Even well-intentioned and caring healthcare providers can make mistakes, particularly if the processes they use and the environment in which they work have not been optimized to prevent errors. That was the realization of the laboratory services team at Halton Healthcare Services (Oakville, Ontario, Canada), a multisite healthcare organization that provides primary and tertiary care hospital services at facilities in the growing communities of Milton, Oakville, and Halton Hills in southwestern Ontario. The laboratory services team was particularly interested in finding ways to reduce incidents in which a patient’s specimen was misidentified.

Despite the previous implementation of quality improvement activities to reflect conventional best practices, data from Halton’s corporate incident reporting and tracking system showed that the correct and positive identification of patient specimens remained a challenge. With support from the organization’s board to try a technological approach, the laboratory services team recommended implementing bar-code technology at the bedside. This approach helped the organization achieve a significant and sustainable reduction in misidentification and mislabeling errors.

Bar-code technology was already being used by the laboratory in a more limited fashion: Bar codes were incorporated into patient sample labels to encode key patient identifiers, along with the required tests ordered for the specific tube drawn. At the lab, these labels facilitated entry of the specimens into the laboratory information system (LIS), and they automated completion of the required testing by the laboratory analyzers. At the bedside, however, no mechanism existed to ensure that the label was placed on the right tube for the right patient. Often, labels were printed in batches away from the patient’s bedside; in the time between when the label was printed and the specimen was collected at the bedside, interruptions or other events that arose in the busy, pressure-filled healthcare environment sometimes led to a specimen being mislabeled.

The laboratory services team proposed that the organization expand the use of bar-code technology to include the patient in the bar-code chain. This would involve enhancing the current patient armband with a bar code, which was not considered to be a giant leap, and also acquiring a specimen positive patient identification (PPID) system that used bar-code technology. The latter required winning approval from the board of directors and senior management. The approved project plan specified the following objectives:

• To positively identify the patient using bar-code technology at the bedside.
• To collect specimens from the right patient, at the right time, into the right specimen container.
• To link the test results back to the right patient.

The organization evaluated systems that were compatible with its LIS and selected one that consisted of a wireless handheld computer with a fully integrated scanner and a portable bar-code label printer. With this system, the specimen collection process works as follows:

• When tests are ordered for a patient, the request is transmitted by a wireless connection to the handheld computer.
• The clinician receives the orders and goes to the patient’s bedside. At the bedside, the clinician scans his or her unique identifier into the system and then scans the bar code on the patient’s armband. The system verifies that the tests displayed on the system are indeed intended for that patient.
• Once this match has been positively established, the portable label printer generates specimen collection labels at the bedside.
• After specimen collection and labeling, the device is used again to scan the bar-coded tubes to confirm that the specimens that were ordered have been collected.
• Once this final step is completed, the specimen status within the LIS changes from “Ordered” to “Collected,” and the date, time, and other relevant details are captured automatically.
• A lockout feature prevents the healthcare provider from continuing to the next patient unless all of the above steps have been completed.

The specimen PPID project plan was first rolled out in an incremental fashion at a single facility. Initially, bar-coded armbands were used on all inpatients and ED patients, but the new PPID system was operated only by staff affiliated with a lab-based blood collection service, as a way to monitor its implementation. With the success of this implementation, use of the PPID system was expanded to nursing staff, first in the ICU, then to the ED, then to other programs and facilities.

To assess the effectiveness of the project, the organization has monitored several indicators before and after implementation; these include specimen turnaround time and the number of incidents of specimen mislabeling and wrong-patient collection. Results show, for example:

• Significant reductions in labeling errors. Halton reports that the errors that do occur are directly related to instances when the system has not been used.
• Fewer unnecessary venipunctures and repeats due to duplicate orders, since phlebotomists and nurses can see on the handheld device whether the patient had a recent sample collected.
• Improved response time to “stat” orders due to a system feature that alerts collection staff to any “stat” order placed. (In an emergency situation in which the patient’s information has not yet been entered in the hospital information system—and therefore a bar code cannot be printed—a backup manual method is used.)

It’s worth noting that the transition to the new system has not always been smooth. Clinicians with a lot of experience using the old process, which was less prescriptive, were less enthusiastic about the new system at first. In addition, connectivity using the wireless system was problematic in some areas, a factor that further frustrated some users as they were trying to adapt to the new system. Such problems were overcome, however. HHS reports that phlebotomy and nursing staff now prefer using the system over the manual process, and the program has been expanded to over 700 active users at several facilities.

Best Practices

Halton implemented an approach to specimen identification that forces the correct specimen collection process, providing assurance that the sample has been collected from the correct patient and that the correct label has been applied to the sample. This approach helps staff to avoid errors. In addition, the automatic capture of the collection date, time, and other relevant information allows for better tracking of specimen status in real time. It also eliminates the need to manually enter this information when the sample is received in the laboratory.

Finally, the organization’s phased rollout of the system allowed it to develop a roadmap for the quick and successful expansion of the system to additional clinical areas, at other sites, and for additional applications, such as medication and blood administration. The team at Halton remarked that the lessons learned during the phased rollout "really paved the way" for applying the technology more broadly.

Congratulations and thanks to the people who submitted Halton’s application for the Health Devices Achievement Award: Rosemary Prikosovich, Judy Maxwell, Dawn Scott, Dianne Olmstead, Elaine Hooper, Sharon Mills, and Deanna Mol.