Affiliation:
1. From the Department of Laboratory Medicine, Boston University Medical Center, Boston, Mass
Abstract
Abstract
Context.—Proper specimen identification and labeling is a critical preanalytic step in pretransfusion compatibility testing.
Objective.—To gather baseline data for specimen mislabeling, specifically targeting major mislabeling events, and to design and implement a plan of corrective action.
Design.—All mislabeled specimens received by the transfusion service for a type and screen were recorded and classified into minor and major mislabeling categories. Major mislabeling events were tracked by origin of the specimen. Locations with a high proportion of major mislabeling were given timely feedback (within 1 week) of the events as they arose.
Setting.—A university hospital.
Main Outcome Measures.—The incidence of major mislabeling.
Results.—The incidence of mislabeling in the transfusion service was 0.5% (243/49 955) during 21 months of data collection. Of these mislabeling events, 47% were classified as major events (unlabeled, mismatched specimen/ requisition, ABO/Rh result on current specimen not matching historical record on file). The emergency department accounted for a high proportion of these major mislabeling events. After the intervention of providing weekly feedback to emergency department staff, their contribution to major mislabeling fell from 47% in 1 year (23/49) to 14% (4/29) in the subsequent 3 quarters.
Conclusions.—Collecting and trending data on mislabeled samples with timely feedback to patient care areas can change phlebotomy practice and reduce specimen mislabeling.
Publisher
Archives of Pathology and Laboratory Medicine
Subject
Medical Laboratory Technology,General Medicine,Pathology and Forensic Medicine
Cited by
23 articles.
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