Mislabel Retraining

If you have received this training, then you have recently mislabeled by name, accession, DDT, test, specimen type, etc. Please use this training to reflect on your process so we can improve patient care and move toward eliminating mislabels.

Where EH Mislabels Occur

Mislabels From Office

Common Causes

  • Full investigation not performed
    • All encounters not reviewed

  • Identifiers not matched to new transmitted orders
  • Ctrl+z used in labeling instructions

Preventions

  • Perform full investigation for ALL issues
    • Do not stop at the first encounter, review all for that patient
  • Review IDs from images and compare to orders
  • Don't use Ctrl+z in labeling instruction field!

Mislabels From Triage

Common Causes

  • Full investigation not performed including:
    • EXCEPT TT not reviewed
    • Other encounters not reviewed
    • Paperwork not reviewed






  • Images not taken of specimens

  • Paperwork not stamped

  • EXCEPT ordered and specimen labeled at separate times
  • Pulling specimens from EH holds or storage
  • Patient IDs not confirmed before attaching ARUP label
  • Specimen type not verified before attaching label
  • Master label used on specimen
  • End of day report not properly used

Preventions

  • Perform full investigation for each issue including:
    • Review LIS images, footnotes, and test statuses
    • Review additional encounters in OMS
    • Review specimen acceptability and stability in LTD
    • Review client contact and note information in CRM
  • Take image of ALL specimens handled in triage
  • Review all details and stamp paperwork accordingly
  • Order EXCEPT and process any applicable tests at the same time
  • Submit fusion forms for labeling instead of retrieving from holds or storage (this will ensure proper documentation as well)
  • Review and confirm specimen IDs and specimen types/tests before attaching OMS specimen or EXCEPT label
    • Build double check into process as specimen is delivered to holds, PUP, S2L, track, or lab
  • If anything remains on end of day report, perform full investigation and ask for help as needed

Mislabels From Labeling

Common Causes

  • Specimen IDs not compared or double checked










  • Accession on specimen not compared to accession on labeling report, ADD TT, fusion form, etc.
  • Differing  or unclear information between report and specimen(s) not investigated




  • Processing multiple tests on one accession separately
  • Container override not performed as instructed


  • Incorrect accession entered in OMS/ESP checkout and not compared to specimen or instructions

Preventions

  • Build ID double checks into labeling process
    • As specimen is pulled from holds/storage
    • As label is attached to specimen
    • As specimen is taken from bin for delivery
    • As specimen is delivered to PUP, S2L, track, or lab

  • Compare specimen identifiers AND accession as specimen is pulled and labeled

  • If number of specimens, name on specimen, specimen types, etc., is different or unclear from instructions, review completed EXCEPT and/or investigate as necessary


  • Process all specimens and tests for each accession at the same time
  • Pay special attention to specimen type for overrides (sub-opt sticker is a good indicator)
  • Copy/paste or scan accession whenever possible

Case Studies

Scenario 1

Scenario 2

Scenario 3

Application of your new knowledge

Match these common causes to their appropriate prevention

  • Define your key...
    Define your answer...
  • Define your key...
    Define your answer...
  • Define your key...
    Define your answer...
  • Specimen IDs not compared or double checked
    Build ID double checks into all processes
  • End of day report not properly used
    If anything remains on end of day report, perform full investigation and ask for help as needed

Please evaluate your process and identify 3 improvements you can make to prevent mislabels.