A group of South Carolina hospitals is trying a simple process and are seeing big results in the way they track lab samples. In a short-term pilot project, the South Carolina Hospital Association (SCHA) aims to reduce 90 percent of mislabeling specimen errors in 90 days in emergency departments.
Their program is being presented and discussed next week at the National Patient Safety Forum in Washington, D.C.
The SCHA Vice President of Quality Improvement and Patient Safety Lorri Gibbons says “It’s a safety issue. We decided that this was an issue that needed to be looked at. We could define very clearly some basic steps on this very simple process that does not take additional time, that does not take additional money, or staff.”
Gibbons explains, “Once the patient’s labs have been drawn the nurse or lab tech who draws this blood puts the label on the lab specimen and then reads aloud, and that’s a critical piece on this, reads aloud the last three numbers of the medical record number, looking at the bracelet and the label that’s on the lab specimen.”
The hospitals involved include Roper St. Francis Healthcare System in Charleston, Baptist Easley, Georgetown Hospital System, tRMC in Orangeburg and Carteret, a hospital in North Carolina
After month of the “Final Check” practice, the errors dropped from 131 in those five hospitals to 13, according to Gibbons. The next month, errors dropped to nine.
Palmetto Health Richland was the first to try the procedure, after they conducted an internal check. Shelly Rorie is the director of patient safety at Palmetto Health Richland.
“We realized that they were not doing everything in the procedure that we thought they were,” says Rorie. At the same time, the common practice of “Red Rules” was punishing employees for mistakes, but not helping to create solutions.
“In health care, we want to learn and prevent any harm and any errors. Putting something out there that sends a message of fear to your employees is not beneficial,” she adds. Palmetto Health is now planning to do away with Red Rules as they adopt the Final Check process.
In the hospital’s high volume trauma center, Rorie says they eliminated all errors on blood samples and are now concentrating on other types of specimens.
“It was a no-brainer. We had a leader come in from an actual lab come in and say,’This was the easiest, cheapest, there’s nothing associated cost-wise, FTE-wise.’ It’s a no-brainer and we’ve had just positive results from everybody involved,” says Rorie.
The five-hospital study will continue through this year.