Karen Quillen1, Kate Murphy. 1. Department of Laboratory Medicine, Boston University Medical Center, Boston, Mass 02118, USA. kq@bu.edu
Abstract
CONTEXT: Proper specimen identification and labeling is a critical preanalytic step in pretransfusion compatibility testing. OBJECTIVE: To gather baseline data for specimen mislabeling, specifically targeting major mislabeling events, and to design and implement a plan of corrective action. DESIGN: All mislabeled specimens received by the transfusion service for a type and screen were recorded and classified into minor and major mislabeling categories. Major mislabeling events were tracked by origin of the specimen. Locations with a high proportion of major mislabeling were given timely feedback (within 1 week) of the events as they arose. SETTING: A university hospital. MAIN OUTCOME MEASURES: The incidence of major mislabeling. RESULTS: The incidence of mislabeling in the transfusion service was 0.5% (243/49 955) during 21 months of data collection. Of these mislabeling events, 47% were classified as major events (unlabeled, mismatched specimen/ requisition, ABO/Rh result on current specimen not matching historical record on file). The emergency department accounted for a high proportion of these major mislabeling events. After the intervention of providing weekly feedback to emergency department staff, their contribution to major mislabeling fell from 47% in 1 year (23/49) to 14% (4/29) in the subsequent 3 quarters. CONCLUSIONS: Collecting and trending data on mislabeled samples with timely feedback to patient care areas can change phlebotomy practice and reduce specimen mislabeling.
CONTEXT: Proper specimen identification and labeling is a critical preanalytic step in pretransfusion compatibility testing. OBJECTIVE: To gather baseline data for specimen mislabeling, specifically targeting major mislabeling events, and to design and implement a plan of corrective action. DESIGN: All mislabeled specimens received by the transfusion service for a type and screen were recorded and classified into minor and major mislabeling categories. Major mislabeling events were tracked by origin of the specimen. Locations with a high proportion of major mislabeling were given timely feedback (within 1 week) of the events as they arose. SETTING: A university hospital. MAIN OUTCOME MEASURES: The incidence of major mislabeling. RESULTS: The incidence of mislabeling in the transfusion service was 0.5% (243/49 955) during 21 months of data collection. Of these mislabeling events, 47% were classified as major events (unlabeled, mismatched specimen/ requisition, ABO/Rh result on current specimen not matching historical record on file). The emergency department accounted for a high proportion of these major mislabeling events. After the intervention of providing weekly feedback to emergency department staff, their contribution to major mislabeling fell from 47% in 1 year (23/49) to 14% (4/29) in the subsequent 3 quarters. CONCLUSIONS: Collecting and trending data on mislabeled samples with timely feedback to patient care areas can change phlebotomy practice and reduce specimen mislabeling.
Authors: Steven R Blumen; Phda Shelly Naud; Mary Val Palumbo; Barbara McIntosh; Burton W Wilcke Journal: Public Health Rep Date: 2010 May-Jun Impact factor: 2.792
Authors: Paramjit Sandhu; Kakali Bandyopadhyay; Dennis J Ernst; William Hunt; Thomas H Taylor; Rebecca Birch; John Krolak; Sharon Geaghan Journal: J Appl Lab Med Date: 2017-09