Volume 7 | Issue 26 | July 8, 2014

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Continued
Most importantly, however, the mishandled specimens increase
the risk of patient harm and delay care delivery, as the Joint
Commission recognized more than a decade ago when it cited
improving the accuracy of patient identication as its top National
Patient Safety Goal.
Every time a specimen has to be resubmitted, a patient suffers,
said Janna Petrie, RN, CCRN, critical care quality specialist with
Clinical Excellence and Patient Safety. Petrie said some specimens
have arrived in the lab with four different patients stickers. In
several cases, the stickers identied two patients with the same
last name.
How would the lab know if the specimen was labeled correctly?
Petrie said.The hundreds of errors are only those that the hospital
has identied, she added.
A new club. Now the hospital has launched a campaign to
decrease the number of labeling errors. Led by the Quality Safety
Advocates (QSAs) representing each unit, the initiative includes
education and new materials designed to help providers avoid
putting more than one patients identifying stickers in a transport
bag. It incorporates many ideas trialed on the Medical Surgical
Progressive Care Unit as part of a UEXCEL project developed by
charge nurse Becky Breidenstein, RN, CVRN-BC, after she noticed
an increase in specimen errors on the unit.
The hospital-wide effort, dubbed Join the C.L.U.B.B. Carefully
Label Ur Body Fluids @ Bedside has the support of nursing
leadership, educators, and managers, said Courtney West, RN,
a Medical Intensive Care Unit nurse who co-chairs the QSA
Committee. An email announcing the campaign and explaining
the importance of accurately labeling specimens went out to all
nurses and other Patient Services staff June 12.
Patient blood draws, one of the most common procedures in health
care, are also one of the most common causes of medical errors
at University of Colorado Hospital. A safety initiative launched this
month aims to change that.
From June 2013 to May 2014, the hospitals Clinical Excellence and
Patient Safety team identied 913 patient specimens that required
the Clinical Laboratory to ask for blood or specimen recollections.
Of these, 46 percent resulted from providers sending more than
one patients specimen or identifying extra zebra label stickers in a
single transport bag.
Thats some 420 specimens the lab automatically rejected to
prevent a patient getting the wrong test results. The errors cost
time: patients must have their blood redrawn and providers
must ll out Safety Intelligence (SI) reports on the hospitals
online system for tracking occurrences that caused or could have
caused patient harm.
A new safety initiative at UCH aims to reduce the number of labeling
errors on blood specimens sent to the Clinical Lab for testing
More than 900 in a single year
Safety Initiative Targets Growing
Number of Lab-Labeling Errors
Volume 7 | Issue 26 | July 8, 2014 | Page 2
West said placing more than one patients lab labels in a single
transport bag is the most common error. The labels look the same
on the community printers used on units, and during busy times, its
easy to inadvertently grab labels for two different patients and toss
them into the same bag, she said.
The C.L.U.B.B. solution to that problem is bright orange cards for
extra labels. If there are extra stickers for a patient, nurses and
ancillary health technicians (AHTs) are to afx them to the cards.
They will also be required to print their names and badge numbers
on the cards.
Thats for accountability, West said. People will have to stop
and pay attention because they have to sign the card. Starting
Aug. 1, the Clinical Lab will reject extra labels that are not on the
orange cards.
Managers will decide on discipline measures for staff who do not
comply with the new policy, West added. But as a compliance
carrot, the QSA Committee and the Clinical Excellence and Patient
Safety Department will provide a pizza party for the unit that has
the lowest percentage of mislabeled lab specimens from June
through August.
Meanwhile, the awareness-raising includes beefed-up education.
ULearn (formerly HealthStream) training assigned to all nurses
and AHTs includes additional material on properly labeling and
sending blood specimens, said Melanie Borneman-Shepherd, RN,
of the Cardiothoracic ICU, who co-chairs the QSA Committee with
West. In addition, the QSA Committee presented details of the lab
error-reduction initiative to the Nurse Manager and Nurse Educator
councils in June, Borneman-Shepherd said.
Future safety steps might include printing a blank label between
each patients lab specimen labels. But patient safety demands
that action be taken now, West said.
We cant wait, she said.
The hospital this month distributed orange cards for afxing extra
labels for blood specimens. Theyre meant to decrease the risk of including
more than one patients label or specimen in a single bag and increase
accountability of those drawing blood.
Members of the Quality Safety Advocate Committee,
which is leading the charge to reduce lab-labeling errors.
Join the C.L.U.B.B.
Carefully Label Ur Body Fluids @ Bedside

Extra labels to send to the Lab?
Use the new ORANGE cards
to send extra labels to the lab
Prevents sending wrong patient
labels & SI reports
Ensures patient identification for
specimens
Lab will reject loose extra labels
not on a card starting 8/1
UCH Clinical Lab Extra Stickers
Name:________________
Badge #: _________________

Affix extra stickers here
1 patients specimens/ bag!

C.L.U.B.B. magnets will be placed on pneumatic tubes in units to remind
providers of proper labeling of specimens placed in biohazard bags.