Specimen Identification Error Reduction: A Collaborative Interprofessional Approach

Purpose:
The purpose of this clinician-led practice and quality improvement initiative was the reduction of specimen identification errors in an acute care hospital setting. Utilizing performance improvement methodologies and direct caregiver involvement, the goal for zero specimen errors was established.

Relevance/Significance:
Specimen identification errors are patient safety issues which can result in adverse events such as diagnostic errors, inappropriate treatments, or potentially life threatening consequences. Interprofessional caregivers collaborated in an evaluation of current clinical practices to identify continual practice improvement strategies. Improving processes for specimen collection, as well as adherence to established policies, were identified as key elements in specimen error reduction.

Strategy and Implementation:
The organization has been monitoring specimen errors since 2007 with gradual improvement. In 2013, hospital administration as well as nursing practice council members identified specimen error reduction as a priority goal. A Specimen Error Reduction Task Force was established in June of 2013 including the Patient Safety manager, Laboratory staff, direct care nurses, nurse administration, and ancillary staff. This task force developed strategies for performance improvement. Guidelines and procedures for specimen collection were established and distributed to hospital staff. The Nursing Practice Council was educated regarding continual practice improvement process with development of unit specific action plans for specimen error reduction. Nursing quality and nurse managers developed educational references and established accountability guidelines. A Nursing Quality Dashboard was created to increase staff awareness of monthly specimen error data and monitor trends per unit.

Evaluation:
The number of specimen errors for nursing staff decreased from 48 in 2013 to 16 in 2014, which represents a 68% reduction. The most significant improvement occurred after initiatives developed by the Specimen Error Reduction Task Force and the Nursing Practice Council were implemented.

Implications for Practice:
Interprofessional clinician engagement is vital to the sustainment of adherence to work practices that support continual practice improvement initiatives for specimen error reduction. Frontline nursing staff involvement in quality and patient safety projects is essential to achieve optimal outcomes.