As any health care practitioner working in the emergency department (ED) setting knows, the pace of workflow is temperamental at best, and chaotic much of the time. Because of this, the ED often is a target of process and performance improvement efforts intended to ensure the safety of a vulnerable patient population. The ED also is often the place of first encounter between the patient and hospital staff, where patients may present with urgent needs that cannot wait until they are fully registered with all the information that process requires. It is because of these and other circumstances that accurate and precise patient information must be transferred when specimens are required for testing in the laboratory.
At Southern Maine Health Care—a not-for-profit health care system comprising two full-service medical centers and emergency departments in Biddeford and Sanford, Maine—positive patient identification and accurate patient information transfer is of the highest priority, as these processes are integral to ensuring the highest quality patient safety. In order to address concerns we had for the veracity of our specimens, we decided to implement an automated, bar coded point-of-care (POC) system for patient specimen collection and tracking throughout the facility.
Bar Code Benefits
The benefits of a bar coded, POC system are significant, as the process supports dual identification, encourages safe patient care practices, improves the efficiency of specimen collection, and reduces errors in specimen processing and resulting. This type of system is essential in today’s health care setting, where patient safety is of the utmost concern and errors are not acceptable. By using a bar-code-based system, the potential for human error is practically eliminated from the patient specimen collection process and therefore, the potential for subsequent harm to a patient due to misidentification also is greatly mitigated.
Not only does this represent a best practices standard of care, but some of the processes enabled by bar coded specimen collection are indeed a part of regulatory and accreditation mandates. The Joint Commission, for one, expects that a process using dual identifiers will be used for all patient specimen collections (see SIDEBAR). When used properly, the bar coding process forces dual identification and prevents the wrong patient from being drawn. Prior to implementing this system, an event occurred where an elevated potassium level was reported on the wrong patient due to mislabeling. Fortunately, a provider questioned the result and had it re-drawn. The second result was normal, but the patient could have received treatment based on the erroneous result. This could have caused unnecessary harm based on simple human error.
Determining Equipment and Interface Needs
The type of system (ie, mobile versus desktop) selected by the facility to perform bar coded patient identification during specimen collections will determine the equipment necessary for the initiative to be successful. To start, a computer or handheld device, a printer, and a scanner are all integral. If a mobile system is selected, handheld devices typically have built-in screens and scanning mechanisms, and often a mobile printer is either integrated or attached. For a desktop program housed on a PC, a separate hand scanner is necessary. In this case, the printer may be attached to the PC or there may be a wireless, mobile printing option. Our choice of a PC-based system is discussed below.
In addition to acquiring basic bar coding equipment, the facility’s dependent software systems, such as the electronic health record (EHR) or computerized provider order entry (CPOE) system, should be evaluated to determine if an interface is needed to enable the bar code specimen collection program to communicate directly with the EHR. Ideally, when an order for a specimen collection is entered in the EHR, that order would cross directly to a queue in the bar coded collection program and once the collection occurs, that information would be communicated back in a two-way fashion.
Value of Interdisciplinary Teamwork
As with all new technology implementations, adopting this type of system can be somewhat costly up front, but in the long run, the gained patient safety and workflow efficiencies are well worth the expense. The system also reinforces to staff the importance of correctly identifying patients and instills good habits of bedside dual identification that go beyond specimen collection. This underscores an important aspect of a successful implementation—it is highly advantageous to involve key stakeholders from the beginning. Although specimens and samples are manipulated in the laboratory, initial input and ongoing feedback from nurses, phlebotomists, physicians, and other bedside clinicians that directly use and interact with the program will be the hallmarks of success. Aligning the practice goals and actual workflow of these clinicians with those of the lab will ultimately foster the best operational environment for all involved.
Overcoming Specific Challenges
One of the most significant challenges we faced prior to implementing this system involved the overall labeling process. Previously, our bedside clinicians used generic chart labels for specimen labeling (an activity fraught with human error potential), but once the specimen arrived in the lab, they had to re-label the specimen with a different, bar coded label that was compatible with the analyzers. This created an additional opportunity for a mislabeled specimen and error in results. By extending bar coding to the point of care and making sure each bar code could be read properly throughout the facility (universal interface), the re-labeling step was eliminated.
