Using the provided paper, write 5 SLOs using Bloom's Taxonomy and the provided rubric.

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Using Handheld PDA Devices to Reduce Specimen

Mislabeling and Rejections

University of West Florida

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Case History

A 68 year old Caucasian woman presented to the ER on Friday evening after returning home

from helping in relief efforts after a hurricane. She was suffering from chest pains that came and went,

she was light headed, and stated that she had a pain in her left arm and back. The patient was also

having a slight shortness of breath. Her height was 5’2, and current weight was 160. Blood pressure

was slightly elevated at 168/90 and her respirations were 22 bpm. An EKG and cardiac panel were

ordered and the patient was administered a nitroglycerine tablet.

The phlebotomist arrived and verified all the required information with the test requisition and

patient bracelet. After the verification, the phlebotomist proceeded to collect the patient’s blood and

label the tube with the preprinted label that was included with the computer generated requisition

form. The phlebotomist then printed her tech code and date and time of specimen collection on the

label by hand and the sample was sent to the lab for testing.

The accessioner who received the sample verified that the date of collection, date of birth, and

patient’s last name matched the requisition but the first name and medical record number were slightly

different. The accessioner then called the ER and notified the department that a sample needed to be

recollected due to the discrepancies in the first name and medical record number of the specimen label

and requisition form.

Student Learning Outcomes

Discussion

Errors can and do occur occasionally with laboratory specimens. There are three types of errors

that can occur in the lab. These errors are commonly known as pre-analytical, analytical and post-

analytical errors. Pre-analytical errors are the most common errors that occur in the laboratory today.

These types of errors occur before the sample is tested. Some examples would be specimen

mislabeling, which could include missing tech codes on a sample, patient name misspellings, or

mismatched specimen and requisition, patient preparation, collection of sample in the wrong tube type

etc. Analytical errors are errors that affect analysis of the specimen during testing such as testing

review, lab interpretations, result accuracy etc. Post-analytical errors are errors that occur after the

testing has been completed. This type of error may include errors in calculations, resulting errors,

failure to report critical values to the correct person etc.

Patient safety and lab turnaround times are of top priority in hospitals and health care facilities

worldwide. Specimen labeling has a great impact on these aspects. In a study done by the College of

American Pathologists, it is estimated that more than 160,000 adverse events in the US per year are the

result of misidentification or mislabeling of patient specimens. [1] One of the top reasons for rejection of

a patient specimen is a mismatch of the specimen and requisition that is sent with that specimen. This

is considered a pre-analytical error that results in the rejection of the sample. A study that was

conducted to determine the most common reason for specimen rejection determined that pre-analytic

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adverse events accounted for 81.1% of the total.[2] Another study done, determined that specimen

identification errors, such as mislabeled specimens are detected at a rate of 0.04% to 0.1% and many

more go undetected.[3]

Rejection of a patient sample causes a need to re-draw the patient and this can lead to undue

stress on the patient and more importantly longer turnaround times in the lab. Longer turnaround

times in the lab can cause a delay in diagnosis and treatment. This could be a serious issue when a

patient presents with symptoms of a heart attack.

In 2003, in an attempt to overcome specimen identification errors, the Joint Commission

suggested the use of automated systems to prevent patient misidentification. [4] Positive patient

identification (PPID) is used in some hospitals to prevent patient misidentification while other hospitals

have taken steps to even further limit the pre-analytical problems by employing an electronic PPID

(EPPID) for all inpatient phlebotomy. As seen in image 1 below, the EPPID is a handheld PDA device that

is equipped with collection manager software that is managed through the laboratory information

system (LIS).

All phlebotomy procedures begin with the receipt of a test requisition (see image 2) that is

generated by or at the request of a health care provider or a worklist with pre-printed labels obtained by

the phlebotomist for their rounds. These forms must include certain information to ensure that the

sample drawn is from the correct patient. The required information on a requisition include, patient’s

first and last name, date of birth, ID/MR# that is also present on patient’s wristband, patient location,

ordering health care providers name, tests requested with the dates and times of collection that must

also be handwritten on the label and requisition form after collection, and the status of the sample, such

as stat, timed, or routine. [5]

As stated previously, some hospitals have taken steps to further limit the problem with

mislabeling by employing an EPPID. One of the hospitals taking these steps is Sacred Heart Hospital in

Pensacola, Florida. Previously at Sacred Heart, a worklist and the corresponding pre-printed labels were

obtained by the phlebotomist at the start of their designated shift. Each phlebotomist was assigned his

or her own floor and had to ensure that the pre-printed labels matched the worklist and that the labels

matched the armband on the patient. A verbal verification of the patient’s name and date of birth was

also obtained as a form of PPID. Once proper verification of the patient took place, the phlebotomist

would draw the patient sample and apply the previously printed label to the tube at the patient’s

bedside and transport the sample to the lab to be assigned an accession number for testing. If there

was an additional order put in for that patient, the phlebotomist would then have to return to the

laboratory to obtain the labels and then return to the patient’s room and draw another sample. This is

especially a problem if there was a STAT test ordered on the patient as time is of the essence. With all

of the transporting to and from the laboratory by the phlebotomist, and the stack of pre-printed labels,

this left room for errors to occur such as mislabeling of specimens, improper handling of the specimens,

or even re-sticks to the patient that would be unnecessary if all the test information would have been

readily available.

