Njfriel's Blog

My capstone quality improvement project, which I will complete this fall, is focused on decreasing the rate of mislabeled lab
specimens on a pediatric oncology unit.  The subject is of interest to me because mislabeling mistakes are a fairly common,
yet preventable, occurrence.  Although unknown to me at the time, I witnessed the mislabeling of a blood specimen.  Fortunately, the laboratory detected a discrepancy, and the error was detected. However, a few years prior, the same hospital had a brush with catastrophe when a child was given a blood transfusion based on the cross-type and match of another patient.  The culprit: a mislabeled specimen.  Fortunately, both children had the same blood type, therefore no hemolytic reaction occurred.  Needless to say, it was a close call.

My capstone project will focus on developing and implementing a solution for the current specimen mislabeling issue at the microsystem
level.  I will investigate barriers to the implementation of the hospital’s specimen collection policy, investigate the root cause of identification errors, consider strategies for improvement, research technological solutions, and develop a plan and means of benchmarking progress.

This project is precisely the type of undertaking that would fall under the purview of a clinical nurse leader (CNL).  Because staff nurses are responsible for drawing labs according to a hospital wide protocol, they are accountable for the mislabeling of specimens during the pre-analytic phase of laboratory testing.  Although laboratory collection is done on the unit, a variety of hospital personnel are, or should be,
involved in ensuring the safety of this process.  It will be necessary to interface with multiple departments within the hospital to ensure that the correct data is analyzed and an effective solution is developed.  This is part of the role of the CNL.  Given the potential for adverse outcomes such
as patient harm, delayed treatment, inefficiency and waste, this is an issue that deserves attention.

March 2018
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