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  • Title: Quality improvement to decrease specimen mislabeling in transfusion medicine.
    Author: Quillen K, Murphy K.
    Journal: Arch Pathol Lab Med; 2006 Aug; 130(8):1196-8. PubMed ID: 16879023.
    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.
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