Reduction of Ambulatory Care Specimen Labeling Errors

Significance and background: Accurate patient identification continues to be at the top of The Joint Commissions (TJC) national patient safety goals to prevent wrong patient errors. TJC identifies two elements to meet this goal which includes using two patient identifiers when collecting specimens and labeling specimen containers in the presence of the patient. A review of ambulatory care specimen labeling errors from FY18-FY21 revealed the ambulatory care sites with the highest number of errors to focus our quality improvement efforts. Scope of work was identified, and lean methodology was utilized to determine the root causes of the errors. This revealed variations in specimen collection workflows, and standard work for specimen collection was developed and implemented in the ambulatory care setting with the highest number of errors.
Purpose: The purpose of the specimen labeling errors project was to reduce errors in the ambulatory care setting.
Intervention: The workgroup consisted of nursing leadership and nurse managers of the ambulatory care clinics with the highest number of errors. An analysis was completed and consisted of a fishbone diagram to identify contributing factors, five whys to determine root cause, development of counter measures into a PICK chart, and creation of standard work. Staff members of the clinic with the highest number of errors were educated to the standard work. The nurse manager and director tracked the five main process measures from the standard work at daily huddle, documenting any defects and their contributing factors. The five process measures included: 1) patient service representative (PSR) provides labels to patients at check-in, performs two identifiers, and communicates those labels stay with the patient for duration of their visit; 2) provider notifies RN/MA of specimen needed and order is entered as a clinic collect; 3) RN/MA utilizes the specimen collection in-basket workflow to print specimen requisition; 4) RN/MA completes specimen labeling process (initials, date, time) in front of patient; and 5) RN/MA perform two identifiers with the patient, checking specimen and requisition. If patient unavailable, complete with another staff member. After 60 days of no defects, leadership began weekly observations of the standard work with real-time corrections of any defects.
Evaluation: Implementation of the standard work for specimen collection was successful in reducing specimen labeling errors. Errors from FY18-FY21 in the implementation clinic totaled 26 errors, with an average of 6.5 errors per year. Standard work implementation began March 30, 2021, and the last specimen error to date occurred on April 14, 2021.
Discussion/lessons learned: During initial implementation, workflows impacted by the new standard work were discussed at huddle and required multiple PDCA cycles by clinic staff. Performing standard work elements out of order was still considered successful if each element of the collection process was met. Current focus is implementation in other ambulatory care clinics. Finding different levels of adaptability within manager team and successful implementation requires clinic leadership knowledge of workflows and front-line participation and observation.
Learning outcome: Reduce specimen labeling errors through lean methodology and implementation of standard work.