Process Improvements Help Hospital Reduce Specimen-Label Errors

Huge numbers of patients, medications, specimens and test results circulate through a hospital, so it is critical that all of them be properly identified.

A hospital in South Carolina found that misidentification is a serious problem – and one that can be easily addressed, at least partly through lean approaches.

An article from HealthLeaders Media describes how Self Regional Healthcare (SRH) in Greenwood, S.C., put together a cross-functional team to study safety “events” (read: problems). The team found that the majority of safety events were identification events – primarily specimens that were either mislabeled or not labeled at all.

By developing and implementing an improvement plan, the hospital reduced ID events by 65 percent after only one month.

Part of the plan involved technology – a network of scanners and bar-code printers used to coordinate patient ID bands with the labels on medications and specimens. The team took a system designed to coordinate the patient and medication bar codes and extended it to cover specimen labels as well.

But to the credit of the team, its members recognized that addressing the problem involved more than just technology.

"Things like where the patient received their bar-coded arm band, who collected the specimen versus how and when it was labeled, and how the specimen was then sent on to the lab all varied depending on the area," says Leisa Butler, RHIA, CPHQ, performance manager in the quality management services department. "So as a team, we decided to come up with a core common process."

In developing a common core process, the team decided that there could be no exceptions to key components. This was decided as a means of decreasing the variability found during the initial assessment. However, the team decided to allow specialty areas to add a step in the process, if necessary. For example, in the OR, there are additional steps for processing and transferring specimens.

Along with that process, Butler and her team noted that steps could be added, but no steps could be left out during the processing or transferring of specimens.

"If an event occurs that deals with specimen labeling or ID labeling, then the standard flow chart must be reviewed, and it has to be noted where in the process things failed," says Butler.

I applaud SRH for their efforts, and hope they serve as a model for other hospitals.