PhlebotomyPositive Patient ID
Team Members:
Laboratory
Admission/Registration
Information Systems
Hospital Administration
Confidential: Quality Improvement Material
Improve the accuracy of patient identification during thephlebotomy process – National Patient Safety Goal #1.-Incorrectly identified patients and specimens increasing annually since2005-Improved documentation and data capture responsible for some of theincrease-Historical data shows an average of 7 incorrectly identified patients andspecimens per quarter- A goal of zero incorrectly identified patients and specimens wasestablishedConfidential: Quality Improvement Material
PROJECT AIM STATEMENT
Gottlieb Inpatient Phlebotomy Statistics
Confidential: Quality Improvement Material
Improve the accuracy of patient identification during thephlebotomy process – National Patient Safety Goal #1.Studies show that up to 5.8% of phlebotomy samples are mislabeled andresult 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).
PROJECT AIM STATEMENT
Confidential: Quality Improvement Material
-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, manualmatching of patients to labels and manual entry of draw and receipt times andperforming phlebotomist-Implemented wireless order transfer to bedside devices through computer interfaceredesign-Developed comprehensive phlebotomy orientation and training program for bedsidedevice use
Solutions Implemented
Confidential: Quality Improvement Material
Results
Confidential: Quality Improvement Material
Analysis
•The implementation of the bedside bar code scanner and labelprinter successfully reduced the frequency of incorrectly identifiedpatients and specimens in the studied patient population
•There have been 13 consecutive months with zero incorrectlyidentified patients or specimens
•The single outlier occurred due to scanning of identifiers other thanthe patient wristband – procedure modification and retrainingperformed
Confidential: Quality Improvement Material
Next Steps
•Expand phlebotomy software system toOutpatient phlebotomy, Emergency Roomand Respiratory Therapy (ABG’s)
•These areas have averaged over 5incorrectly identified patients or samplesper quarter over the last two years
Confidential: Quality Improvement Material
Giuseppe Lippi, Gian Luca Salvagno, Martina Montagnana, Massimo Franchini, Gian Cesare Guidi, "Phlebotomy Issuesand 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.
Bologna L, Hardy G, Mutter M. Reducing specimen and medication error with handheld technology, Presented at2001 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 processto increase productivity, streamline workflow and improve patient care." ADVANCE for Administrators of theLaboratory, October 2006.
Works Cited
Confidential: Quality Improvement Material