Mislabelled lab specimens have the potential to cause patient harm, especially patients in critical care who need accurate and frequent blood work throughout their stay in hospital.
The Cardiac Services Intensive Care Unit (CSICU) at Royal Columbian Hospital (RCH) recently implemented a zero tolerance policy when it comes to incorrect labelling of patients’ blood samples. Deljit Bains, Manager, Cardiac Services, realized there was an issue when she noticed a trend in their BC PSLS data. Through her investigation, Deljit identified why lab specimens were being labelled incorrectly and used this information to educate staff.
“When I looked at our PSLS data I could see we had a lot of mislabelled lab specimens,” says Deljit. “If you mislabel a lab specimen it delays the process of care and delays treatment. Many of our patients are recovering from open heart surgery so there’s no room for that kind of preventable error.”
To raise awareness among staff and motivate change, Deljit held several staff meetings, circulated informational bulletins describing the most common errors and placed laminated labels at each patient’s bedside. In addition, Deljit included the RCH Hematology lab manager, Winn Thomas, to promote cross-department teamwork and ensure staff in both areas was aware of the new blood collection procedures.
“All of a sudden people really started paying attention and the errors quickly dropped,” Deljit says. “I believe it just takes a little awareness and a few small changes to ensure our patients receive the best care.”
Deljit and the CSICU team are embracing patient safety in their daily work and have successfully reduced lab specimen errors by 98%. And their partnership with RCH lab is ongoing so if any other issues come up they will address them together.
“It’s not about having enough people to do our job, it’s about the work we’re doing and how we engage each other in quality of care,” says Deljit. “The CSICU team is very focused on patient safety and I would say they feel a strong sense of ownership when it comes to our PSLS data. The system has brought a lot of positive change for our team and our organization.”
Congratulations to all!