Simple initiative shown to reduce mislabeled blood specimens by 90 percent

The College of American Pathologists estimates that 1 in 1,000 blood specimens ends up being labeled with the wrong patient identifiers. That type of error can potentially harm two patients—the patient whose blood was mislabeled as well as the patient who was incorrectly linked to that specimen. Both patients may end up with incorrect diagnoses, missed treatment, or treatment that they do not need.

Now, a collaboration between Palmetto Health Richland Hospital, the South Carolina Hospital Association, and Outcome Engenuity, LLC, has resulted in a simple intervention that hospitals can use to dramatically reduce the rate of mislabeled blood specimens. Called The Final Check, the intervention was used for the first time at Palmetto Health in 2011, resulting in a 90 percent decrease in mislabeled specimens in the first month it was used. Those results have since been validated at five other hospitals in South Carolina and sustained for five consecutive months to date.

Outcome Engenuity offers The Final Check Toolkit free of charge via the website, www.thefinalcheck.org.

David Marx, chief executive officer of Outcome Engenuity, described the intervention as being created through prospective risk modeling that looked at the various ways mislabeling can occur. Palmetto Health had previously tried to reduce the rate of mislabeled specimens through a highly rigorous Red Rule that required nurses and phlebotomists to ask the patient’s name and date of birth, and then to check both the 9-digit medical record number and the 10-digit patient account number.

After observing the staff at work, and realizing that few were actually following the Red Rule, Marx and his team turned that punitive routine upside down. “Instead of adding steps, we eliminated steps,” he said.

The Final Check still calls for the patient’s name and date of birth to be confirmed. But instead of checking the complete medical record number, the nurse or phlebotomist now reads only the last three digits of the medical record number on the label and on the patient’s wristband—and recites them out loud.

According to Marx, saying the numbers out loud ensures that the person is “on the task,” and also makes the staff accountable to the patient.

Marx, who was recently appointed to the National Patient Safety Foundation’s Board of Governors, is well known in the health care industry for his work around Just Culture principles, human factors engineering, and the design of socio-technical systems. The Final Check was designed with certain principles in mind—that people have free will, that effective systems make it easy for people to do the right thing, and that disciplining people for making errors does not necessarily stop errors from occurring.

View and download the Final Check Toolkit or visit www.thefinalcheck.org.