Healthcare News & Insights

Best practices: Hospitals reduce mislabeled blood specimens by 90%

Mislabeled blood specimens are one of the most basic safety problems in hospitals — happening as often as one out of every 1,000 blood draws. And now there’s a way to significantly reduce these mislabelings.

It’s called the Final Check. It’s a simple program, but results are impressive — reducing mislabeled blood specimens by 90% in 90 days.

Here’s how it works:

After a specimen is labeled, a verbal confirmation is made of the last three digits of the medical record number, as read from the specimen label AND the patient’s arm band.  The numbers are read out loud so the patient hears it and a verbal confirmation is made.

The process for Final Check started in May of 2011 when Palmetto Health Richland Hospital in Columbia, SC, and the South Carolina Hospital Association teamed up with Outcome Engenuity, a Dallas -based management consulting firm.

The firm wanted to prove that through the power of a concept called the “Just Culture,” hospitals could significantly reduced blood specimen mislabelings. Because even to make something as simple as Final Check successful, you need compliance among the nurses and lab staff.

And when it comes to compliance, punishment of mistakes doesn’t work. When you punish people who make mistakes, you breed a culture of secrecy — “don’t tell and they won’t find out.” That’s not good for patient safety.

The Just Culture model encourages facilities to console the human error, coach the at-risk behavior and punish the reckless behavior. Plus, focusing staff on their task, such as looking at the last three digits of the medical record number and patient arm band, and reading them out loud, makes staff more aware of what they’re doing.

Final Check also tries to minimize non-value-added steps, such as only checking the last three digits instead of the entire number.

For example, Palmetto Health eliminated the relabeling check of account and medical record numbers, because they had low compliance levels since they were 10- and 9-digit numbers. Instead they found that a quick confirmation of the patient name upon entering the patient’s room and date of birth (label against patient), in addition to the Final Check got them the 90% reduction they wanted.

With Final Check staff are more likely to catch any mislabeling errors and report them as a learning experience for everyone involved.

For a best practice toolkit on the Final Check, click here.



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