Addressing the Problem of Mislabeled and Unlabeled Clinical Laboratory Specimens at the Hospital of the University of Pennsylvania

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Advisor: Jim Pelegano, MD, Thomas Jefferson University.


Our interdepartmental team addressed mislabeled specimens by utilizing process improvement tools such as process mapping, fishbone diagramming, Plan, Do, Study and Act (PDSA) cycles and Failure Mode and Effects Analysis (FMEA) to eliminate mislabeled clinical laboratory specimens on an intensive care unit. Implementation of a multi-phase one-group (ICU) natural experiment project design identified the frequency of mislabeled events during a pre and post intervention period. After an uptick shortly after the first PDSA, a second PDSA developed stronger and consistent education and heightened staff awareness to eliminate the number of mislabeled events from the unit. To date the number of events appears to be trending in the correct direction. Collaboration and recognition of contributing factors associated with mislabeled specimens by the staff on the Heart and Vascular Intensive Care Unit develop a best practice protocol and a personal accountability tool to eliminate mislabeling events on their unit by “getting it right the first time and every time”.

Presentation: 25 minutes

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