PA hospitals cut label errors by 37%

9 hospitals target blood specimens

A project designed to analyze labeling errors and devise solutions resulted in a 37% decrease in errors across nine hospitals in Pennsylvania.

From August 2009 through October 2010, the Pennsylvania Patient Safety Authority (PPSA) sponsored a multi-hospital blood specimen labeling collaborative. The PPSA worked with the hospitals to measure blood specimen labeling error rates, document hospital-specific interventions to reduce the labeling error rate, and measure the outcome of the interventions.

Eight acute care hospitals and one rehabilitation hospital participated in the collaborative, says Megan Shetterly, RN, MS, patient safety liaison for the Northeast Region of the PPSA. Each hospital assembled a team to participate in the collaborative, and team members included laboratory directors, phlebotomy supervisors, patient safety officers, and risk management, quality and performance improvement, and regulatory compliance personnel. Some of the hospitals used bar coding technology in some areas but not throughout the hospital.

PPSA provided educational sessions about reliable design, just culture, and human factors engineering. Subsequently, each hospital team mapped its blood specimen labeling process, assessed the process for compliance through direct observation, and presented an overview of the processes to the rest of the collaborative participants.

This project was an opportunity for the collaborative participants to identify barriers to labeling compliance that transcended specific care areas and organizations, Shetterly says. Common barriers were those related to technology, communication, education, staffing, workflow, and leadership.

PPSA also trained participants in root cause investigations, and by October 2010 it had collected and analyzed 485 investigations. Facilities reported 520 contributing factors associated with the mislabeling errors. The top three contributing factors were procedures not followed, distractions and interruptions, and unplanned workload increase.

20 interventions address six domains

The collaborative participants implemented more than 20 interventions between April and July 2010. There were six major categories of barriers to blood specimen labeling accuracy: technology, communication, education, staffing, workflow, and leadership. The collaborative participants implemented several interventions within these domains to improve specimen labeling accuracy. Overall, there was a 37% statistically significant decrease in blood specimen labeling errors in the collaborative over the 18-month period, Shetterly says.

The PPSA project also involved patients by encouraging them to question caregivers about following proper identification procedures. Patients were given pens as a small gift that might be used and seen often, and signs were posted in rooms with the slogan "Did you ID me?" Shetterly also encourages hospitals to shadow staff doing blood draws and other specimen collection.

"We followed around some of these nurses who were doing the blood collection, and we saw things that the project managers in the hospital didn't see," Shetterly says. "Sometimes it takes a fresh set of eyes. If you're around the same place long enough, you don't notice that cobweb up in the corner anymore." (The full PPSA article, "Reducing Errors in Blood Specimen Labeling," is available online at