Reducing Mislabeled Specimens
Outcome Engenuity and the South Carolina Hospital Association (SCHA) are offering information and a free toolkit for an intervention designed to reduce the rate of mislabeled blood specimens in hospitals. The process, The Final Check, is designed to be simple enough to be done reliably every time a specimen is collected.
Whoever draws the blood specimen does The Final Check by verifying that the medical record number on the patient’s wristband matches the label on each specimen by saying the last three digits of the number out loud. The process is designed to fit easily into the workflow and therefore is unlikely to be avoided or subverted. Success with this program also depends on the Just Culture model of accountability. Nurses and lab technicians must recognize that to skip The Final Check process is a reckless choice. Making the right thing easy to do encourages the safe, reliable choice, as does Just Culture’s structure of behavioral choices and responsibility.
Hosptials that have implemented the program report that previous, punitive approaches to mislabeling, including the use of “red rules,” were unsuccessful. Among other problems, punitive response is always reactive; punishment is delivered after a defect—in this case, a mislabeled blood specimen—has occurred and been discovered. The initiaitve’s website reports, “The Final Check was initially piloted at Palmetto Health Richland in South Carolina, and consequently adopted by five other hospitals, recruited by The South Carolina Hospital Association– all of which have now demonstrated and sustained at least a 90% drop in the number of mislabeled blood specimens since implementation of The Final Check.
Outcome Engenuity and its CEO David Marx are known for helping organizations use the principles of Just Culture to establish transparency, fairness, and accountability and thereby improve outcomes. The Final Check may sound familiar to those who attended NPSF’s Patient Safety Congress in May. David Marx discussed this program in his keynote presentation on the final day of Congress. Earlier this month, SCHA received the Dick Davidson Quality Milestone Award, which is given by the American Hospital Association to “recognize state, regional or metropolitan hospital associations that demonstrate leadership and innovation in quality improvement and contribute to national health care improvement efforts.”