Another benefit of POC bar coding is realized when caring for patients not yet admitted to the facility who require immediate medical intervention (such as those in the ED). Thus, we deliberately implemented bar coded POC identification in the ED, as this department often needs to manage unregistered patients at the time of specimen collection. The program we ultimately selected has a mechanism for creating demographic labels that can be used to label specimens at the time of collection and in the presence of the patient. The label contains name and date of birth, which can be used as a dual identifier.
The Current Process
At our facility, when a specimen is ordered, that order crosses automatically to the bar coding system and is queued for nursing. The nurse then attends to the patient and scans the patient bracelet to confirm identity. The program also outlines exactly what tubes need to be collected, the order of draw, and any special instructions (eg, on ice, no tourniquet). At this point, the labels print, the nurse collects the specimen and immediately attaches the labels, then scans each specimen to mark them as collected in the system. Lastly, the specimen is bagged and sent to the lab via the pneumatic tube system.
When we first adopted a bar code POC specimen collection system, we chose a mobile, wireless handheld-based method. However, we began to experience issues with device connectivity in particular areas of the department that led to delayed login times. Likewise, the need to connect the handheld device to the printer to produce labels was not efficient. Lastly, but perhaps most important, was the fact that the printing function could occur anywhere a patient label could be obtained, not necessarily at the bedside; this obstructed one of the primary reasons for the system in the first place, which was to force labeling at the exact time of collection.
Due to these challenges, we opted to switch to a desktop version, which proved more successful. We have PCs located in each patient room, so the program was installed in each room, which forced the process to be performed directly at the bedside. This also eliminated any concerns with connectivity, as there was no wireless component, which also eliminated the delays in opening the program and logging in. Because the printer and scanner are hardwired to the PC, the entire process is kept in close proximity to the collection activities.
Both the clinical and laboratory staff have become reliant on the ease and peace of mind provided by the program, which makes specimen collection quicker and more efficient. It also has reduced the number of specimens rejected by the lab for incomplete or incorrect labeling, which in turn reduced the need to re-draw patients (aiding in patient satisfaction) and eliminated the extended turnaround times associated with these mistakes (aiding in clinician satisfaction). While there have been periodic software updates and the occasional need to replace a handheld scanner, system changes and maintenance have been minimal. All practitioners involved have embraced this uninterrupted workflow and its benefits are apparent.
Many facilities have yet to adopt bar coded specimen collection technology, despite a desire to reduce errors and better manage identification practices. Based on our experiences thus far, as well as the proliferation of bar coding throughout health care practices of all disciplines, I foresee the use of bar codes for precise identification and tracking of patient specimens expanding and evolving in the future. The potential is there to augment these processes with new or improved technologies, particularly involving the mobile, handheld versions. Many of the current devices are bulky and heavy, and have small viewing screens. Given the universal trend in creating smaller, lighter electronic devices with more detailed visual capabilities, gains will certainly be made in improving mobile devices.
In the meantime, implementing a bar coded, POC process for specimen collection can greatly improve workflow, enhance patient safety, and reduce unnecessary errors. While the technology enables these benefits, these devices do not work by themselves. Human interaction will always be necessary to a degree, so be sure to involve key practitioners and truly weigh their input before choosing a system. Convincing staff of the value of the program and its benefits will be the ultimate barometer of success.
Jennifer Granata, FNP-C, MSN, CEN, CPEN, CNML, is the emergency department nurse manager at Southern Maine Health Care in Biddeford, Maine. She received her Bachelor’s Degree in nursing from the University of Southern Maine and her Master’s Degree from Husson University in Bangor, Maine. Jennifer’s professional interests include ensuring patient safety through dual identification and patient throughputprocesses.
The Joint Commission’s National Patient Safety Goals1
The very first NPSG in The Joint Commission’s Hospital Accreditation Program is to improve the accuracy of patient identification. Although this can be accomplished manually with two individuals performing verification, introducing automated identification technology, such as bar coding, can allow a single patient care practitioner to perform the dual identification.
Goal 1 – Improve the accuracy of patient identification.
Use at least two patient identifiers when providing care, treatment, and services.
Rationale for NPSG.01.01.01
Wrong-patient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is two-fold: first, to reliably identify the individual as the person for whom the service or treatment is intended; second, to match the service or treatment to that individual. Acceptable identifiers may be the individual’s name, an assigned identification number, telephone number, or other person-specific identifier.
Elements of Performance for NPSG.01.01.01
Eliminate transfusion errors related to patient misidentification.
Elements of Performance for NPSG.01.03.011.
(See also NPSG.01.01.01, EPs 1 and 2)
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