• The improper labeling of specimens can pose a serious risk to patient safety. Failing to document two unique patient identifiers is a National Patient Safety Goal violation, and the re-labeling of specimens in Lab consumes time, resources, additional paperwork and reduces overall processing throughput and prolongs result turnaround times.
• The purpose of the project is to determine system, hardware and workflow problems that contribute to improper labeling of specimens, and to determine appropriate interventions to solve or mitigate those problems.
Aim Statement: Reduce labeling events to from 1.51 to 0.5/1000 accessions by January 2019
Methodology: Achieving and Maintaining Improvements with Jidoka
1. Lab Processor: Identify a specimen labeling issue and alert lab supervisor.
2. Lab Supervisor: Enter the specimen labeling event information into event reporting system (A), notify the attributed unit’s charge nurse/ANM of by phone, and log the event in the OneDrive event log (B).
3. Charge Nurse/Assistant Nurse Manager (ANM): Address the specimen labeling error with staff and assign the individual the self-auditing tool (C) for coaching purposes. Email the event description to the Nurse Leadership Team.
4. Clinical Safety: Follow up on any outstanding issues with the Nurse Manager/ANM, and/or Lab.
5. Nurse Manager: Final documentation of review/corrective action in the event reporting system
Interventions: Intervention #1 Staff Education (Q4 CY 2016): The specimen labeling training module was developed and pushed out to nursing staff to provide training and help dispel the notion that processing through the collection manager interface is too time consuming.
Intervention #2 Targeted Auditing (Q2 CY 2017): Final Check® audits are assigned to staff members for whom specimen labeling events have been attributed to. The Final Check® is a specimen labeling best practice to eliminate the occurrence of mislabelled specimens.
Intervention #3 Jidoka (Q4 CY 2017): A process to resolve patient safety issues due to mislabeled, incompletely labeled and unlabeled specimens in realtime by providing meaningful and timely resolution to event reports and giving staff immediate feedback regarding process, behaviors, and expectations for proper specimen labeling.