Which of the following is a potential consequence of a phlebotomy mislabeling a blood bank specimen?

The potential consequences of misidentified laboratory specimens span from a near miss to severe patient injury or death.

S. Design an experiment to identify what ion(s) is(are) present in this unlabeled solution.

Safe Labeling of Laboratory Specimens Mandatory training module for all staff obtaining patient specimens Fall 2007.

The consequences of these errors include repeat lab draws, leading to pain from unnecessary phlebotomy experiences, along with delays in care, increased cost and possibly incorrect diagnoses.

Results Of the 136 institutions providing information on a total of 1811 mislabeling occurrences, the overall mislabeling rates per 1000 were 1.1 cases, 1.0 specimen, 1.7 blocks, and 1.1 slides.

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A mislabeled case is defined as one in which the wrong accession number is applied to the entire case.

Aside from the numerous health risks that are associated with mislabeled fish, seafood substitution is also a form of economic fraud.Economic fraud occurs when a lower-priced fish is labeled as a higher priced fish in order to sell the lower

CLSI Guideline EP33.

incorrect specimen containers and zero unnecessary phlebotomies after six months and 8,000 phlebotomies. Richard C. Friedberg, MD, PhD, and Christopher M. Lehman, MD, helped author a recent Q-Probes study on specimen mislabeling in blood banks for more or less one reason: If the labels wrong from the get-go, everything else we do about accuracy and reliability and precision goes out the window, Dr. Friedberg says. Our interdepartmental team addressed mislabeled specimens by utilizing process improvement tools such as process mapping, fishbone diagramming, Plan, Do, Study and Act (PDSA) cycles and Failure Mode and Effects Analysis (FMEA) to eliminate mislabeled clinical laboratory specimens on an intensive care unit. Medical errors are among the top five leading causes of preventable death or patient harm in the United States.1 Included in the broad category of medical errors are specimen-labeling errors comprising mislabeled, incomplete, and unlabeled laboratory specimens. 1 Not receiving the necessary treatment or receiving the wrong treatment can harm the patient, resulting in unnecessary morbidity and mortality. surgical specimen. For hospitalists, an erroneous lab result can mean redundant or unnecessary testing, even mismanagement of the patient, Dr. Ferguson says.

Types of mislabeling included wrong, missing, incomplete, or illegible labels.

Literature reviews have identified specimen labeling error rates of 0.1% to 6.5%.

The consequences of patient identification errors due to specimen mislabeling can be deleterious. In an effort to decrease the risk of potential harm caused by labeling errors, Children's Hospitals and Clinics of Minnesota successfully implemented a Zero Tolerance Laboratory Specimen Labeling process. Here are 3 Ways Specimen Labeling Errors Threaten Your Laboratory: 1. will be discarded and the test cancelled.

Introduction. The phlebotomist is required to fill out an incident report. 3 Which of the following is an example of a QA indicator? The rates of specimen mislabeling and WBIT were otherwise unassociated with any of the other practice variables evaluated. Proceedings of International Conference 2017, Organized by TMIMT Moradabad.

Mislabeled/Unlabeled Blood Bank specimens are not accepted for testing. Specimen rejection has significant clinical consequences, including patient discomfort, significant delay in result availability, and high rate of specimen/test abandonment. Specimen labeling errors accounted for 55.5 percent of identification errors in a study conducted by the College of American Pathologists. Verification of patient identity using 2 patient identifiers.

Conclusions.-The rates of ABO blood typing specimen mislabeling and WBIT are not statistically different from those determined in a similar study performed in 2007 (P= .94 and P = .10). the average monthly mislabeled/unlabeled specimens was 28 a month on the Acuity Adaptable Units. Therefore, in the lab, if a swab used to collect an anterior nares specimen is mislabeled as C. difficile and run on PCR, it will generate a potentially false negative result. ARUP Lab. The misidentification or mislabeling of a laboratory specimen can result in devastating consequences for the patients.

Mislabeled specimens can lead to morbidity and even death. Mislabeling can occur and is a potentially disastrous situation.

On analysis, 9 of the top 10 causes were determined to be addressed by the technol- Our

Using Data to Drive Better Practices The potential consequences of misidentified laboratory specimens span from a near miss to severe patient injury or death. 6 Mislabeled specimens- Mislabeled and unlabelled samples were also common errors in the pre-analytical phase. And thanks to a recent QProbes, the rates of mislabeled specimens submitted for ABO blood typing and of wrong-blood-in-tube errors are now as clear as water. Anne Ford.

