SC hospitals taking on mislabeled specimens

'You have to do it out loud'

What do you do when something you desperately want to fix just won't be fixed? For one quality improvement manager in a South Carolina academic medical center, the problem was mislabeled lab specimens that didn't get any less common over 18 months, despite policy changes and even red rules that would leave staff open to discipline for failing to abide by them. Nothing worked. She talked about this with her peers at a meeting about creating a just culture. Listening was Lorri Gibbons, RN, CPHQ, vice president for quality improvement and patient safety at the South Carolina Hospital Association.

"She talked about how the staff said the emergency room was just too busy a place to get better than a certain level," Gibbons recalls. The conference included sessions with David Marx, sometimes talked about as the godfather of just culture and CEO of Dallas-based Outcome Enginuity (

He said that the number of labeling errors in the South Carolina teaching hospital could move by 90% in 90 days, and it could be sustained at that level. He offered to come to South Carolina and— along with Gibbons and the South Carolina Hospital Association — work with this quality manager.

For a week, Gibbons says, he observed, pulled in ED and lab staff, asked for input. They did probability risk assessments to figure out where the gap was, where the key would fit that would unlock the mystery of continually mislabeled specimens.


Everyone involved in collecting specimens was invested in the project, she says, which helped the final program to be seen as staff-driven, not department-driven. If it was just nursing, why would lab personnel feel engaged? And if it was lab-driven, then why would nurses listen? "We didn't care what department you worked in, we just wanted to make sure that everyone involved was there."

It came down to one simple thing, Gibbons says. "You do everything you are supposed to do — you walk in, you say your name, you check the name and date of birth of the patient, you draw the specimen, and you put the label on it — and then you read aloud the last three digits of the medical record number on the vial of blood and match that out loud to the last three digits of the record on the patient's identification band. The critical piece is to say that, to match that out loud. If you do that, you will drastically reduce unlabeled or mislabeled labs."

There is no cost. There are no extra staff. There really isn't any training to do. But Gibbons says it works because you can't read those numbers out loud and be on autopilot.

"Think of the times you have gone somewhere and don't realize how you got there," she says. "Or how many times you think you're reading something, but you don't recall what it says. Part of what we do in assessing a risk is to identify what act can reduce the risk of error. Saying something in your mind isn't the same as reading something out loud. You want to do something consciously."

Program expanded to 10 hospitals

Often nurses will look at a patient they've seen a half dozen times before and figure they know the record number, they've said it in their head a million times, Gibbons says. "But the one time you don't really check it, that's the time you miss the error. You have to do it out loud."

The out loud part of the project helps to make other people part of the accountability system — patients and other staff expect to hear someone collecting a specimen match the two sets of numbers out loud. Another part of the project was for staff to report when they discovered errors in the labels.

This started out as a small project — just a single hospital in a system. But it expanded quickly to 10 pilot hospitals, and if it's sustained for a year, Marx says he'll take it national. All the hospitals barring one have seen their rates of mislabeling drop — one went up in July, and there is a team already investigating what went wrong there, Gibbons says. The drop, by the way, was the anticipated 90% or more in the facilities participating.

Some of the hospitals are expanding to other kinds of samples, such as urine, or in departments like radiology, and Gibbons says she's getting calls from around the country to ask about the program. (The toolkit is available for download from

At The Regional Medical Center in Orangeburg, SC, the program was piloted on the unit with the highest rate of mistakes in labeling — the emergency department. But the program seemed so promising, they rolled it out to other units while still participating in data collection for the hospital association pilot program.

Convincing stakeholders

Phlebotomists ask patients to state their name and date of birth, and check it with the patient's arm band. After blood is collected, they are labeled with preprinted labels. Once those labels are put on the tubes, the phlebotomists read the last three digits of the medical record arm band and the specimen labels. They have to match. Sometimes patients ask why, and the program is explained.

Gary Ferguson, BSMT, MHA, the director of pathology and laboratory medicine at the center, says that he was interested in the program for a couple of reasons.

The first was the low cost and impact to procedures already in place. Nothing much had to change. Second was how shallow the learning curve is for the program. Indeed, the hardest thing was "convincing the stakeholders that there was a potential for significant patient harm whenever a mislabeling event occurred."

The success in the pilot probably helps convince new units: from a baseline of 3.5 mislabeled samples per month to just 2 after 30 days, 1 after 60 and down to nothing after 90 days. The next units to get the program are intensive care and coronary care. And Ferguson thinks it will go very smoothly.

"I believe we will have their full support and appreciation that this will make their jobs a little easier," he says.

For more information on this topic, contact:

  • Lorri Gibbons, RN, CPHQ, Vice President for Quality Improvement and Patient Safety, South Carolina Hospital Association, Columbia, SC. Telephone: (803) 796-3080.
  • Gary Ferguson, BSMT, MHA, Director, Department of Pathology and Laboratory Medicine, The Regional Medical Center, Orangeburg, SC. Email: