Thesis
Specimen mislabeling quality improvement project
Master of Science (M.S.), Drexel University
03 Jun 2021
DOI:
https://doi.org/10.17918/00001544
Abstract
Upon completing a microsystem assessment of the Emergency Department at the Hospital of the University of Pennsylvania a trend of mislabeled lab specimens was discovered. There were a total of 14 mislabeled specimens in fiscal year 2020 and 4 mislabeled specimens as of January fiscal year 2021. Specimen labeling errors put patients at risk for transfusion-related death, medication errors, misdiagnosis, and patient mismanagement. A quality improvement project was initiated to determine if proposed changes would decrease the amount of mislabeled lab specimens by 50% in the Hospital of the University of Pennsylvania's Emergency Room by May 2021. Proposed changes included posting of signage and reminders, shift huddles, and signing of an accountability form. Data was collected by pulling reports from the safety event reporting system from fiscal year 2020 and comparing it to data post implementation of the proposed changes, specifically looking to compare it to data for February and April of 2021. Data collection revealed 1 lab-mislabeling error in February 2021 and 2 errors in April 2021. There was a 25% reduction in lab-mislabeling errors when analyzing the data. The 3 errors that occurred in the Emergency Room post implementation cost the institution around $1,500. Signage, huddles, and the accountability forms do not remove human error from the lab labeling process. Research suggests that the use of barcode scanning for lab specimens is the real fix for the issue at hand. As the gateway to care in the hospital, the Emergency Department presents an added level of danger for mislabeling errors. Keywords: Specimen, mislabeling, errors, lab, Emergency Department
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Details
- Title
- Specimen mislabeling quality improvement project
- Creators
- Matthew Ekimoglou
- Contributors
- Alicemarie R. Poyss (Advisor)
- Awarding Institution
- Drexel University
- Degree Awarded
- Master of Science (M.S.)
- Publisher
- Drexel University; Philadelphia, Pennsylvania
- Number of pages
- 28 pages
- Resource Type
- Thesis
- Language
- English
- Academic Unit
- Nursing (Graduate); College of Nursing and Health Professions; Drexel University
- Other Identifier
- 991020220849604721