Section 502 of the Federal Food, Drug and Cosmetic Act (FFDCA) contains provisions on misbranding including some that relate to false or misleading labeling. One study reviewed 4.29 million specimens collected over 24 months and found the frequency of mislabeled specimens, unlabeled specimens, and specimen-requisition mismatches to be 1.0%, 4.6%, and 6.3%, respectively, with mislabeling presenting the greatest danger (). 1 Specimen labeling errors continue to threaten all healthcare facilities, no matter their size or amount of specimens processed. After Collection Inappropriate handling and storage conditions- The studies also showed that handling and storage of samples outside the laboratory both have an impact on the quality of worst-case scenarios include missed cancer, unnecessary mastectomy, 9 and hemolytic transfusion reactions. Specimen collection and labeling.

CLSI. Discontinue preparation of specimen labels prior to patient visit/collection of specimen.

Specimens which can be recollected (eg. The team

The rates of mislabeled cases, specimens, blocks, and slides were tested for association with institutional demographics and practice variables. In an eort to decrease the risk of potential harm caused by labeling errors, Childrens Hospitals and Clinics of Minnesota successfully implemented a Zero Tolerance Labo-ratory Specimen Labeling process. hospital departments, 54 of 91 mislabeled specimens originated from the surgery department.

errors, 11 (12%) involved specimens associated with an incor-rect patient assignment.

The two most important consequences of mislabeled specimens are the failure to provide proper and immediate care and the provision of inappropriate care.

What are the consequences of not labeling specimens correctly?

A specimen was mislabeled on the floor. with 55 specimens (0.030%) determined to be mislabeled. Specimens must be properly labeled at the time of collection, by using positive patient identification prior to administering the patients test, and applying the label to the specimen.

After discussion, education was formed on mislabeling of specimens for the nursing staff and a policy was developed Patient label identification errors can have serious consequencesmislabeled or misinterpreted specimens can lead to incorrect diagnoses and incorrect treatment.

PCA did not check patient name, date of birth/Medical Record number on the patient clinic card prior to stamping teh labels. Seafood substitution occurs when "one species of fish, crustacean or shellfish is sold as another species".

Improperly identified specimens can result in delayed diagnosis, additional laboratory testing, treatment of the wrong patient for the wrong disease, and severe transfusion reactions. The total testing process consists of the pre-analytic, analytic, and post-analytic phases. November 2015Blood is thicker than water, the saying goes.

One study reviewed 4.29 million specimens collected over 24 months and found the frequency of mislabeled specimens, unlabeled specimens, and specimen-requisition mismatches to be 1.0%, 4.6%, and 6.3%, respectively, with mislabeling presenting the greatest danger . When to Conduct Pathological Specimen DNA Identity Testing. Use of Delta Checks in the Medical Laboratory.

Nursing is a dynamic profession where the staff is often pressured to complete activities

We describe two near-miss events involving mislabeled breast specimens from two patients who sought treatment at our institution. Within the gross

A mislabeled specimen can lead to devastating consequences for a patient. Seventy percent of all information used by clinicians to diagnose conditions and treat patients comes from the laboratory setting. Specimens which cannot be recollected (eg.

A mislabeled specimen can lead to devastating consequences for a patient. In their study, specimens most com-monly mislabeled were breast, skin, and colon. Policy for Mislabeled Specimens TriHealth Laboratory Services cannot accept unlabeled or mislabeled samples.

A Healthcare Risk Control ( HRC) member recently asked for tools to address risks related to specimen preparation and management in pathology and general laboratories. Relabeling of incorrectly labeled specimens was found to be of little benefit and was associated with a substantial percentage of subsequently mislabeled specimens.

sample identification errors and their consequences.3 McDougals experience is dramatic, but not isolated. | Find, read and cite all the research you need on ResearchGate Labeling away from the bedside was the second-leading cause. Hosptials that have implemented the program report that previous, punitive approaches to mislabeling, including the use of red rules, were unsuccessful. Recollection of the specimen will be required. Consequence: Unnecessary administration of antibiotic & extended length of hospitalization due to false-positive blood culture.

Specimen labeling is one of the biggest risks for misidentification, with errors leading to delayed or wrong diagnoses, missed or incorrect treatments, blood transfusion errors, and additional laboratory testing. Relabeling of incorrectly labeled specimens was found to be of little benefit and was associated with a substantial percentage of subsequently mislabeled specimens.

