Phlebotomy Positive Patient ID Team Members: Laboratory Admission/Registration Information Systems Hospital Administration Confidential: Quality Improvement Material

PROJECT AIM STATEMENT Improve the accuracy of patient identification during the phlebotomy process – National Patient Safety Goal #1. -Incorrectly identified patients and specimens increasing annually since 2005 -Improved documentation and data capture responsible for some of the increase -Historical data shows an average of 7 incorrectly identified patients and specimens per quarter - A goal of zero incorrectly identified patients and specimens was established Confidential: Quality Improvement Material

Gottlieb Inpatient Phlebotomy Statistics Confidential: Quality Improvement Material

PROJECT AIM STATEMENT Improve the accuracy of patient identification during the phlebotomy process – National Patient Safety Goal #1. Studies show that up to 5.8% of phlebotomy samples are mislabeled and result in misdiagnosis, unnecessary treatment and wasteful tests (Giuseppe). 1 in 18 sample identification errors leads directly to an adverse event (Valenstein). Sample identification errors cost the healthcare industry an estimated $200 – 400 million dollars per year (Bologna). Confidential: Quality Improvement Material

Solutions Implemented -Evaluated and selected commercially available mobile phlebotomy software system -Reformatted wristbands and labels to include barcodes compatible with handhelds, scanners and current laboratory instrumentation -Redesigned laboratory processes to eliminate the use of pre-printed labels, manual matching of patients to labels and manual entry of draw and receipt times and performing phlebotomist -Implemented wireless order transfer to bedside devices through computer interface redesign -Developed comprehensive phlebotomy orientation and training program for bedside device use Confidential: Quality Improvement Material

Results Confidential: Quality Improvement Material

Analysis The implementation of the bedside bar code scanner and label printer successfully reduced the frequency of incorrectly identified patients and specimens in the studied patient population There have been 13 consecutive months with zero incorrectly identified patients or specimens The single outlier occurred due to scanning of identifiers other than the patient wristband – procedure modification and retraining performed Confidential: Quality Improvement Material

Next Steps Expand phlebotomy software system to Outpatient phlebotomy, Emergency Room and Respiratory Therapy (ABG’s) These areas have averaged over 5 incorrectly identified patients or samples per quarter over the last two years Confidential: Quality Improvement Material

Works Cited Bologna L, Hardy G, Mutter M. Reducing specimen and medication error with handheld technology, Presented at 2001 Annual Conference and Exhibition.  Healthcare Information and Management Society, Feb 4-8, 2001, Chicago, IL, cited by Margaret Herrin in "A Pledge of Safety:  How one laboratory automated its specimen collection process to increase productivity, streamline workflow and improve patient care." ADVANCE for Administrators of the Laboratory, October 2006. Giuseppe Lippi, Gian Luca Salvagno, Martina Montagnana, Massimo Franchini, Gian Cesare Guidi, "Phlebotomy Issues and Quality Improvement in Results of Laboratory Testing," Clin.Lab.5+6/2006. Valenstein Paul MD, Stephen S. Raab, MD, Molly K. Walsh, PhD "Identification Errors Involving Clinical Laboratories: A College of American Pathologists Q-Probes Study of Patient and Specimen Identification Errors at 120 Institutions," Archives of Pathology and Laboratory Medicine: Vol.130, No.8,pp. 1106-1113. Confidential: Quality Improvement Material