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 * Healthcare Risk Management
 * July 1, 2011

Patient identification errors continue to plague the healthcare industry despite
years of efforts to eradicate this potentially disastrous problem. Understanding
why patients and specimens are misidentified is key to reducing or eliminating
errors, and risk managers can make progress by focusing on the human behavioral
components of healthcare work.


SPECIMEN LABELING STILL A MAJOR RISK FOR ID ERRORS AND HUGE LIABILITY

July 1, 2011

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Specimen labeling still a major risk for ID errors and huge liability

Technology, focus on human factors can help

Patient identification errors continue to plague the healthcare industry despite
years of efforts to eradicate this potentially disastrous problem. Understanding
why patients and specimens are misidentified is key to reducing or eliminating
errors, and risk managers can make progress by focusing on the human behavioral
components of healthcare work.

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

Recognizing this risk, The Joint Commission has implemented two hospital
National Patient Safety Goals (NPSGs) for 2011 related to patient
identification: NPSG.01.01.01 is "Use at least two ways to identify patients.
For example, use the patient's name and date of birth. This is done to make sure
that each patient gets the correct medicine and treatment." NPSG.01.03.01 is
"Make sure that the correct patient gets the correct blood when they get a blood
transfusion." The College of American Pathologists also includes patient and
sample identification as one of its five top patient safety goals.

Phlebotomy is one of the fields most focused on labeling errors, and many health
care providers take a punitive approach to errors, says Fran Charney, RN, MSHA,
CPHRM, CPHQ, CPSO, FASHRM, director of educational programs with the
Pennsylvania Patient Safety Authority (PPSA) in Harrisburg, PA. Before joining
the PPSA, Charney was a risk manager and patient safety officer.

"Many organizations talk about taking a systems approach, but when it comes to
phlebotomy, they have a 'three strikes and you're out' approach," Charney says.
"Then we ask if the problem went away when they fired that phlebotomist, and of
course they say it didn't."

Charney encourages risk managers to look at specimen labeling errors as a system
problem, treating them much like any adverse event and asking not just who made
the error, but why that error was possible and how it could be prevented. "A lot
of times we don't dig deep enough to see why the error occurred," she says. "We
just say Sally the phlebotomist made a mistake and put that in her record. If
she forgot to double check the ID because the phone was ringing off the hook,
why was that? Because you were short staffed? And that was because you had a flu
epidemic?"

Understanding human factors is a big part of reducing identification errors,
says Megan Shetterly, RN, MS, patient safety liaison for the Northeast Region of
the PPSA. When investigating an error, ask not only what happened and how, but
why, she says. "We need to ask them why several times, to drill down and find
out what led to this error, not the simple mechanics of how it happened,"
Shetterly says. "The nurse or phlebotomist might say she grabbed the wrong
label, but you can't leave it at that. Why did she take the wrong label? What
was going on, and what about your procedures made it possible for her to do
that?"

Common causes are disruptions, interruptions, and increased work load, Shetterly
says. The most often cited explanation is that the employee was not following
procedures, but the next question must be why, she says. The answer also
involves the workload. "They often say that to get the workload done, they don't
have time to do the A, B, C, and D that are spelled out in the policies and
procedures," Charney says. "So they decide C isn't really necessary, and they do
a workaround. That sounds like an individual decision, but we put them in an
unsafe place where that looks like the only way out."

Patients should be involved with confirming their identification as much as
possible, Charney says. Too often, she says, the caregiver enters the room and
asks "Are you Mr. John Smith?" or says "You're Mr. Smith, right?" and the
patient nods or mumbles a response. That is not an acceptable interaction,
Charney says. "A much better way is to say, 'Can you state your name for me?'"
she says. "That is a very different question, and you get a much better
response. Sometimes you can go on and ask the patient to spell the last name.
That kind of active participation by the patient is crucial."

Bar coding technology can significantly reduce patient identification errors but
it is not a panacea, Shetterly says. She notes that the Centers for Disease
Control and Prevention has recognized bar coding as a best practice for specimen
collection."The technology is very good, but it's only as good as the person
using it," Shetterly says. "You still have the human element, so errors can
occur. We've seen people printing out labels ahead of time, for instance, which
facilitates mixing up the labels."

Are you at risk for being sued?

The malpractice implications of a mislabeled specimen are significant, says
Laura A. Dixon, JD, RN, CPHRM, director of the Department of Patient Safety for
the Western Region of The Doctors Company, a malpractice insurer in Napa, CA.

A patient might receive care indicated for someone else, while the other patient
does not receive needed treatment. "Some of these errors can have long term,
lasting physical effects on the patient," Dixon says. "But in addition to the
physical problems, the individual also may have emotional trauma. Of the claims
we have from identification errors, the majority are about emotional trauma
rather than physical injury."

The typical lawsuit involves a relatively young and healthy individual who
underwent an unnecessary procedure and believed for some period that he had
cancer or another serious illness, Dixon says. The potential liability will
depend on how state law addresses claims of emotional distress, but the payout
tends not to be in the millions of dollars, she says.

Delayed diagnosis is a bigger liability risk, Dixon says. A delayed diagnosis of
cancer because of a specimen mixup, for instance, could result in a costly
malpractice lawsuit, she says.

"Those cases tend to involve real injury and perhaps an impact on long term
survivability, so they can be quite costly, both in terms of the payout and the
cost to defend them," Dixon says.

Sources

Fran Charney, RN, MSHA, CPHRM, CPHQ, CPSO, FASHRM, Director of Educational
Programs, Pennsylvania Patient Safety Authority, Harrisburg. Telephone: (717)
346-0469. E-mail: fcharney@state.pa.us.

Laura A. Dixon, JD, RN, CPHRM, Director, Department of Patient Safety, Western
Region, The Doctors Company, Napa, CA. Telephone: (800) 421-2368. E-mail:
info@thedoctors.com.

Megan Shetterly, RN, MS, Patient Safety Liaison, Northeast Region, Pennsylvania
Patient Safety Authority, Harrisburg, PA. Telephone: (717) 346-0469. E-mail:
mshetterly@state.pa.us.

 * Issue Date: July 1, 2011
 * 

Subscribe Now

Table of Contents

 * Specimen labeling still a major risk for ID errors and huge liability
 * PA hospitals cut label errors by 37%
 * Reduce ID errors with 24/7 phlebotomy
 * Bedside barcodes reduce pharm errors
 * ECRI PSO issues caution on cardiac monitoring ID
 * Surgeon whistleblower awarded $4.7 million
 * Clash with hospital led to restriction of duties
 * Surgeon's competence claimed to be the issue
 * OIG advises caution with joint ventures
 * Referrals are obstacle in joint venture plans
 * Watch for risk factors in a joint venture
 * AHRQ: Good teamwork but weak in handoffs
 * LRC: Failed coiling procedure and inadequate follow-up leads to partial
   paralysis, $23 million verdict
 * LRC: Diagnosis delay leads to permanent blindness

Financial Disclosure: None of the authors or planners for this educational
activity have relevant financial relationships to disclose with ineligible
companies whose primary business is producing, marketing, selling, reselling, or
distributing healthcare products used by or on patients

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