Q&A with Sherri Huber, MT(ASCP), CMQ/OE(ASQ)
Minnesota CLMA Chapter
MedicalLab Management: What are the most common specimen labeling errors in the ambulatory setting?
Sherri Huber: In our experience, specimen labeling errors in the ambulatory setting are similar to those in the inpatient setting. Labeling errors tend to plague those specimens collected outside of the laboratory; in ambulatory care, that is the exam room. Of those specimens collected in exam rooms, the most common labeling errors involve labeling the specimen with the wrong patient name. The primary reason for this is the placement of the order in the wrong patient’s chart during the visit.
MLM: Why did you focus on labeling mistakes in the ambulatory exam room setting in your facility?
Huber: This was largely due to inconsistent and non-standardized practices for specimen labeling in the ambulatory setting. There are very few published studies that focus on labeling errors in the ambulatory setting. Those that are available generally were performed in organizations that implemented positive patient identification technology (PPID). Our review of ambulatory processes helped identify the lack of a consistent, standardized process for clinicians to confirm either a patient’s identity or that they were reviewing the correct chart. Often, we found this confirmation was not occurring at all. In the ambulatory setting, there tend to be fewer electronic tools by which to confirm patient identity and proper specimen labeling. Few organizations provide wristbands in the ambulatory setting, so PPID technology often is not an option.
In my experience, there is a lack of awareness of the number and magnitude of patient identification and specimen labeling errors; especially for small physician offices and independent practice groups that rarely gather or analyze such data. When errors occur, there is a tendency to simply “fix” the problem, instead of developing a consist process to evaluate the root cause of the event.
MLM: Are there specific problems caused in the ambulatory setting by mislabeling events?
Huber: Certainly there are many of the same issues and potential for error as are encountered in the inpatient setting: Misdiagnosis, mistreatment, poor outcomes, adverse events, and so on. The distinction of the ambulatory setting is that it is more difficult to reengage a patient with an unexpected follow-up appointment. With inpatients, it is far easier (although not without issue) to recollect a patient sample or otherwise remediate an error. Thus, samples such as urine or mucus membrane swabs, which are the most common specimens taken in the ambulatory exam room, can fairly easily be retaken from inpatients, but require the ambulatory patient to return to the clinic.
MLM: What has been your experience in addressing this issue from a systems solution perspective?
Huber: We have found that a systemized approach is absolutely necessary. Over the course of our process improvement project designed to reduce or eliminate specimen labeling errors, one prominent indicator was the lack of a defined, systematic process for how and when to identify patients during the course of a visit, and how specimens should be labeled. In addition, we found many of our facility’s previous process improvement initiatives focused on improving the identification of labeling problems after the specimen was received in the laboratory, instead of following the issue to where the problem occurred (ie, the exam room) and making improvements there.
This brings us to the concept of collaborating with clinical practitioners outside of the laboratory in order to affect positive change. As laboratorians, we know most pre-analytical events occur outside the laboratory, and in order to affect change, the improvement project must venture outside the lab and incorporate all applicable practice areas. This was one of the most valuable lessons we learned from our project.
MLM: What specific events led your facility to initiate a specimen labeling process improvement project?
Huber: This was an issue that had built itself up over time. Year after year, we were experiencing the same numbers of specimen labeling errors and events, and despite following up with staff and performing minor improvement interventions at various sites and locations, the trend continued. This required us to take a step back and reevaluate the entire process, because minor, non-systemic approaches were not working and we needed to start over with a better approach, which turned out to be collaboration with nursing, and seeking to implement a simple and straightforward process for identifying patients and labeling specimens at the most common point of error: the exam room.
MLM: How did you review the specimen collection and labeling process for error points?
Huber: My organization uses the care model process structure for visits and patient management. It contains steps that correlate to events or specific clinical processes that should take place during an ambulatory patient visit or for specific types of patient visits for optimal care. In the past, laboratorians in our organization generally operated under the misconception that nursing and physicians did not use prevailing or standardized processes during the ambulatory visit, thus, our attempts to artificially overlay a laboratory improvement process on a nursing function were logically unsuccessful. Part of our project included developing spaghetti diagrams of various clinic visit types. Once we had a clearer picture of these workflows, we met with our nurse and physician managers and asked them how the process might work best for them, and where we could input suggestions from the laboratory’s perspective.
MLM: What were some examples of laboratory’s input?
