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Solutions for Patient Safety Fall 2020 Learning Session Abstracts

Reaching for Zero: Eliminating Mislabeled Specimens

Montgomery, Vicki L. MD*; Hudson, Robert W. RN, BSN, MSN

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Pediatric Quality and Safety: March/April 2021 - Volume 6 - Issue - p e445
doi: 10.1097/pq9.0000000000000445
  • Open


Mislabeled specimens (MLSs) create risk of harm for 1 or more patients per mislabeling event due to missed or delayed treatment, unnecessary interventions, pain due to recollection, and additional blood loss which is especially important in premature or critically ill children. Specimens were considered mislabeled if no label was present, some or all patient identifiers were missing, or multiple patient samples were in the same bag. MLSs create waste, including expense of $712 per MLS for repeat testing, supplies, and staff time. Before 2015, most interventions deployed to decrease MLS were focused on general education of frontline staff.


To eliminate MLS by using high reliability strategies.


Laboratory staff members enter a safety report into the organizations safety reporting system each time when there is an MLS. The report includes the type of mislabel. A laboratory leader distributes the MLS report each month to hospital leaders. After joining the Solutions for Patient Safety Network in 2015, we deployed error prevention training and safety culture training throughout our hospital. Subsequently, various strategies learned during safety culture training were deployed to decrease MLS. Directors engaged and created an accountability model. Mislabeling a specimen became a “never” event.


After implementing high reliability strategies that included data transparency, Stop-think-act-review, and 200% accountability as well as finding and fixing issues that made printing and obtaining labels challenging, the MLS rate decreased from 1.2 (2015) to 0.23 (2020) per 1000 specimens (Fig. 1). Currently, there are 10 or fewer MLS per month with an average of 28,698 specimens per month. Since 2015, a minimum of 689 children (some mislabeled specimens involve more than 1 patient) were not harmed and $490,568 were saved.

Fig. 1.
Fig. 1.:
Annotated run chart with centerline shifts noted.
Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.