Unit Project
Unit Project: Reduction and Elimination of Specimen Errors on the Medical Surgical Progressive Care Unit (MS PCU).
I researched how I could add value to my unit and decrease the amount of specimen and laboratory errors within the hospital setting. Best practice overwhelmingly showed that the use of bar code scanning eliminated these errors. In one study I read, it's results showed that "bar code technology significantly reduced the rate of specimen identification errors" (Morrison, 2010). Due to the costs associated with this, I knew that was not going to be an option at this point and needed to implement a change in a more creative manner.
After discussing this with my manager, associate nurse manager, nurse educator, the Quality Safety Advocate Committee (QSA) and the Director of Clinical Lab, I was approved to begin a trial labeling process on the MS PCU. The process that I decided to trial was to have each collector write his/her employee number on every specimen label. Through my literature review, I found that identifying yourself on the specimen label would:
This project kicked off on February 24rd, 2014 and included all staff members on the MS PCU and Ancillary Health Techs (AHT's) that are competent to collect specimens. Joseph, Manager of the AHT's was very willing to have his staff participate in this trial. Teaching techniques that I utilized were speaking at unit staff meetings, emails and one-on-one in-services.
The outcomes of this project added value to the MS PCU by creating a better culture of self-awareness and accountability. At the conclusion of my project, lab errors were decreased from 4.75 per month to 3.5 per month.
Because of the awareness my project brought about, the QSA sub-committee for labeling error reduction created a similar process for accounting for extra specimen labels and initiated this hospital wide. Working along side other Quality Safety Advocates, we began a Laboratory Campaign hospital-wide initiative in rolling out a new practice of sending loose labels to the lab. This new policy that was added to the Specimen Integrity Policy was the use of Orange Cards to affix any extra labels to. The part of policy that came about from my project is that the employee number must be on every Orange Card that is used. This process just started August 1st and I'm looking forward to seeing the reduction in errors that occur by implementing this.
Reference
Morrison,A. P., Tanasijevic, M. J., Goonan, E. M., Lobb, M. M., Bates, M. M., Lipsitz, S. R., ... Melanson, S. E. (2010). Reduction in Specimen Labeling Errors After Implementation of a Positive Patient Identification System in Phelbotomy. American Journal of Clinical Pathoogy, 133, 870-877. http://dx.doi.org/10.13
I researched how I could add value to my unit and decrease the amount of specimen and laboratory errors within the hospital setting. Best practice overwhelmingly showed that the use of bar code scanning eliminated these errors. In one study I read, it's results showed that "bar code technology significantly reduced the rate of specimen identification errors" (Morrison, 2010). Due to the costs associated with this, I knew that was not going to be an option at this point and needed to implement a change in a more creative manner.
After discussing this with my manager, associate nurse manager, nurse educator, the Quality Safety Advocate Committee (QSA) and the Director of Clinical Lab, I was approved to begin a trial labeling process on the MS PCU. The process that I decided to trial was to have each collector write his/her employee number on every specimen label. Through my literature review, I found that identifying yourself on the specimen label would:
- Require the collector to take an extra look at the label, ensuring that it is the correct patient for the specimen and decrease the chance of errors to occur.
- Allow for accountability of the collector that is obtaining the specimen.
- Decrease the amount of repeat specimen collection from the patient.
- Increase patient satisfaction.
This project kicked off on February 24rd, 2014 and included all staff members on the MS PCU and Ancillary Health Techs (AHT's) that are competent to collect specimens. Joseph, Manager of the AHT's was very willing to have his staff participate in this trial. Teaching techniques that I utilized were speaking at unit staff meetings, emails and one-on-one in-services.
The outcomes of this project added value to the MS PCU by creating a better culture of self-awareness and accountability. At the conclusion of my project, lab errors were decreased from 4.75 per month to 3.5 per month.
Because of the awareness my project brought about, the QSA sub-committee for labeling error reduction created a similar process for accounting for extra specimen labels and initiated this hospital wide. Working along side other Quality Safety Advocates, we began a Laboratory Campaign hospital-wide initiative in rolling out a new practice of sending loose labels to the lab. This new policy that was added to the Specimen Integrity Policy was the use of Orange Cards to affix any extra labels to. The part of policy that came about from my project is that the employee number must be on every Orange Card that is used. This process just started August 1st and I'm looking forward to seeing the reduction in errors that occur by implementing this.
Reference
Morrison,A. P., Tanasijevic, M. J., Goonan, E. M., Lobb, M. M., Bates, M. M., Lipsitz, S. R., ... Melanson, S. E. (2010). Reduction in Specimen Labeling Errors After Implementation of a Positive Patient Identification System in Phelbotomy. American Journal of Clinical Pathoogy, 133, 870-877. http://dx.doi.org/10.13