July 2012
Feature Story

Mariann Stephens

Any laboratory that pulls off an 81 percent drop in blood specimen labeling errors has some explaining to do. Which is why Myra L. Wilkerson, MD, vice chair, Division of Laboratory Medicine for the Geisinger Health System in Danville, Pa., and laboratory director for the Geisinger Medical Laboratories Northeast, might have expected a few questions from her colleagues at a recent meeting of the Compass Group, an association of lab leaders from 20 not-for-profit integrated delivery network health care systems. Questions such as: How did you do it? Are you sure you can prove it? Was it something in the water in Wilkes-Barre? Yes. Yes. And no.

Dr. Wilkerson was at Henry Ford Health System in Detroit, where the group met in April to share best practices, to report what she and others learned when one of the Geisinger hospitals, Geisinger Wyoming Valley Medical Center, joined a patient safety collaborative.

Pennsylvania, the first state in the nation to require that health care facilities report adverse events and near-miss incidents, established the Pennsylvania Patient Safety Authority to which such events could be reported and as a hub of study and teaching of systems-based improvements. “They analyzed their data and found a lot of items related to specimen labeling and identification,” Dr. Wilkerson says. In April 2009, the safety authority invited hospitals to participate in an 18-month initiative to reduce the number of blood specimen labeling errors, and Geisinger Wyoming Valley was one of the nine to step up. Its labeling errors in the medical intensive care unit fell by 81 percent during the study period. The collaborative overall achieved a mean decrease in error rates of 37 percent. (Fig. 1)

The safety authority was interested in working with a cooperative group across multiple hospitals to better understand what does and doesn’t work in different settings. “The idea was to provide a common forum so different groups could take those tools back to their own institutions to effect change,” Dr. Wilkerson says. “They also wanted the members of the collaborative to be resources, and cheerleaders, for each other.”

Each hospital assembled a team culled from its various departments—laboratory, patient safety, phlebotomy, risk management, regulatory compliance. Each hospital determined for itself what events (missing or partial label, missing patient name, incorrect ID, misspelling) would constitute reportable errors. “One problem the collaborative had was getting everyone to agree on what constitutes an error. They finally said ‘follow your local policy,’” Dr. Wilkerson says. Point-of-care testing was excluded.

Members of the collaborative reported instances of blood specimen labeling error electronically via the confidential Pennsylvania Patient Safety Reporting System and submitted a monthly report to an authority analyst. They hosted one another at monthly meetings to share what they were doing and to design useful tools and techniques. They talked strategy, role-played investigative interviews, and exchanged ideas on how to recruit boosters within their hospitals. Perhaps their most useful innovation was an interview template used to investigate incidents.

An article in the June 2011 “Pennsylvania Patient Safety Advisory” (published by the safety authority and online at patientsafetyauthority.org under Patient Safety Advisories) sets out the factors they found to be most often related to error in blood specimen labeling. Failure to follow procedures came in first, by far. Distractions and interruptions were second, and unplanned workload increases were third.

In all, 485 events were reported. Baseline error rates ranged from 0.1–4.1 errors per 1,000 opportunities. Post-intervention rates: 0.0–1.3 per 1,000 opportunities.

Barbara A. Booth, MT(ASCP), Geisinger Wyoming Valley’s service improvement coordinator and Geisinger’s project manager and collaborative representative, says the GWV team set out to involve laboratory, nursing, and respiratory therapy personnel from all shifts. One challenge, Booth says, was getting front-line personnel to the meetings. “Their input was important,” she says, though they couldn’t always get away. “They did their best and were involved in other ways.”

The idea was to start small, Booth says, so they selected the 25-bed medical intensive care unit, where all three groups collect blood specimens. “Since it’s intensive care, some patients have lines, so there was a nice mix of collectors from lab, nursing, and respiratory. It was selected not on the basis of the number of errors but on the diversity of the collectors of blood specimens.”

When an event occurred, a one- or two-member team would use the template to conduct a post-error interview as soon as possible. “We just walked through the steps of what happened and what was supposed to happen,” Booth says. “Why it didn’t happen, when interruptions occurred, what shift, whether someone was agency or not, if they were aware of the procedure, if they ordinarily followed the procedure, what made it difficult for them to do so.”

Employees who were uneasy at the start of the post-error meeting became part of the solution, Dr. Wilkerson says, attributing that to the strength of the interview tool and to the skill the interviewers developed. “We emphasized that they were well educated, that they knew their jobs,” she says. “The team would say, ‘You know the procedure. Something is wrong with the procedure or with your environment because you made a wrong choice. But it’s not necessarily your fault that something went wrong, and we need your help to fix it.’” (Fig. 2)

Some of the best moments came when other departments began to get the message, when they no longer saw labeling safety as an issue for the laboratory alone. For example, when they realized that only one printer in the MICU was printing labels with a visual break between those for each patient (which minimized the chance that a patient’s specimen would get the wrong label), the IT department intervened so that labels sent to the second printer in the MICU would also be produced with that visual break. When they had data showing that even the phlebotomy staff had labeling errors when they didn’t have access to bedside printers or handheld electronic devices to scan bar codes on wristbands, others became more interested in hearing about the value of those tools. And when the post-incident interviews showed that everyone was interested in doing things right, the investigations became a lot easier.

The collaborative has ended, but lab and nursing continue to use the interview tool for labeling-ID errors, with the employee always part of the solution. “Even though the interview template was developed for blood specimen identification errors, we’re using the tool as a coaching document for other errors in the lab,” Booth says.

“Our staff learned a lot,” she says. “At first, we more or less wrote off outside lab errors, saying ‘We can’t do anything about that.’ But as a lab, we have changed our culture and our job. We needed to fix it because whether or not it affected something in the laboratory, it affected patient welfare. We know now it’s best for the patient for us to reach out to these departments. We now say that if an issue affects lab service, we need to be a part of the solution.”

Others have learned too. Since the study ended, errors have crept back up. But nursing’s leaders and the chief medical and operations officers now understand the value of handheld scanning and printing devices used at bedside and the relationship of proper specimen labeling to patient safety. “So nursing will be piloting these in the MICU in a couple of months,” Dr. Wilkerson says.

Next on the list? Lobbying for even wider use of bedside label printers, bar-code technology, electronic devices that assist in confirming a patient’s identity, and expansion to all body fluids, not just blood. “I will not be happy until I can standardize all collections,” Booth says. ?