SARAH TENUTO, MSN, RN, CNL

CANDICE WASHILEWSKI, MSN, RN

KRISTIN MARCH, PERFORMANCE IMPROVEMENT CONSULTANT

Mislabeled Specimens

Background

An increase number of errors regarding correctly labeling specimens became a high concern to Adventist Hinsdale Hospital and Adventist La Grange Memorial Hospital. A

Performance Improvement Project was initiated to better understand failure points

and vulnerabilities in the specimen collection process that lead to mislabeled specimen and identify actions to reduce

occurrence of failure.

Goals & Objectives

The overarching goal of the project is to decrease mislabeled specimens from RN

draws and to increase patient safety.

A secondary goal is to standardize the process of drawing specimens and to increase the

efficiency of the process.

Methods

1) A task force was assembled with staff from both AHH & ALMH

2) The task force reviewed the risk masters and examined the potential reasons for mislabeled specimens

3) It was determined that the process needed to be streamlined to minimize distractions and to make supplies readily available to expedite the process for RN’s

Action Plan

Lab draw kits were created and placed on the units. Each kit contains all the essential supplies an RN would need to obtain a specimen from a PICC line or port. In

addition to this, patient labels are now kept in the patients room clipped to the

communication board. The RN verifies the label against the patients wristband for the two identifiers to ensure that specimens are

properly labeled.

Before

After

Results to Date

The trial for the new process began on July 28th on 4 West at ALMH. Since then, there

have been zero risk masters involving mislabeled specimens.

The project was expanded to the rest of the inpatient units on January 1st. It is now

moving towards implementation at AHH.

Decreased Non-Value Added Steps

Key Performance Metrics

Baseline Current

Number of steps to complete the process

154 steps 66 steps

Times it takes to complete the process

(mm:ss)

02:09 00:35

Key Learnings

1.) Engaging front line staff in performance improvement enables them to “own” the solutions and take pride in their accomplishments.

2) Process change requires collaboration from many different disciplines. In this case, nurses, PCT's, EVS and Lab were all involved.

3) Standardizing a new process takes persistence and reinforcement before it can become a norm.

4.)We have the potential to impact patient care in both positive and negative ways. It is important to reflect on our processes and make changes that can improve our patient care outcomes.