This discussion post reply summarizes steps taken at Sacred Heart Hospital to reduce specimen mislabeling errors through the use of an electronic positive patient identification (EPPID) system called Collection Manager. The post discusses how previously Sacred Heart used pre-printed labels that could result in errors, but now uses Collection Manager which prints labels at the patient's bedside after their armband is scanned. This eliminates manual writing and pre-printed labels, reducing errors. The post provides examples of how Collection Manager integrates with the laboratory information system to ensure accurate labeling. It is reported that Sacred Heart saw a reduction in mislabeling errors from about 10 per year to only 1 error per year after implementing Collection Manager.
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1. Discussion post reply
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Post # one
Misty B
I have chosen to become a Psychiatric Mental Health Nurse
Practitioner. I chose this path because I feel God is calling me
to help guide and mentor people through this age of transition.
With the increase of the digital age, social media specifically,
and the COVID Pandemic, peoples’ mental health needs need to
be cared for in a better manner than how they are currently
being managed. “The role of the PMHNP is to assess, diagnose
and treat the mental health needs of patients. Many PMHNPs
provide therapy and prescribe medication for patients who have
mental health disorders or substance abuse problems.”
(American Association of Nurse Practitioners, n.d.) I believe
your overall health begins with a healthy mind. When your
mental health is not healthy you can spiral out of control and
turn to substances (illicit drugs, alcohol, food, etc.) or self-
harm. This can lead to other health problems such as obesity,
diabetes, cardiovascular disorders, liver disorders, kidney
disorders, etc. I feel as a PMHNP I will be able to start with
the root cause of a patient’s overall health. I waxed and waned
with my decision between a PMHNP and FNP. I feel starting
with PMHNP is the best option for me at the moment and
continuing afterward to have a dual certification as an FNP.
Professional Organization
“Another factor essential to a nurse’s professional development
is active membership in 1 or more professional organization.
2. Memberships provide exposure and access to education
resources (eg, websites, webinars, publications, and
conferences) and rewarding networking opportunities with peers
and colleagues.” (Cherry et all, 2019)
Having been a member of the Emergency Nurses Association
(ENA) for 8 years, I too feel it is important to become a
member of your of an association for your nursing specialty. I
have chosen to become a member of the American Psychiatric
Nurses Association. Their mission statement and beliefs are
parallel to my own.
APNA is committed to the practice of psychiatric-mental health
nursing, health and wellness promotion through identification of
mental health issues, prevention of mental health problems, and
the care and treatment of persons with mental health disorders.
APNA champions psychiatric-mental health nursing and mental
health care through the development of positions on key issues,
the dissemination of current knowledge and developments in
PMH nursing, and collaboration with stakeholders to promote
advances in recovery-focused assessment, diagnosis, treatment,
and evaluation of persons with mental health disorders.
(American Psychiatric Nurses Association, n.d.)
Becoming a member was as easy as going to their
website www.apna.org and selecting your membership type, fill
in the required information, and pay the fee. Being a member
will give me access to educational opportunities, resources, and
connection through conferences, publications, and information
on advanced certifications.
3. Post #2
Lilia B
Top of Form
I thought I would not go back to school, but here I am today,
expecting a graduation date in my sixties. I did not have any
difficulties choosing a nursing specialty within the program. I
have decided to become a Psychiatric Mental Health Nurse
Practitioner. My background is in Med-Surg ICU, ED, Mental
Health, and Administration. From all my experiences, my
passion is Mental Health and becoming a PMHNP. My decision
was driving due to this populations' significant stigma and
vulnerability. I have chosen to get my PMHNP degree from
Walden University because it is a personalized program led by
faculty with a doctoral degree, offers support and flexibility to
students to achieve their dreams (Walden University, 2021).
The factor that has driven my decision to become a Psychiatric
Mental Health Nurse Practitioner is the need for our
professional coworkers and community to understand mental
illness. Studies show that knowledge, values, and stigma of
mental illness affect patient care and recommend that nursing
curriculums integrate studies that minimize these factors and
increase the quality of patient care (Abuhammad et al., 2019).
Once I become a PMHNP, I will be able to serve and actively
advocate for changes in mental health in my daily practice.
The American Psychiatric Nurse Association aligns with my
practice and goals of serving patients with mental health
disorders by expanding my knowledge to improve patient
quality of care through evidence-based practice. The APNA
offers CEUs, a resource library, and network opportunities
(American Psychiatric Nurses Association, 2021). I plan to join
the American Psychiatric Nurse Association in the future to
support my career goals, network, and professional
development. According to Echeverria (2018), "Professional
organizations can serve as a venue for nurses to become
engaged in the transformation of healthcare delivery.
Ultimately, the transformation starts with the nurse and his or
4. her individual actions" (p. 38).
