Reduction in Hospital-Wide Clinical Laboratory Specimen Identification Errors following Process Interventions: A 10-Year Retrospective Observational Study.

Hsiao-Chen Ning,Shu-Yu Peng,Chiao-Ni Wen,Chia-Ni Lin,Hsin-Ming Yu,Yung-Ta Chang,Daniel Tsun-Yee Chiu,Tsu-Lan Wu,Tsung-Lan Chu,Gavin Daker-White

doi:10.1371/journal.pone.0160821

Abstract

BackgroundAccurate patient identification and specimen labeling at the time of collection are crucial steps in the prevention of medical errors, thereby improving patient safety.MethodsAll patient specimen identification errors that occurred in the outpatient department (OPD), emergency department (ED), and inpatient department (IPD) of a 3,800-bed academic medical center in Taiwan were documented and analyzed retrospectively from 2005 to 2014. To reduce such errors, the following series of strategies were implemented: a restrictive specimen acceptance policy for the ED and IPD in 2006; a computer-assisted barcode positive patient identification system for the ED and IPD in 2007 and 2010, and automated sample labeling combined with electronic identification systems introduced to the OPD in 2009.ResultsOf the 2000345 specimens collected in 2005, 1023 (0.0511%) were identified as having patient identification errors, compared with 58 errors (0.0015%) among 3761238 specimens collected in 2014, after serial interventions; this represents a 97% relative reduction. The total number (rate) of institutional identification errors contributed from the ED, IPD, and OPD over a 10-year period were 423 (0.1058%), 556 (0.0587%), and 44 (0.0067%) errors before the interventions, and 3 (0.0007%), 52 (0.0045%) and 3 (0.0001%) after interventions, representing relative 99%, 92% and 98% reductions, respectively.ConclusionsAccurate patient identification is a challenge of patient safety in different health settings. The data collected in our study indicate that a restrictive specimen acceptance policy, computer-generated positive identification systems, and interdisciplinary cooperation can significantly reduce patient identification errors.

Highlights

There has been increased interest in issues involved with reducing patient errors and improving patient safety since publication of a report entitled “To Err is Human: Building a Safer Health System” by the Institute of Medicine [1]
The following series of strategies were implemented: a restrictive specimen acceptance policy for the emergency department (ED) and inpatient department (IPD) in 2006; a computer-assisted barcode positive patient identification system for the ED and IPD in 2007 and 2010, and automated sample labeling combined with electronic identification systems introduced to the outpatient department (OPD) in 2009
The total number of institutional identification errors contributed from the ED, IPD, and OPD over a 10-year period were 423 (0.1058%), 556 (0.0587%), and 44 (0.0067%) errors before the interventions, and 3 (0.0007%), 52 (0.0045%) and 3 (0.0001%) after interventions, representing relative 99%, 92% and 98% reductions, respectively

Summary

Introduction

There has been increased interest in issues involved with reducing patient errors and improving patient safety since publication of a report entitled “To Err is Human: Building a Safer Health System” by the Institute of Medicine [1]. Patient identification (ID) and accurate specimen labeling during phlebotomy procedures are crucial first steps in the prevention of medical errors [2]. Patient and specimen ID errors have been reported at rates of 0.005–1.12% among various institutions, and many more such errors may be underreported [11,12,13,14]. Accurate patient identification and specimen labeling at the time of collection are crucial steps in the prevention of medical errors, thereby improving patient safety

Methods

Results

Conclusion