10 specimen identification errors, such as mislabeled or unlabeled specimens, are detected at a rate of 0.04% to 0.1%, 1113 and many more may go undetected. A mislabeled specimen would be wrong labeling due to mixup of specimens within a case, such as right versus left specimens in a bilateral biopsy from the same patient. Outpatient: 0.35%. This includes samples labeled with a patients name but without a date of birth or other second identifier.

It isnt hard to imagine the ensuing disaster. Provide signatures and/or initials as indicated on the requisition. Implementation of a multi-phase one-group Issues involving labeling have been classified as follows: Injuries associated with phlebotomy specimen mislabeling can have a significant clinical, financial, and emotional effect on all involved.

Specimen mislabeling is a potential pitfall to be borne in mind while evaluating unusual presentations in breast core biopsies. PDF | On Jan 1, 2001, Mohamed S. Mohamedsaid published Implications for mislabeling specimen. The mislabeling rate hasnt changed much since a similar QProbes study was performed in 2007. Handling Mislabeled and Unusable Specimens: 1.

The areas involved included the ED, medical/surgical units, critical care, and maternal child health. Pre-analytic errors and specimen rejection can result in delayed patient treatment, increased length of stay, and the need to recollect specimens. The consequences of the second mislabeled specimen are greater than the consequences of the first, and further action must be taken to retest the patient, correct results, issue apologies, and so forth.

The Delta Check in Action:Causes and consequences of discrepant laboratory results. labeling.

1st ed.

In 2015, the average monthly mislabeled/unlabeled specimens was 40 a month on the Acuity Adaptable Units During the project timeframe January 2016 to May 2016, the average monthly mislabeled/unlabeled specimens was 28 a month on the Acuity Adaptable Units. Seafood substitution.

The occurrence rate of Wrong Blood in Tube (WBIT) has been reported as 1:1986 specimens specimen mislabeling errors.

- Staff felt they could keep track of which specimen belonged to which patient based on their own workflow process. Mislabeling of laboratory specimens has been a long-standing problem in most facilities. The multifaceted strategy approach was successful in reducing mislabeled/unlabeled specimens on the Acuity Adaptable Units. - Batching labeled and unlabeled specimens at the nurses station until lunch or the end of the day was routine. - Several unlabeled specimens from different patients were grouped together with little or no identifying information.

Specimen labeling, the most common error, occurred more than twice as much as the second-most common cause.

The Emergency Department in this leading pediatric level one trauma center was identified as Upon receipt of a mislabeled or unusable specimen in the laboratory, notify. 2010 Feb;134:244 -55. Morrison et al, (2010) also conducted a five item survey to determine the effects of PPI The C. difficile test is a PCR-based test. Standard of Practice I

The lab department started to keep track of these mislabeled specimens and senior leadership was informed.

Therefore, proper patient specimen handling, which includes labeling, is a crucial factor in ensuring accuracy.

blood, urine, swabs, etc.) specimen.

Specimen rejection has significant clinical consequences, including patient discomfort, significant delay in result availability, and high rate of specimen/test abandonment.

Accurate specimen identication is a. challenge in all hospitals.

In 3.25% of cases (n = 59), a corrected report was issued, and in 1.3% of cases (n = 24), participants assessed that patient care was affected in some way.

A 2009 Q-Probes study found the rate of tube mislabeling of blood bank samples to be 1.12%. Our interdepartmental team addressed mislabeled specimens by utilizing process improvement tools such as process mapping, fishbone diagramming, Plan, Do, Study and Act (PDSA) cycles and Failure Mode and Effects Analysis (FMEA) to eliminate mislabeled clinical laboratory specimens on an intensive care unit.

In May 2011, the hospital was experiencing an increase in mislabeled specimens among the ED and other inpatient nursing units. Allowing routine relabeling of incorrectly labeled specimens is a dangerous practice, with little measureable benefit and with an increased risk to patient safety. CONCLUSION Specimen rejection has significant clinical consequences, including patient discomfort, significant delay in result availability, and high rate of specimen/test abandonment. A specimen is mislabeled if it arrives in the laboratory with a requisition bearing different names on the requisition and the label OR if the name in the computer does not match the label.

Anne Ford. Irreversible Damage From Unnecessary Treatment It is a simple mistake that can lead to catastrophic consequences. Error Incidents by the Location at Which the Error Occurred View large Table 3. It is the responsibility of the laboratory to reject patient specimens which Suggestion for new guidelines. Specimen identifications errors have been reported to occur at rates of 0.1% to 5% (Waga., Stankovic., Raab., Nakhleh., & Walsh.

Voucher specimens are not a requirement by GenBank today, which is a known problem as errors are frequently discovered in the submissions without any possibility of checking the original material.