Bottom of Form
Bottom of Form
1
Using Handheld PDA Devices to Reduce Specimen
Mislabeling and Rejections
University of West Florida
2
Case History
5. A 68 year old Caucasian woman presented to the ER on Friday
evening after returning home
from helping in relief efforts after a hurricane. She was
suffering from chest pains that came and went,
she was light headed, and stated that she had a pain in her left
arm and back. The patient was also
having a slight shortness of breath. Her height was 5’2, and
current weight was 160. Blood pressure
was slightly elevated at 168/90 and her respirations were 22
bpm. An EKG and cardiac panel were
ordered and the patient was administered a nitroglyceri ne tablet.
The phlebotomist arrived and verified all the required
information with the test requisition and
patient bracelet. After the verification, the phlebotomist
proceeded to collect the patient’s blood and
label the tube with the preprinted label that was included with
the computer generated requisition
form. The phlebotomist then printed her tech code and date and
time of specimen collection on the
label by hand and the sample was sent to the lab for testing.
The accessioner who received the sample verified that the date
of collection, date of birth, and
patient’s last name matched the requisition but the first name
and medical record number were slightly
6. different. The accessioner then called the ER and notified the
department that a sample needed to be
recollected due to the discrepancies in the first name and
medical record number of the specimen label
and requisition form.
Student Learning Outcomes
Discussion
Errors can and do occur occasionally with laboratory
specimens. There are three types of errors
that can occur in the lab. These errors are commonly known as
pre-analytical, analytical and post-
analytical errors. Pre-analytical errors are the most common
errors that occur in the laboratory today.
These types of errors occur before the sample is tested. Some
examples would be specimen
mislabeling, which could include missing tech codes on a
sample, patient name misspellings, or
mismatched specimen and requisition, patient preparation,
collection of sample in the wrong tube type
etc. Analytical errors are errors that affect analysis of the
specimen during testing such as testing
7. review, lab interpretations, result accuracy etc. Post-analytical
errors are errors that occur after the
testing has been completed. This type of error may include
errors in calculations, resulting errors,
failure to report critical values to the correct person etc.
Patient safety and lab turnaround times are of top priority in
hospitals and health care facilities
worldwide. Specimen labeling has a great impact on these
aspects. In a study done by the College of
American Pathologists, it is estimated that more than 160,000
adverse events in the US per year are the
result of misidentification or mislabeling of patient specimens.
[1] One of the top reasons for rejection of
a patient specimen is a mismatch of the specimen and
requisition that is sent with that specimen. This
is considered a pre-analytical error that results in the rejection
of the sample. A study that was
conducted to determine the most common reason for specimen
rejection determined that pre-analytic
3
adverse events accounted for 81.1% of the total.[2] Another
study done, determined that specimen
8. identification errors, such as mislabeled specimens are detected
at a rate of 0.04% to 0.1% and many
more go undetected.[3]
Rejection of a patient sample causes a need to re-draw the
patient and this can lead to undue
stress on the patient and more importantly longer turnaround
times in the lab. Longer turnaround
times in the lab can cause a delay in diagnosis and treatment.
This could be a serious issue when a
patient presents with symptoms of a heart attack.
In 2003, in an attempt to overcome specimen identification
errors, the Joint Commission
suggested the use of automated systems to prevent patient
misidentification. [4] Positive patient
identification (PPID) is used in some hospitals to prevent
patient misidentification while other hospitals
have taken steps to even further limit the pre-analytical
problems by employing an electronic PPID
(EPPID) for all inpatient phlebotomy. As seen in image 1
below, the EPPID is a handheld PDA device that
is equipped with collection manager software that is managed
through the laboratory information
system (LIS).
9. All phlebotomy procedures begin with the receipt of a test
requisition (see image 2) that is
generated by or at the request of a health care provider or a
worklist with pre-printed labels obtained by
the phlebotomist for their rounds. These forms must include
certain information to ensure that the
sample drawn is from the correct patient. The required
information on a requisition include, patient’s
first and last name, date of birth, ID/MR# that is also present on
patient’s wristband, patient location,
ordering health care providers name, tests requested with the
dates and times of collection that must
also be handwritten on the label and requisition form after
collection, and the status of the sample, such
as stat, timed, or routine. [5]
As stated previously, some hospitals have taken steps to further
limit the problem with
mislabeling by employing an EPPID. One of the hospitals
taking these steps is Sacred Heart Hospital in
Pensacola, Florida. Previously at Sacred Heart, a worklist and
the corresponding pre-printed labels were
obtained by the phlebotomist at the start of their designated
shift. Each phlebotomist was assigned his
10. or her own floor and had to ensure that the pre-printed labels
matched the worklist and that the labels
matched the armband on the patient. A verbal verification of
the patient’s name and date of birth was
also obtained as a form of PPID. Once proper verification of
the patient took place, the phlebotomist
would draw the patient sample and apply the previously printed
label to the tube at the patient’s
bedside and transport the sample to the lab to be assigned an
accession number for testing. If there
was an additional order put in for that patient, the phlebotomist
would then have to return to the
laboratory to obtain the labels and then return to the patient’s
room and draw another sample. This is
especially a problem if there was a STAT test ordered on the
patient as time is of the essence. With all
of the transporting to and from the laboratory by the
phlebotomist, and the stack of pre-printed labels,
this left room for errors to occur such as mislabeling of
specimens, improper handling of the specimens,
or even re-sticks to the patient that would be unnecessary if all
the test information would have been
readily available.
