#57
PROJECT NAME: Microbiology Specimen Labeling
Incidents
Institution: The University of Texas MD Anderson Cancer Center
Primary Author: Joe Yarsa
Secondary Author: Andrea Cain, Myra Granada, Ron A. Phipps
Project Category: Lab
Purpose/Aim:
Non-blood specimens for microbiology are ordered, collected, and labeled by staff on the inpatient floors.
Specimens will arrive in microbiology unlabeled or the label on the specimen and the label on the requisition
will not match. 59% of these specimens are relabeled which involves a nurse coming to the microbiology lab
to place the correct label on the specimen. The other 41% of specimens are recollected. This causes delays
in the lab to other specimens waiting to be processed and impacts the nurses care of other patients. It could
also lead to incorrect lab results and incorrect treatment to patients.
This project aligns with National Patient Safety Goals:
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NPSG 01.01.01: Improve the accuracy of patient identification. Use at least two patient identifiers when
providing laboratory services. Label containers used for blood and other specimens in the presence of the
patient.
NPSG 02.03.01: Improve the effectiveness of communication among caregivers. Report critical results of
tests and diagnostic procedures on a timely basis.
The goal of this project is to reduce the number of UHC Patient Safety Net reports regarding
unlabeled/mislabeled non-blood microbiology specimens from inpatient units P9 and G18 by 50% by
December 31, 2013.
Tools and Measurement:
Baseline data: The team queried the PSN (Patient Safety Net) for PSN incidents from 9/2011 to 8/2012
involving the laboratory. Approximately a third of all incidents involve mislabeled or unlabeled specimens
received by the lab. Most of the labeling incidents are arising from inpatient nursing units.
A questionnaire was developed so the team could capture the voice of the customer (different inpatient
areas). The results from the questionnaire were used to create a process map and the variations among floors
were noted. In all, 36 different methods were noted. A fishbone diagram was created to help understand the
potential problems that could result in a mislabeled microbiology specimen. A weighted solution prioritization
matrix was created to help the team focus on specific problems.
Intervention and Improvement:
Included in the changes the team proposed were:
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Making changes to the microbiology form that allowed the form to be completed on line and printed with
the patient’s demographics and barcode. The form also expanded the number of tests which decreased
the number of write in tests.
Created a two bin system. Microbiology specimens would be placed in the 1st bin after they were
collected, labeled and placed in the specimen bags. Another person would check the specimen to verify
that the specimen and the requisition were labeled and the labels matched. After which they would place
the verified specimens into the 2nd bin and call specimen transportation for their pick-up. The bins have
visual cues to remind employee to check for correct labeling
The team discovered that the scanners in the lab could not read the bar code on the requisition. The
scanners in the labs were reprogrammed and are now able to scan the MRN
Created a Stoplight Report Card of Microbiology PSN Incidents by floor. This report is sent to the nurse
managers monthly to let them know how many mislabeled micro specimens they had and how they
compare with other areas.
The team discussed various ways to communicate the changes to all involved personnel.
More detailed information is being attached to the PSN reports so all staff in the area have the appropriate
information to communicate to their staff for corrective action.
The team decided to make changes to the microbiology requisition form. The form being used was not
barcoded and could not be completed on line. This could cause a mislabeling error by allowing a wrong
MRN label being placed on the requisition.
Intervention Timeline:
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January 2013: New Microbiology Requisition Form implemented
Mid April: Myra Granada and Andrea Mayfield meet with their staff to discuss the new process of requiring
two employees to verify identification when placing labels on patient’s specimens. They also discussed
the use of two bins for laboratory specimens.
April 16: Pilot floors begin using two bins for microbiology specimens
April 30: Lab scanners programmed to scan MRN
May 7: Pilot floors requested larger bins
May 15: Article in Employee Notes discussing the need for properly labeled microbiology specimens
May 21: Passed out flyers at the Patient Safety Town Hall
May 2013: Stoplight Report Card put into use
June 5: Spoke to the CAD meeting about the changes being implemented on the pilot floors
Intervention Results:
The team was able to meet and surpass their goal of a 50% error rate reduction. Only one error involving the
pilot floors was recorded between May and June. This error involved a rotating employee who was not aware
of the changes in policy. By using Stoplight reports to highlight each floor’s errors as reported in PSN the team
plans to maintain this improvement.
Revenue Enhancement /Cost Avoidance / Generalizability:
Correcting a labeling error takes time away from other specimens and patient care. The lab and nursing
personnel time saved by reducing the number of errors translates into approximately $3000/year.
Labeling errors result in delay of testing which can cause a patient to be discharged a day later which can
result in between $1,466 to $1,898 additional charge to the patient.
Labeling errors can result in the reporting of an incorrect lab result/delay or incorrect treatment of the patient.
This becomes a potential legal liability to MD Anderson
This project is being monitored using Monthly Stoplight Report Cards that are being sent to the floor by
microbiology to insure visibility of errors. Each individual error (PSN report) submitted provides information on
the proper methods to use so the areas can use it for corrective actions.