Reduction in Hospital-Wide Clinical Laboratory Specimen Identification Errors following Process Interventions: A 10-Year Retrospective Observational Study

Abstract

BackgroundAccurate patient identification and specimen labeling at the time of collection are crucial steps in the prevention of medical errors, thereby improving patient safety.MethodsAll patient specimen identification errors that occurred in the outpatient department (OPD), emergency department (ED), and inpatient department (IPD) of a 3,800-bed academic medical center in Taiwan were documented and analyzed retrospectively from 2005 to 2014. To reduce such errors, the following series of strategies were implemented: a restrictive specimen acceptance policy for the ED and IPD in 2006; a computer-assisted barcode positive patient identification system for the ED and IPD in 2007 and 2010, and automated sample labeling combined with electronic identification systems introduced to the OPD in 2009.ResultsOf the 2000345 specimens collected in 2005, 1023 (0.0511%) were identified as having patient identification errors, compared with 58 errors (0.0015%) among 3761238 specimens collected in 2014, after serial interventions; this represents a 97% relative reduction. The total number (rate) of institutional identification errors contributed from the ED, IPD, and OPD over a 10-year period were 423 (0.1058%), 556 (0.0587%), and 44 (0.0067%) errors before the interventions, and 3 (0.0007%), 52 (0.0045%) and 3 (0.0001%) after interventions, representing relative 99%, 92% and 98% reductions, respectively.ConclusionsAccurate patient identification is a challenge of patient safety in different health settings. The data collected in our study indicate that a restrictive specimen acceptance policy, computer-generated positive identification systems, and interdisciplinary cooperation can significantly reduce patient identification errors.

Adherence to the objectives of the Safe Surgery Saves Lives Initiative: perspective of nurses

“…This finding is in line with the results of a study with 31 nursing professionals from a surgical center in São Paulo, Brazil, of which 92.9% considered the inappropriate disposal of a surgical specimen a serious adverse event 15 . In Taiwan, of the 200,345 specimens collected at a medical center, 1023 were with misidentification 39 .…”

Adhesion to patient safety protocols in emergency care units

“…A Brazilian study (5) identified the absence of use of identification bracelets in UPA, corroborating the results of our research. Safe and standardized identification assisted in error reduction during identification of blood samples, as stated in a Thai study (18) . In this context, the blood collection in laboratory tests is also a usual practice in UPA.…”

Monitoring and capturing patient identification errors in laboratory medicine

“…That study also further highlighted the importance of reporting errors to originating departments. 10 Respondents identified a number of mechanisms for reporting errors; however, none availed of the departmental website as a communication option. As laboratory professionals, it is critical that samples that do not meet the sample acceptance criteria are rejected given the high risk to the patient.…”