In an eort to decrease the risk of potential harm caused by labeling errors, Childrens Hospitals and Clinics of Minnesota successfully implemented a Zero Tolerance Labo-ratory Specimen Labeling process.

blood specimen labeling are expensive and have not been widely implemented. The occurrence rate of Wrong Blood in Tube (WBIT) has been reported as 1:1986 specimens specimen mislabeling errors.

FMEA. While these single-point weaknesses exist within an infinite set of complex and continually changing processes, a few practical steps can be taken to eliminate these errors.

CONCLUSION Specimen rejection has significant clinical consequences, including patient discomfort, significant delay in result availability, and high rate of specimen/test abandonment. Here are 3 Best Practices for Reducing Specimen Labeling Errors: 1. To begin the HFMEA, a team was assembled that included representatives from all departments of the hospital where specimen collections were performed. Medical testing error occurs most frequently during the pre-analytic phase. What information is NOT part of the report? Specimen storage, preservation, and stability.

Conclusion The rate of mislabeled and unacceptable specimens collected for our study was 1.8% (588/33,000). Specimen identification errors have been reported to occur at rates of 0.1% to 5%.

Explain the effects of contaminated blood cultures; Support proper specimen collection; Identify properly labeled specimens; Course Description.

Regarding our hemolyzed specimens, national benchmarks prove that improper specimen collection/handling is the most common lab specimen error (86%).

Data tabulating the frequency of mislabeled and miscollected blood samples from 10 hospitals in five countries from 2004 to 2006 were used to demonstrate the method. Addition of an excess of 0.

Because of the potential patient adverse consequences associated with mislabeled specimens such as transfusion-related death, medication errors, and misdiagnosis, every labeling error should be treated seriously, said Sandhu. 050 M formic acid is 1. Compromise Patient Safety. Mislabeled specimens decreased by 85 percent after implementing barcode technology. Specific risk areas identified in the query included: Patient preparation. mislabeling rates must combined with other data in order to understand the extent and potential consequences of mislabeling. Out of those 54, the surgical procedures in which specimens were most commonly mislabeled are: procedures for the handling and care of specimens, and the consequences to the patient if there are errors. mislabeled specimens. It will next be rolled out in intensive- and coronary-care units.

Conclusion Specimen rejection has significant clinical consequences, including patient discomfort, significant delay in result availability, and high rate of specimen/test abandonment.

11/19/2018 Accurate specimen identification is critical for quality patient care. collection staff training program, and defined specimen collection policies, there continued to be mislabeled specimens in the community teaching hospitals maternal child health division, equating to approximately one to two specimens per month, or 0.0250%.

The consequences of patient identification errors due to specimen mislabeling can be deleterious. In the receipt of 871 units of UCB in 6 years, we have identified 2 (0.2%) units that were mislabeled, and 2 of 499 (0.4%) of our patients would have received the incorrect CBU if According to one study, one in 18 sample identification room was the leading cause of specimen mislabeling.

After implementing bedside specimen scanning, a decrease in errors was noted with 184,043 specimens collected and 32 specimens (0.017%) deemed to be mislabeled (Morrison et al., 2010). specimen (although this can also be seen in true TB patients). Inpatient: 1.0%. The potential consequences of a mislabeled specimen include misdiagnosis, potential miss-transfusion, patient discomfort in obtaining a new specimen, delays in treatment, and poor utilization of expensive resources. Table 2. Unneeded exposure to side effects; A lack of positive therapeutic benefits: When a person is not taking a drug that is critically needed, even if the drug he or she is taking doesnt have negative side effects, that person still does not get the health benefits he or she expects. The most common scenario involves a technician or other individual at the lab labeling a specimen from one patient with the name of another patient.

Even the change to barcoding has not improved the problem. Patient Information Section ____Specimen previously unlabeled OR ____ Specimen incorrectly labeled as _____ _____ Patient Name Medical Record # The specimen should be correctly labeled as: Use at Least Two Patient Identifiers. It is the responsibility of all departments involved with the collection of specimens that the system affords no opportunity for specimen misidentification or inadequate preservation. 72% of errors due to mislabeled specimens Arch Pathol Lab Med.

What can happen to the sample if a phlebotomist fails to notice the collection tube used is expired when drawing blood for testing?

What is the most serious error in phlebotomy?

Which of the following potential outcomes is the most damaging if data is entered incorrectly into the automated laboratory information system?

Which of the following actions should a phlebotomy technician take to verify the quality of venipuncture supplies?