With Sacred Heart’s employment of the collection manager, the worklist as well as all

information needed for the draw such as, tube colors, order of the draw and status of sample are

generated in the PDA handheld device when the patient’s armband is scanned (see image 3). The

phlebotomist tech code and time of the draw are also automatically entered into the system and the

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specimen is automatically assigned an accession number. If the wrong patient is scanned, either no

orders are displayed or if the patient does have blood work ordered, only his information will be

displayed for the tests that he will have performed. Because the EPPID eliminates the need for manually

inscribing the date, time and technologists code, this eliminates errors that may occur due to illegible

handwriting. Collection Manager also eliminates the need for pre-printed labels because all of the labels

are printed bedside from the portable printer (see image 4) and will only print the labels for the specific

patient that is being cared for at that particular time. This helps to cut back on the number of

mislabeled specimens that can occur due to organizational problems.

Barbara Nero, Laboratory Supervisor at Sacred Heart Hospital, states that overall, the

employment of the collection manager at Sacred Heart has shown a decrease in labeling errors from

approximately 10 mislabeling errors per year to about 1 error per year. The move to collection

manager has also increased patient safety and reduced turnaround times for inpatient phlebotomy.

This is very important as this ensures faster results to the healthcare provider and patient.

The collection manager is not without its flaws though. There is still room for error if a

phlebotomist does not adhere to the proper procedures using the collection manager. For instance if

the labels are printed before the sample is collected and the result of the procedure is that the

phlebotomist could not get any blood from the patient, collection manager would have already

recognized that the sample was drawn and assigned an accession number. The printing of the label

signifies that the collection has been completed, when in reality, it had not. Another problem that could

arise is the fact that these handheld devices are PDA’s and can sometimes crash or go down. Also, the

PDA runs on battery power and if the battery runs out while with a patient, this requires the

phlebotomist to change out the battery while with the patient and restart the device. However, with

the proper procedures, patience and carrying an extra battery, these obstacles are easy enough to

overcome.

Case Conclusion

The nurse who drew the samples on the patient in the ER explained to the patient that there

was a discrepancy between the identifiers on the tube and requisition and had to re-collect the sample

from the patient. The sample was recollected and identifiers were double checked to ensure that there

was not a repeat of the initial error. The sample was then hand delivered to the laboratory for testing

with the double and triple checked requisition.

Once the lab results from the cardiac panel were obtained, it was determined that the patient

had not suffered a heart attack but was advised to follow up with her primary care physician as soon as

possible to discuss her high blood pressure.

Summary

Quick turnaround times and patient safety in the lab are important because it demonstrates an

aspect of the quality of care that a patient or the lab’s customers will receive. A quick turnaround time

with accurate results is an attribute that all hospitals strive for. Longer turnaround time in the lab can

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cause a delay in treatment or care for the patient as well as causing more time for unneeded or

unwanted stress.

The primary type of error that occurs in the laboratory today is a pre-analytical error that can

be limited in most situations with the use of an electronic positive patient identifier called the collection

manager. This pre-analytical error is patient specimen mislabeling and can have a tremendous effect on

patient safety and laboratory turnaround times. With the use of the collection manager, the lab has the

ability to bypass accessions and collect and verify requisitions with the use of a barcode scanner and

collect the patient sample all at the bedside of the patient. This is very important as it decreases the

change of hands with the paper requisitions and pre-printed labels as well as travel time for the

phlebotomist to and from the laboratory to obtain labels for added draws.

Images

Image 1: Electronic Positive Patient Identification; Handheld Personal Data Assistant Scanning device

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Image 2: Manual Test Requisition generated by or at the request of a healthcare provider

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Image 3: Information displayed on the handheld device once the patient is highlighted.

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Image 4: Portable label printer with printed labels that are generated upon completion of the sample

collection.

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References

[1] Valenstein PN, Raab SS, Walsh MK. Identification Errors Involving Clinical Laboratories: A College of

American Pathologists Q-Probes Study of Patient and Specimen Identification Errors at 120 Institutions.

Arch. Pathol. Lab. Med. 2006; 130, 8: 1106-1113.

[2] Rowshan A, Rowshan H. Mislabeled Hospital Laboratory Specimen-A Risk Assessment Perspective.

AJN. 2014; 3, 1: 1-4.

[3,4] Morrison AP, Tanasijevic, MJ, Goonan EM, et al. Reduction in Specimen Labeling Errors After

Implementation of a Positive Patient Identification System in Phlebotomy, Am. J. Clin. Pathol. 2010; 133:

870-877.

[5] Strasinger SK, Di Lorenzo MS. The Phlebotomy Textbook. 3rd ed. Philadelphia, PA: F. A. Davis

Company; 2011.