Strict Specimen Labelling Criteria - A Safety Initiative Experience from a Hospital

Abstract

Aim Correct patient and specimen identification and labelling are critical to ensuring that the correct results are issued for the right patient, and that medical decisions and treatments given on the basis of these test results are appropriate. This is particularly critical in pre-transfusion testing with the risk of ABO mismatch transfusion and potential fatality a real possibility. Background: Over 11 months, data relating to mislabelled specimens demonstrated a basal rate of 2 ‘wrong-blood-in-tube’(WBIT) incidents per month and 8 of 23 were for pre-transfusion testing. These incidents were detected only where inconsistencies either in clinical information or previous test results were apparent. Intervention Our pathology service developed a set of strict minimum identification criteria for ALL pathology specimens and a policy of rejection of specimens that do not comply. These criteria align with ANZSBT guidelines for pre-transfusion samples. An 8 week education and notification phase followed by strict application of the criteria in February 2004 and a subsequent follow-up phase was conducted. Result Smooth implementation of a major network-wide initiative has occurred over the last 5 months, as evidenced by the low specimen incident rate of 1%. Early indicators of success include an increased awareness of WBIT episodes with three self-reported episodes of WBIT since implementation. Unlabelled specimens have reduced by at least 50% compared to the same period prior to intervention. Conclusion Our experience may be of interest to other institutions considering similar initiatives. A reduction in WBIT events is the most preferred outcome, however it may be many months before this can be appreciated due to low detection levels.