QI project slashes mislabeling rates

Computer re-education a key to turnaround

The ED at Boston Medical Center has reduced major mislabeling events from 47% (23/49) to 14% (4/29) in a year, thanks to a quality improvement project that kept the ED informed weekly when errors occurred. The initiative was an important one, notes Karen Quillen, MD, medical director of the blood bank, Department of Pathology and Laboratory Medicine, who oversaw the hospitalwide project, because acute hemolysis, primarily the result of ABO (the main blood types) incompatibility, is an important cause of transfusion-related mortality and morbidity.

Quillen targeted blood group inconsistencies. "I would get blood group results based on a sample, but when I compared it to the patient's historic record, some had different blood types two months or two years ago," she says. "We know your blood type cannot change, so one of those times it was wrong."

All mislabeled specimens received by the transfusion service for a type and screen were recorded and classified into minor and major mislabeling categories. The major mislabeling events were tracked by origin of the specimen, and the areas with a high proportion of major mislabeling were given feedback within one week of the events.

"We collected all relevant data, and only when we looked at it after a year did patterns emerge," notes Quillen. "We did not focus on the ED, but they do a lot of labeling, and from the prior data analysis we could tell where the high problem areas were."

Having a large number of mislabeling errors originate in the ED can be a serious problem, Quillen adds. ED samples sent to the blood bank don't always request transfusions. "Sometimes it's a 'just-in-case' situation when they're doing a work-up," she says. "But if they do order a transfusion, and we don't pick [the mislabeling] up, it could potentially be disastrous."

Identifying the causes

Linda Fisher, MSN, director of emergency nursing, received weekly e-mails from Quillen noting all major mislabeling events.

"She let me know each time an error occurred so I could speak with the individual nurses," Fisher recalls. She would approach the nurses and, in a nonaccusatory fashion, retrace process steps to see what had gone wrong. "This was simply observation of practice," she explains.

This was what ultimately uncovered some common problems in the department. "Initially [speaking with the nurses] was the only intervention, but we soon realized the mislabeling had become an issue when we went to electronic documentation and order entry," Fisher notes.

That problem was not with the system itself (ibex PulseCheck, from Chicago-based Pangaea Information Technologies) but with the way the nurses were using it, she says. After a number of discussions with the nurses, it became clear that the way the nurses were entering the information was a major cause of the errors.

The most frequent error involved nurses hitting the "enter" key after each specimen was drawn, instead of after all specimens were drawn from that one patient. Problems arose when more than one nurse was on a computer simultaneously. "If I hit 'enter' after one specimen for Mr. Jones, and another nurse hit 'enter' after one specimen for Mr. Brown, and a third did the same after drawing one specimen for Mr. Smith, the labels could get interspersed (at the printer), and that was the main cause of errors," Fisher explains.

Solving the problem

Fisher took several steps to eliminate these errors. "First, we talked to the nurses and explained they should not hit 'enter' until they were completely done with the patient," she says. "This way they would have all their Patient Smiths and Patient Joneses together."

As a fail-safe measure, she asked the information technology staff to alter the system so that whenever the 'enter' key was hit, a blank label would be printed. "This acts as a 'stop sign' for the nurse," she explains. "She now knows she has all the labels she can have for Mr. Smith."

Of course, the nurses often will draw extra blood early in the encounter 'just in case' more tests are needed later, in order to avoid an additional needle stick. "We are a safety net facility, so some of the patients are a very difficult draw," Fisher explains. "If the nurses have drawn an extra tube of blood, they have to manually label that for later."

The nurses are grateful that these errors have been eliminated, Fisher says. "After all, if the lab called and told them, 'This can't be Mr. Smith's blood. You have to re-draw,' they then had to re-draw the patient and explain why," she says.


For more information on quality improvement in blood labeling, contact:

  • Linda Fisher, MSN, Director of Emergency Nursing, or Karen Quillen, MD, Department of Laboratory Medicine, Boston Medical Center, One Boston Medical Center Place, Boston. Phone: (617) 638-8000.