Monitoring of Mislabeled Specimens by Nursing Staff: A Collaborative Project to Help Ensure Patient Safety

In May 2011, the hospital was experiencing an increase in mislabeled specimens among the ED and other inpatient nursing units. The lab department started to keep track of these mislabeled specimens and senior leadership was informed. After discussion, education was formed on mislabeling of specimens for the nursing staff and a policy was developed regarding disciplinary action for mislabeling of specimens. The general goal of this project was to educate staff on the importance of labeling specimens correctly and decreasing the rate of mislabeled specimens by staff each month. Overall since 2011, the mislabeled specimen count has greatly decreased from 42 at the highest in 2012, to five as of June 2014.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state. These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)