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Mislabelled Hospital Laboratory Specimen-A Risk Assessment Perspective

Received: 24 February 2014     Accepted: 14 April 2014     Published: 30 April 2014
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Abstract

Mislabeling of laboratory samples has been found to be a high-risk issue in acute care hospitals. In cases where hospitals adopted a bar code tracking system to ensure proper identification of specimens moving from bedside to the laboratory, the error rates were reduced from 108 to just 8. It is therefore concluded that adoption of bar code tracking system is an effective strategy for reducing error rate when sample specimen are collected at the bedside and transmitted to the laboratory. In this literature review, we propose to explore the use of bar code technology as and alternative method to reduce mislabeling of patients’ specimen. Although the focus group assembled to explored the risk assessment issues surrounding the mislabeled labeled specimen did not, we believe based on the review of the existing literature that bar code technology is the only method that provide the most patient safety.

Published in American Journal of Nursing Science (Volume 3, Issue 1)
DOI 10.11648/j.ajns.20140301.11
Page(s) 1-4
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2014. Published by Science Publishing Group

Keywords

Mislabeling of Laboratory Samples, Specimen Collection, Delta Checking, Preanalytic Errors, Analytic Errors, Laboratory Errors, Patient Impact, Physician and Nursing Responsibilities

References
[1] Brown, Judy E., Nancy Smith, and Beth R. Sherfy. "Decreasing mislabeled laboratory specimens using barcode technology and bedside printers." Journal of Nursing Care Quality 26.1 (2011): 13-21.
[2] Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem. 2002;48:691–698.
[3] Lapworth R, Teal TK. Laboratory blunders revisited. Ann Clin Biochem. 1994; 31:78–84.
[4] Plebani M, Carraro P. Mistakes in a stat laboratory: Types and frequency. Clin Chem
[5] Howanitz PJ. Errors in laboratory medicine: practical lessons to improve pa-tient safety. Arch Pathol Lab Med. 2005;129:1252–1261.
[6] Alenstein PN, Raab SS, Walsh MK. Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions. Arch Pathol Lab Med. 2006;130:1106–1113
[7] Bhat, Vivek. Tiwari, Manikchandra. Chavan, Preeti. Kelkar, Rohini :Analysis of laboratory sample rejections in the pre-analytical stage at an oncology center. Clinica Chimica Acta. 413(15-16):1203-6, 2012 Aug 16.
[8] Snydman, Laura K. Harubin, Beth. Kumar, Sanjaya. Chen, Jack. Lopez, Robert E. Salem, Deeb N: Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports from 30 health care organiza-tions. American Journal of Medical Quality. 27(2):147-53, 2012 Mar-Apr
[9] Hill PM. Marei-niss D. Murphy P. Gardner H. Hsieh YH. Levy F. Kelen GD: Significant reduction of laboratory spe-cimen labeling errors by implementation of an electronic ordering system paired with a bar-code specimen labeling process. Annals of Emergency Medicine. 56(6):630-6, 2010 Dec.
[10] Grimm E. Friedberg RC. Wilkinson DS. AuBuchon JP. Souers RJ. Lehman CM: Blood bank safety practices: mislabeled samples and wrong blood in tube--a Q-Probes analysis of 122 clinical laboratories. Archives of Pathology & Laboratory Medicine. 134(8):1108-15, 2010 Aug.
[11] Morrison AP. Tanasijevic MJ. Goonan EM. Lobo MM. Bates MM. Lipsitz SR. Bates DW. Melanson SE: Reduction in specimen labeling errors after implementation of a positive patient identification system in phlebotomy. American Journal of Clinical Pathology. 133(6):870-7, 2010 Jun
[12] Yuan S, Astion ML, Schapiro J, Limaye AP. Clinical impact associated with corrected results in clinical microbiology testing. J Clin Microbiol. 2005;43:2188–2193
[13] Astion ML, Krueger-Nielsen S, Davison B, Miller B. Errors and patient outcomes associated with problems in stat chemistry testing. Clin Chem. 2004; 50(suppl 6):A114–A11 abstract.
[14] Nosanchuk JS, Gottmann AW. CUMS and delta checks. A systematic approach to quality control. Am J Clin Pathol. 1974;62:707–712
[15] Astion ML. Putting power into patient safety interventions. Lab Errors Patient Saf. 2005;1:9–11.
[16] Bologna LJ, Mutter M. Life after phlebotomy deployment: re-ducing major patient and specimen identification errors. J Health Inf Manag. 2002;16:65–70
Cite This Article
  • APA Style

    Anne Rowshan, Hooman Rowshan. (2014). Mislabelled Hospital Laboratory Specimen-A Risk Assessment Perspective. American Journal of Nursing Science, 3(1), 1-4. https://doi.org/10.11648/j.ajns.20140301.11

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    ACS Style

    Anne Rowshan; Hooman Rowshan. Mislabelled Hospital Laboratory Specimen-A Risk Assessment Perspective. Am. J. Nurs. Sci. 2014, 3(1), 1-4. doi: 10.11648/j.ajns.20140301.11

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    AMA Style

    Anne Rowshan, Hooman Rowshan. Mislabelled Hospital Laboratory Specimen-A Risk Assessment Perspective. Am J Nurs Sci. 2014;3(1):1-4. doi: 10.11648/j.ajns.20140301.11

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  • @article{10.11648/j.ajns.20140301.11,
      author = {Anne Rowshan and Hooman Rowshan},
      title = {Mislabelled Hospital Laboratory Specimen-A Risk Assessment Perspective},
      journal = {American Journal of Nursing Science},
      volume = {3},
      number = {1},
      pages = {1-4},
      doi = {10.11648/j.ajns.20140301.11},
      url = {https://doi.org/10.11648/j.ajns.20140301.11},
      eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajns.20140301.11},
      abstract = {Mislabeling of laboratory samples has been found to be a high-risk issue in acute care hospitals. In cases where hospitals adopted a bar code tracking system to ensure proper identification of specimens moving from bedside to the laboratory, the error rates were reduced from 108 to just 8. It is therefore concluded that adoption of bar code tracking system is an effective strategy for reducing error rate when sample specimen are collected at the bedside and transmitted to the laboratory. In this literature review, we propose to explore the use of bar code technology as and alternative method to reduce mislabeling of patients’ specimen. Although the focus group assembled to explored the risk assessment issues surrounding the mislabeled labeled specimen did not, we believe based on the review of the existing literature that bar code technology is the only method that provide the most patient safety.},
     year = {2014}
    }
    

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    AB  - Mislabeling of laboratory samples has been found to be a high-risk issue in acute care hospitals. In cases where hospitals adopted a bar code tracking system to ensure proper identification of specimens moving from bedside to the laboratory, the error rates were reduced from 108 to just 8. It is therefore concluded that adoption of bar code tracking system is an effective strategy for reducing error rate when sample specimen are collected at the bedside and transmitted to the laboratory. In this literature review, we propose to explore the use of bar code technology as and alternative method to reduce mislabeling of patients’ specimen. Although the focus group assembled to explored the risk assessment issues surrounding the mislabeled labeled specimen did not, we believe based on the review of the existing literature that bar code technology is the only method that provide the most patient safety.
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Author Information
  • Hospital for Sick Children, Toronto, Canada, York University Department of Nursing, Toronto, Canada

  • College of Pharmacy, University of Florida, Gainesville, Florida, USA

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