2. Background
An increase number of errors regarding
correctly labeling specimens became a high
concern to Adventist Hinsdale Hospital and
Adventist La Grange Memorial Hospital. A
Performance Improvement Project was
initiated to better understand failure points
and vulnerabilities in the specimen
collection process that lead to mislabeled
specimen and identify actions to reduce
occurrence of failure.
3. Goals & Objectives
The overarching goal of the project is to
decrease mislabeled specimens from RN
draws and to increase patient safety.
A secondary goal is to standardize the process
of drawing specimens and to increase the
efficiency of the process.
4. Methods
1) A task force was assembled with staff from
both AHH & ALMH
2) The task force reviewed the risk masters
and examined the potential reasons for
mislabeled specimens
3) It was determined that the process needed
to be streamlined to minimize distractions
and to make supplies readily available to
expedite the process for RN’s
5. Action Plan
Lab draw kits were created and placed on the
units. Each kit contains all the essential
supplies an RN would need to obtain a
specimen from a PICC line or port. In
addition to this, patient labels are now kept in
the patients room clipped to the
communication board. The RN verifies the
label against the patients wristband for the
two identifiers to ensure that specimens are
properly labeled.
8. Results to Date
The trial for the new process began on July
28th on 4 West at ALMH. Since then, there
have been zero risk masters involving
mislabeled specimens.
The project was expanded to the rest of the
inpatient units on January 1st. It is now
moving towards implementation at AHH.
9. Decreased Non-Value Added Steps
Key Performance
Metrics
Baseline Current
Number of steps to
complete the process
154 steps 66 steps
Times it takes to
complete the process
(mm:ss)
02:09 00:35
10. Key Learnings
1.) Engaging front line staff in performance improvement enables
them to “own” the solutions and take pride in their
accomplishments.
2) Process change requires collaboration from many different
disciplines. In this case, nurses, PCT's, EVS and Lab were all
involved.
3) Standardizing a new process takes persistence and
reinforcement before it can become a norm.
4.)We have the potential to impact patient care in both positive and
negative ways. It is important to reflect on our processes and make
changes that can improve our patient care outcomes.