Huber: The primary focus from the lab’s perspective was to collaborate with front line staff on both the front end (nursing/provider) and the back end (laboratory). Laboratory Services detailed our requirements for specimen labeling and we discussed these with frontline staff and actively involved them in deciding what steps to take, when during the visit these steps should occur, and how to embed these steps into their visit workflow to enable improvement. This is where collaboration with nursing became so important. Ultimately, the nurse/laboratory team identified three easy steps that need to be done correctly and accurately for every specimen collection:
- Correct patient identification
- Ensure labels are for correct patient
- Label the specimen while in the presence of the patient
Variation in these practices was the crux of the potential failure points identified by the laboratory. After providing this input, we left it to nursing and other frontline clinicians to decide how best to enable these improvements. A secondary key to the success for the overall project was to audit the new process during both the pilot and implementation stages to make sure they were having the intended effect and reinforcing the new process steps for nurses and clinicians.
MLM: Can you give an example of your auditing process?
Huber: Over the course of a few pilots, our clinic lab staff utilized a simple spreadsheet for auditing. Like many organizations, we have a facility patient electronic medical record system and a laboratory information system (LIS), so specific labels must be generated and used by the LIS in the lab. One of the core steps performed by nursing for this project was the review of labels to ensure they were for the correct patient. This process was documented by the nurse’s initials on the labels. So, when a specimen collected in the exam was received in the clinic lab, the lab staff member would take note in the spreadsheet of the provider name, then examine the specimen with two questions in mind: Does it have a label on it (yes or no in the spreadsheet)? And, are there initials on the label?
The results of this simple audit process were given to the nurse manager weekly, who then followed up with individual locations and providers/nurse teams to provide feedback on how the process was being incorporated. Some locations gained improvement more quickly than others, but all locations exceeded 90% within approximately 6 weeks.
MLM: Outside of some of the technologies more common to inpatient specimen/patient ID management, what options are available in the ambulatory setting?
Huber: Certainly there are options dependent on budget. Hardware such as label printers located in each exam room can be incorporated for improvement. Likewise, there are handheld scanners and printers, assuming a bar coding systems also is in place (although some handheld devices can be used with or without a patient identification bar code). Our organization is in the process of migrating to a new LIS that will help eliminate the issues that occur between disparate computer systems for the care delivery portal and the laboratory portal. We will explore how this integrated computer system might simplify some of our patient identification and specimen labeling processes and what technology and tools might be newly available.
MLM: How would you characterize the degree of improvement based on this project?
Huber: We have contributed the most marked improvement to the use of our 1-2-3 Identify Me process, the name we developed for our patient identification and specimen labeling project. Providing our nurses and physicians with a simple but consistent series of steps and integrating those steps within specific areas of the Care Model Process Visit module, has helped make a significant difference. As the project moved forward, we created subsets of the process. For example, well into the project, we noticed we were still receiving a high number of unlabeled potassium hydroxide (KOH) and slide preps. So we created a 1-2-3 Identify Me focus for KOH and slide specimens, and that was implemented approximately 1 year ago. Since then, not a single labeling event for KOH and slide specimens has been reported (after previously experiencing 1 to 2 such reports a week).
MLM: Do you expect to continue tailoring your process to other laboratory testing disciplines?
Huber: With the 1-2-3 Identify Me process, there have been dramatic improvements in the labeling of what I call specialty specimens, such as biopsies, fine needle aspirates, and other pathology-connected specimens that tend to be more difficult (or impossible) to retrieve. Nonetheless, there remains a need for greater improvement for these specimens.
We continue to receive a relatively high number of labeling events involving either a mismatch between the source listed in the order and what is listed on the specimen, or the source information is missing, which is necessary for those types of specimens not only from a diagnostic standpoint, but from a patient treatment and monitoring standpoint. Accordingly, we have just completed designing 1-2-3 Identify Me processes tailored specifically for pathology, cytology, and microbiology specimens, and we expect to implement those plans shortly.
MLM: How do you expect the management of specimens to continue improving in the future?
Huber: As with so many issues in health care, a large part of a real solution comes from instilling open communication and collaboration with other departments. One of the unexpected benefits of doing so is that we were able to redesign our EMR labels to be smaller while still containing all the necessary information. This enables a better fit for specimens collected in the exam room or for kits given to patients for home specimen collection. Now that we have established a good communication process, we have been able to identify other quality issues not related to patient ID or specimen labeling, which has enabled us to improve those processes in a timely manner.
Creating standardization and standard processes where possible for these types of tasks can reap significant gains in accuracy and safety. Clearly, technologies such as bar coded wristbands and other PPID technology have benefits, but our project served as a good reminder that a robust, standardized process supporting that technology is always required. Ultimately, technology will only assist you; it does not solve problems in a vacuum. Operational pieces that support that technology are necessary for real success.
Sherri Huber, MT(ASCP), CMQ/OE(ASQ), is a senior laboratory quality and operations consultant with HealthPartners in Minneapolis and is president of the Minnesota Chapter of CLMA. She has over 30 years of experience as an MT and in clinical laboratory management.
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