September / October 2005
Barcoding and RFID
Labeling and Tracking Preventing Errors in the Lab
According to the Centers for Disease Control and Prevention, more than 7 billion tests are run each year in medical laboratories throughout the United States, contributing to more than 70% of all medical decisions (Boone, 2003). One of the biggest challenges laboratories face when working with this vast number of tests is the ability to accurately label and track laboratory specimens throughout the lab process in order to avoid potential misidentification errors. Recently, there have been great improvements in reliable and cost-effective technology that removes many of the potential error points along the process of specimen collection, grossing, staining, analysis, and archiving. This has enabled labs to develop "closed-loop" specimen identification and tracking systems that use advanced labeling and barcode technology to greatly reduce errors and increase workflow efficiencies.
Lab technicians have known for decades that the process of identifying and tracking specimen cassettes and slides is not an accurate science. The harsh chemicals and stains that slides and cassettes are exposed to have frustrated attempts to use simple barcode labels to identify specimens as they are created in grossing or as specimen slides are cut and prepared. Rather than labeling a slide before staining, many lab technicians are forced to write the information on the slide label by hand once the staining process has been completed in an effort to match specimen cassettes and/or slides with the right block, cut, patient, or accession number. This inefficient method is prone to potential errors, whether from illegible handwriting, misidentified or misplaced slides, or inaccurately matching slides to the wrong patients.
For example, in January 2003, United Hospital of Minnesota revealed that a tragic mistake had been made when a patient's biopsy slides and paperwork were "mixed up" with another patient's records. As a result, the wrong patient went through a double mastectomy. The woman also suffered from infections and was forced to endure more surgeries, in addition to the emotional trauma from a procedure that should have never happened.
During the past decade, patient safety and high-quality patient care have increasingly become the focus for healthcare organizations across the country. This focus has extended beyond administration and the point-of-care into the laboratory. Such is the case for Baptist Hospital in Pensacola, Florida, and Massachusetts General Hospital in Boston.
Opened in 1951 with 140 beds and one of the nation's first post-operative recovery rooms, Baptist Hospital is now the largest hospital in the Baptist Health Care Network with more than 490 beds. This award-winning hospital provides a full range of medical, surgical, and obstetrical services. Specialized critical care is provided by the hospital's emergency center and three intensive care units: coronary, surgical, and neurological intensive care.
Baptist Hospital has been frequently recognized for providing a quality work environment, as well as demonstrating a commitment to quality care by implementing processes, procedures, and technology to reduce medical errors. On March 9, 2004, Baptist was awarded the Malcolm Baldrige National Quality Award, the nation's premier award for performance excellence and quality achievement. The award is given annually to organizations that are considered role models of world-class excellence with employees that represent the highest ethical standards in public responsibility and corporate stewardship.
With 15 different stations, Baptist Hospital's pathology lab analyzes approximately 25,000 specimens each year. Just like many clinical laboratories across the country, Baptist Hospital's lab struggled with the challenge of accurately tracking specimen slides throughout the lab process. The procedures forced lab technicians to manually type or write 12- to 15-digit accession and block numbers on a standard slide label. This label had to be applied to the slide after the specimen was stained, requiring technicians to spend time attempting to accurately match typed or handwritten labels to specimen slides after staining.
"When we first started working with Baptist Hospital, the lab technicians were labeling their slides after the staining process and using a variety of manual methods to identify the slides, including handwriting with pens," commented Pat Fulford, a healthcare products reseller. "Unfortunately, the process that was used by Baptist is not unusual, as most hospitals are still identifying and tracking slides using similar, inefficient methods."
"The manual process wastes significant time in the lab and leads to incorrect identification of specimen slides," said Tonia Breckenridge, pathology supervisor at Baptist Hospital. "Incorrectly typing or labeling delays tests or forces technicians to repeat processes. In an environment where delays affect people's lives, errors are unacceptable."
To ensure that vital information could be printed and remain on the specimen slide throughout the lab process, Baptist integrated a new identification system designed for pre-stainer labeling of tissue and specimen slides. Printed using a direct thermal label printer that is integrated with the laboratory information system, these specially-designed labels allow lab technicians to print on-demand, patient-specific labels, with or without barcodes. The labels are then applied to the slides as the specimens are cut and prepared at the Microtome, prior to any exposure to the harsh chemicals, solvents and stains of a slide staining and preparation process.
Breckenridge added, "With the labels, we can now label slides before staining so that after coverslipping, the slides are ready to go. The labels can be customized to any application, can withstand the chemicals used in staining, and the program is very easy to use. We have the flexibility to print virtually any data we want on the label to identify the specimen slide."
Massachusetts General Hospital
Massachusetts General took slide labeling one step further by adding barcodes to the tracking process. As the oldest and largest hospital in New England, Massachusetts General Hospital (MGH) has more than 893 beds, admits approximately 44,000 inpatients, and handles more than 1.5 million visits each year in its extensive outpatient programs at the main campus and at its 4 health centers. MGH's pathology laboratory processes roughly 400,000 specimens each year.
Before implementing barcodes, MGH's pathology lab was like many other labs in the country; using standard labels, handwritten numbering, and visual verification. As a result of the large number of tests processed each year, MGH required a labeling solution that could withstand the rigors of the lab, as well as the ability to print barcodes that could be scanned at the cutting station, after the staining process, and throughout its storage life.
"A single mislabeled slide could represent a significant diagnostic error," said Dr. Ulysses J. Balis, director of pathology informatics and assistant professor of pathology›at Harvard Medical School and Massachusetts General Hospital. "Using just-in-time identification and tracking methods avoids the potential harm to any single patient from a misidentified slide and is quite simply, quality patient care."
MGH implemented direct thermal label printers and barcode scanners at each cutting station and introduced the same durable slide labeling solution as Baptist Hospital. The combination of the special slide label and direct thermal printer allows lab technicians to label the slides at the cutting stations with a hi-resolution barcode that can be scanned at each step to track the specimen and match corresponding accession numbers and patient data. Each time the barcode is scanned, data is uploaded into the laboratory's information system (LIS), providing the lab with a complete workflow history.
The barcodes enable lab technicians to quickly organize slides by patient and help doctors to track and monitor their patient's tests, while eliminating the need to manually key-in accession and block numbers in multiple computers.
"Printing on-demand labels for specimen slides makes our jobs easier by cutting down the time it takes to print out labels versus typing or hand-writing labels," commented Breckenridge. "The pre-stainer labels we chose are important to our lab because they have significantly increased our efficiency and clarity. Winning the Malcolm Baldrige National Quality Award demonstrates our hospital's commitment to our patients and quality care, and we have seen a measurable improvement in lab processes since implementing pre-stainer labeling."
Just as in 1846 when doctors at MGH performed the first surgery using anesthetic, MGH is once again on the forefront of medical technology. At MGH, Dr. Balis has established a unique and cost-effective barcode-based system that tracks specimens at every step in the lab process, eliminates inefficiencies and errors, and improves quality patient care and safety.
Ralph Moher (firstname.lastname@example.org) is the director of corporate marketing and communications for General Data, a provider of specialized labeling and identification products and solutions based in Cincinnati, Ohio. Kevin Wilson (email@example.com) is the founder of Kevin Wilson Public Relations, Inc. in Cincinnati.
Boone, D. J. (2003). Division of Laboratory Systems, CDC/HHS. Quality Institute Conference.
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