Hospitals seek 90% reduction in specimen errors in 90 days

Can hospitals see a 90% reduction in mislabeled specimens within 90 days? Some hospitals in South Carolina have, and others are about to find out by trying a new toolkit to prevent mislabeled blood specimens used by a hospital that did experience that huge improvement.

Released recently by the South Carolina Hospital Association (SCHA), the toolkit was built from a proposition that by promoting the "just culture" concept, hospitals can radically reduce errors.

The mislabeled blood specimen is an example of a classic, simple, but potentially tragic error. Blood is drawn from one patient at bedside, but the barcoded identification label of another patient is affixed to the vial, says David Marx, father of the just culture concept and CEO of Outcome Engenuity, a Dallas-based management consulting firm that worked with the SCHA to develop and release the toolkit.

"It is not a rare event in our nation's hospitals, occurring as frequently as one out of every 1,000 blood draws," Marx says. "The impact can be disastrous. You're incorrectly diagnosed with a disease you do not have, an unnecessary procedure is performed on you, or you receive the wrong blood in a transfusion, simply because another patient's pre-printed label is affixed to your blood specimen."

The just culture approach is ideal for addressing this problem, Marx says. The problem won't be solved by blaming individuals for errors, he says. "Around the country, hospitals are trying to fix problems by whacking their employees into submission," Marx says. "It's not a good strategy, for the employee or the patients they serve."

Using the just culture method, the toolkit employs a specific strategy for blood collection safety called The Final Check. A nurse at bedside draws the blood, affixes a pre-printed label, and then speaking out loud, in front of the patient, reads the last three digits of the medical record number from the patient's arm band and then from the blood specimen container. For example, the nurse would say "749, 749, confirmed" so the patient could hear.

The process reduced mislabeled blood specimens by 90% at Palmetto Health Richland Hospital in Columbia, SC, where the Final Check was first designed and implemented, says Lorri Gibbons, vice president of quality improvement and patient safety at the South Carolina Hospital Association. Similar results were seen at five other hospitals: four in South Carolina, and one in North Carolina.

"The just culture shifts focus from the harm and who to blame, and instead targets the design of the system around the healthcare provider and the behavioral choices of providers in those systems," Gibbons says.

Rather than waiting to discover a mislabeled specimen and then disciplining the nurse or lab technician involved, hospitals would instead focus their employees on the behavioral choices most critical to the safe patient care, Gibbons explains. The hospital leaders recognize that their staff members cannot be perfect, but that they do have choices to make. With the right system around them and the proper focus on how to label a specimen, healthcare providers could produce much better results, she says.

"We had to show the world that there was a better way," Gibbons says. "We wanted to show nurses and lab technicians that there was indeed a better way to do their work. We had to help them be safe. In doing so, we've created a national best practice for specimen labeling."

The Final Check toolkit, as well as reference videos, is available free of charge at www.thefinalcheck.org.

Sources

• Lorri Gibbons, Vice President of Quality Improvement and Patient Safety, South Carolina Hospital Association, Columbia, SC. Telephone: (803) 744-3549. Email: lgibbons@scha.org.

• David Marx, CEO, Outcome Engenuity, Dallas. Telephone: (469) 222-6880. Email: dmarx@outcome-eng.com.