessions clerk in the laboratory had an effective system for confirming the labels against the requisition prior to placing laboratory barcode labels on the specimens for testing.
  • However, due to the fast-paced nature of the ED environment, staff often drew specimens before the doctor ordered the associated labs (often even before labels had been printed for the patient in question) which only occurred at the completion of the full registration process. This resulted in unlabeled specimens in the ED awaiting future labels and there was no standard procedure to ensure such unlabeled specimens remained with the appropriate patient until they could be labeled and transported to the lab. This posed a high risk of one patient’s specimens being associated with another patient’s labels and requisition, which leads to incorrect test results impacting the second patient’s treatment.
  • There was also no system in place to ensure that specimens for ordered tests had been collected and sent to the lab in a timely manner. Another issue was the miscommunication between who was responsible for printing requisitions for ordered tests prior to collecting the specimen., Medical assistants (MAs) and patient care techs (PCTs) were waiting for nurses to print the requisitions while nurses assumed the MAs and PCTs were doing so on their own initiative. Both factors resulted in a high risk of delayed patient care, with some specimens not even being collected until providers noticed a significant delay in receiving test results back from the lab.

THE OPPORTUNITIES:

  • Temporary Hand-Written Labels: Introducing the use of blank labels for those specimens drawn prior to a provider’s order, which staff could immediately handwrite the associated patient’s name and date of birth, would greatly reduce the potential for unlabeled specimen mix-ups currently present in the ED. In the absence of bedside on demand label printers, such hand-written temporary labels would serve as effective placeholders until permanent labels could be printed and applied, without significantly impacting the efficiency requirements leading to such specimens being drawn in the first place.
  • Tests Ordered and Specimens Transported Tracking System: Establishing a tracking system for lab orders versus specimens transported to the lab would facilitate early identification of delays in collecting and transporting necessary specimens, which would significantly reduce patient care issues caused by delayed laboratory tests.
  • Clarifying Procedural Responsibilities for Test Requisitions and Collection: Refining the existing procedures for printing laboratory test requisitions and collecting associated specimens to ensure all relevant parties (nurses, MAs, and PCTs) know who was responsible for what parts of the process would significantly reduce confusion which resulted in delayed specimen collection.

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