Literature Review for Specimen Labeling and Blood Bank

Laboratory specimens continue to be mislabeled or improperly labeled with many studies and
initiatives throughout the country within hospitals and private laboratories. Working on education of
staff and auditing blood bank specimens I have become familiar with how often these types of events
occur. These events have potential to cause harm to patients, either by treating incorrect lab values,
transfusing incorrect blood, not treating quickly enough waiting for results, or simply longer lengths of
stays and increased costs. Many hospitals have examined their practices to improve labeling processes
and reduce error risk and rates and ultimately improve patient care and safety.
Hill et al. (2010) conducted a cohort post-intervention study to see how electronic ordering and
bar-coded specimens may reduce error rates. The emergency department is notorious for mislabeled
specimens as with the high volume of labs drawn or collected and the chaos of a continuously changing
environment. They reported that with physician order entry and barcode labels can significantly
reduce ED specimen-related errors.
1
They also concluded that many of the specimens continued to be
mislabeled as human contact was necessary with handling and labeling. In this article, they cited that
almost 100,000 people die annually from preventable errors within hospitals. Through all research they
were able to conclude that the electronic system and barcodes had the potential to help errors rates but
the human element continued to be evident.
Synder et al. (2012) completed a meta-analysis to question if barcoding would reduce laboratory
specimen errors that showed similar results. The report accurate identification of patients their
specimens and laboratory test results linked to them is essential in all healthcare settings for providing
effective, safe, timely, efficient, equitable, and patient-centered healthcare.
2
The also stated that most
errors of laboratory specimens are associated with human error and under the control of the
laboratory. They also explained that errors that are reported are probably underreported as some go
unidentified and others simply not reported by staff. The article also notes that most detected errors
do no harm patients since their detection results in the associated erroneous test reports typically not
being released by the laboratory, however errors consequences include incorrect, delayed and/or lack
of treatment which may cause injury, disability, death, longer lengths of stay, higher healthcare costs, as
well as other patient harm and diverted resources. This article emphasizes that error rates are low,
about 0.1 percent, but that number accounts for hundreds of thousands of errors. Through their
review, they established that Barcoding practices demonstrated effectiveness as reducing ID errors for
patient specimen and laboratory testing identification is generalized to most common hospital settings
and patient populations. They reported that limitations including unpublished status and that many of
the studies had missing or undocumented information.
Many studies/articles have also solely focused on blood bank specimen labeling and the
potential for errors with drawn specimens and transfusing uncross-matched blood. ONeill et al. (2009)
describes the strict policies of the blood bank should be used for all laboratories. They state that blood
banks have been able to reduce error rates by 73.5% with low cost education initiative and policy
change.
3
By providing weekly updates and incident feedback they reported a 28% decrease in
mislabeled specimens from their emergency department. This was also accomplished by visually
watching phlebotomists verify patient names information, technique and labeling procedures and
providing immediate feedback and retraining with variances. They concluded that with increased
awareness and stricter policies as adopted by the blood bank for rejection, a decrease in errors had
been noted. They stated that it is unknown if it was solely the stricter policies and education but no
other initiatives had been conducted during the study period.
Tondon et al. (2010) completed a study of errors within the cross match lab and noted that the
most frequent incidents encountered with bedside being the major site of deviation.
4
The describe that
initially there was not strict enforcement of policies for sampling and labeling and a leniency on the
laboratory for acceptance of specimens that were either mislabeled, incorrectly labeled, or partially
labeled. They found that the majority of mislabeled specimens occurred with failure to verify at the
bedside and more than half occurred during the day shift, presumed to relate to volume of patients. At
the conclusion of the study they proposed that a stricter policy be adopted to reject all labs that were
not completely or properly labeled so that clinical staff clearly understands that every specimen will be
rejected if not properly and completely labeled. A recent adoption by our own hospital has mirrored
this policy to hopefully increase awareness and be able to track where deviances occur and by whom.
The laboratory staff is usually those that discover or identify the mislabeled specimens and are
able to track and check patient results. Salinas et al. (2013) explain many national organizations have
listed improvement of patient identification accuracy as the first of their recommended goals.
5
They
also reported that lab results can influence patient care in up to 70% of cases and thus laboratory
safety is crucial for patient safety. This was a simple study that essential showed that with electronic
order entry there are fewer errors reported, however this emphasizes the fact that human intervention
is still clue despite the advantages of the new technologies and highlights the role of the laboratory
professional to detect errors in order to plan the appropriate barriers. This article reports the study
was limited in that it only studied errors relating to demographic data registration.
Lastly, a publication by the Pennsylvania Patient Safety Authority identified where errors occur
and possible reasons why. They also developed methods to limit those errors by targeting the causes.
They describe contributing factors with the most frequent being: procedures not being followed,
distractions/interruptions, emergency situations, and unplanned workload increased. By far the main
factor was procedures not being followed and interventions for correction included education and re-
education, mandatory competencies, as well as other interventions to address other factors. They
concluded that post interventions they were able to reduce errors by 37% and specimen identification
error analysis combined with interventions to reduce specimen labeling errors can contribute to
improvements in patient safety.
6
A limitation of the study was identified as they were unable to
standardize results between hospitals reviewed.
My initiatives to audit and address blood bank specimen labels with education and re-education
coincide with the above initiatives and suggested interventions to reduce errors. I also presented a
labeling lecture at our yearly skills day to help educated on proper labeling techniques for all specimens.
Our hospital has now undertaken an initiative to be stricter on accepting specimens, much like blood
bank, and to hold those accountable for errors. I believe these more drastic measures are necessary to
increase awareness and attention to preventing errors. The information provided in these studies and
articles supports my attempts at education off staff and prevention of lab specimen related errors.


References:

1. Hill, P. M., Mareiniss, D., Murphy, P., Gardner, H., Hsieh, Y. H., Levy, F., & Kelen, G. D. (2010).
Significant reduction of laboratory specimen labeling errors by implementation of an electronic
ordering system paired with a bar-code specimen labeling process. Annals of Emergency
Medicine, 56(6), 630-636. (LOE 4)

2. Snyder, S. R., Favoretto, A. M., Derzon, J. H., Christenson, R. H., Kahn, S. E., Shaw, C. S., ... &
Liebow, E. B. (2012). Effectiveness of barcoding for reducing patient specimen and laboratory
testing identification errors: a Laboratory Medicine Best Practices systematic review and meta-
analysis. Clinical Biochemistry, 45(13), 988-998. (LOE 1)

3. ONeill, E., Richardson-Weber, L., McCormack, G., Uhl, L., & Haspel, R. L. (2009). Strict adherence
to a blood bank specimen labeling policy by all clinical laboratories significantly reduces the
incidence of wrong blood in tube. American Journal of Clinical Pathology, 132(2), 164-168.
(LOE 7)

4. Tondon, R., Pandey, P., Mickey, K. B. C., & Chaudhary, R. (2010). Errors reported in cross match
laboratory: A prospective data analysis. Transfusion and Apheresis Science, 43(3), 309-314. (LOE
6)

5. Salinas, M., Lpez-Garrigs, M., Lillo, R., Gutirrez, M., Lugo, J., & Leiva-Salinas, C. (2013).
Patient identification errors: The detective in the laboratory. Clinical Biochemistry, 46(16), 1767-
1769. (LOE 7)

6. Reducing Errors in Blood Specimen Labeling: A Multihospital Initiative. Pennsylvania Safety
Authority, 8(2), 47-52. (LOE 7)