With Sacred Heart’s employment of the collection manager, the
11. worklist as well as all
information needed for the draw such as, tube colors, order of
the draw and status of sample are
generated in the PDA handheld device when the patient’s
armband is scanned (see image 3). The
phlebotomist tech code and time of the draw are also
automatically entered into the system and the
4
specimen is automatically assigned an accession number. If the
wrong patient is scanned, either no
orders are displayed or if the patient does have blood work
ordered, only his information will be
displayed for the tests that he will have performed. Because the
EPPID eliminates the need for manually
inscribing the date, time and technologists code, this eliminates
errors that may occur due to illegible
handwriting. Collection Manager also eliminates the need for
pre-printed labels because all of the labels
are printed bedside from the portable printer (see image 4) and
will only print the labels for the specific
patient that is being cared for at that particular time. This helps
to cut back on the number of
12. mislabeled specimens that can occur due to organizational
problems.
Barbara Nero, Laboratory Supervisor at Sacred Heart Hospital,
states that overall, the
employment of the collection manager at Sacred Heart has
shown a decrease in labeling errors from
approximately 10 mislabeling errors per year to about 1 error
per year. The move to collection
manager has also increased patient safety and reduced
turnaround times for inpatient phlebotomy.
This is very important as this ensures faster results to the
healthcare provider and patient.
The collection manager is not without its flaws though. There
is still room for error if a
phlebotomist does not adhere to the proper procedures using the
collection manager. For instance if
the labels are printed before the sample is collected and the
result of the procedure is that the
phlebotomist could not get any blood from the patient,
collection manager would have already
recognized that the sample was drawn and assigned an accession
number. The printing of the label
signifies that the collection has been completed, when in reality,
it had not. Another problem that could
13. arise is the fact that these handheld devices are PDA’s and can
sometimes crash or go down. Also, the
PDA runs on battery power and if the battery runs out while
with a patient, this requires the
phlebotomist to change out the battery while with the patient
and restart the device. However, with
the proper procedures, patience and carrying an extra battery,
these obstacles are easy enough to
overcome.
Case Conclusion
The nurse who drew the samples on the patient in the ER
explained to the patient that there
was a discrepancy between the identifiers on the tube and
requisition and had to re-collect the sample
from the patient. The sample was recollected and identifiers
were double checked to ensure that there
was not a repeat of the initial error. The sample was then hand
delivered to the laboratory for testing
with the double and triple checked requisition.
Once the lab results from the cardiac panel were obtained, it
was determined that the patient
had not suffered a heart attack but was advised to follow up
14. with her primary care physician as soon as
possible to discuss her high blood pressure.
Summary
Quick turnaround times and patient safety in the lab are
important because it demonstrates an
aspect of the quality of care that a patient or the lab’s customers
will receive. A quick turnaround time
with accurate results is an attribute that all hospitals strive for.
Longer turnaround time in the lab can
5
cause a delay in treatment or care for the patient as well as
causing more time for unneeded or
unwanted stress.
The primary type of error that occurs in the laboratory today is
a pre-analytical error that can
be limited in most situations with the use of an electronic
positive patient identifier called the collection
manager. This pre-analytical error is patient specimen
mislabeling and can have a tremendous effect on
patient safety and laboratory turnaround times. With the use of
15. the collection manager, the lab has the
ability to bypass accessions and collect and verify requisitions
with the use of a barcode scanner and
collect the patient sample all at the bedside of the patient. This
is very important as it decreases the
change of hands with the paper requisitions and pre-printed
labels as well as travel time for the
phlebotomist to and from the laboratory to obtain labels for
added draws.
Images
Image 1: Electronic Positive Patient Identification; Handheld
Personal Data Assistant Scanning device
6
Image 2: Manual Test Requisition generated by or at the
request of a healthcare provider
16. 7
Image 3: Information displayed on the handheld device once
the patient is highlighted.
8
Image 4: Portable label printer with printed labels that are
generated upon completion of the sample
collection.
9
References
[1] Valenstein PN, Raab SS, Walsh MK. Identification Errors
Involving Clinical Laboratories: A College of
17. American Pathologists Q-Probes Study of Patient and Specimen
Identification Errors at 120 Institutions.
Arch. Pathol. Lab. Med. 2006; 130, 8: 1106-1113.
[2] Rowshan A, Rowshan H. Mislabeled Hospital Laboratory
Specimen-A Risk Assessment Perspective.
AJN. 2014; 3, 1: 1-4.
[3,4] Morrison AP, Tanasijevic, MJ, Goonan EM, et al.
Reduction in Specimen Labeling Errors After
Implementation of a Positive Patient Identification System in
Phlebotomy, Am. J. Clin. Pathol. 2010; 133:
870-877.
[5] Strasinger SK, Di Lorenzo MS. The Phlebotomy Textbook.
3rd ed. Philadelphia, PA: F. A. Davis
Company; 2011.
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