Sample Identification and Labeling Errors in Clinical Settings: A Review of Prevention Strategies Involving Nursing and Laboratory Practice

Authors

  • Adel Mohammed Abdullah Altheeb
  • Reem Arif Khalaf Almuhawish
  • Alenezi Maha Abbas S
  • Alanazi, Nader Basheer M
  • Talal Muneer M Alsirhani
  • Abdullah Hasan Alnakhli
  • Layla Wadi Dalman Alenazi
  • Alanazi, Saif Awad F
  • Adel Salem Alruwaili
  • Alhazmi, Shaman Matar A
  • Mohammed Osaylan Shutayt Alanazi

DOI:

https://doi.org/10.22399/ijcesen.4417

Keywords:

Sample identification errors, labeling errors, clinical settings, patient safety, treatment outcomes, nursing practice

Abstract

Sample identification and labeling errors in clinical settings pose significant risks to patient safety and treatment outcomes. These errors can lead to incorrect diagnoses, inappropriate treatment plans, and ultimately compromise patient trust in healthcare systems. The complexity of healthcare environments, combined with high patient volumes and the potential for miscommunication among healthcare professionals, often exacerbates the likelihood of such errors. Effective prevention strategies must, therefore, integrate nursing and laboratory practices to ensure accurate sample identification and labeling. Enhancing communication and adopting standardized protocols can help mitigate the risk of errors, ensuring that each sample is accurately matched to the corresponding patient. Involving nursing staff in the labeling process is crucial, as they are typically the first point of contact for patients and specimens. Training nurses in the importance of meticulous sample handling, as well as providing them with user-friendly labeling technology, can significantly reduce errors. Moreover, laboratory personnel should play a central role in developing comprehensive protocols that outline best practices for sample identification. Regular audits and an emphasis on teamwork between nursing and laboratory departments can foster a culture of safety and accountability. By leveraging technology, such as barcode scanning systems, and implementing robust education programs focused on the significance of correct sample identification, healthcare facilities can minimize the incidence of labeling errors and enhance overall patient care quality.

References

1. Cadamuro J, Gaksch M, Wiedemann H, Lippi G, von Meyer A, Pertersmann A, et al. Are laboratory tests always needed? Frequency and causes of laboratory overuse in a hospital setting. Clin Biochem. 2018;54:85–91. DOI: https://doi.org/10.1016/j.clinbiochem.2018.01.024

2. Badrick T, Gay S, McCaughey EJ, Georgiou A. External Quality Assessment beyond the analytical phase: an Australian perspective. Biochem Med (Zagreb). 2017;27:73–80. DOI: https://doi.org/10.11613/BM.2017.009

3. Zhi M, Ding EL, Theisen-Toupal J, Whelan J, Arnaout R. The landscape of inappropriate laboratory testing: a 15-year meta-analysis. PLoS One. 2013;8:e78962. DOI: https://doi.org/10.1371/journal.pone.0078962

4. Carraro P, Plebani M. Errors in a stat laboratory: types and frequencies 10 years later. Clin Chem. 2007;53:1338–42. DOI: https://doi.org/10.1373/clinchem.2007.088344

5. Simundic AM, Bolenius K, Cadamuro J, Church S, Cornes MP, van Dongen-Lases EC, et al. Joint EFLM-COLABIOCLI Recommendation for venous blood sampling. Clin Chem Lab Med. 2018;56:2015–38. DOI: https://doi.org/10.1515/cclm-2018-0602

6. Chan JS, Baker SL, Bernard AW. Pseudohyperkalemia without reported haemolysis in a patient with chronic lymphocytic leukaemia. BMJ Case Rep. 2012;2012:bcr1220115330. DOI: https://doi.org/10.1136/bcr.12.2011.5330

7. Snyder SR, Favoretto AM, Derzon JH, Christenson RH, Kahn SE, Shaw CS, et al. Effectiveness of barcoding for reducing patient specimen and laboratory testing identification errors: a Laboratory Medicine Best Practices systematic review and meta-analysis. Clin Biochem. 2012;45:988–98. DOI: https://doi.org/10.1016/j.clinbiochem.2012.06.019

8. Atay A, Demir L, Cuhadar S, Saglam G, Unal H, Aksun S, et al. Clinical biochemistry laboratory rejection rates due to various types of preanalytical errors. Biochem Med (Zagreb). 2014;24:376–82. DOI: https://doi.org/10.11613/BM.2014.040

9. Simundic AM, Church S, Cornes MP, Grankvist K, Lippi G, Nybo M, et al. Compliance of blood sampling procedures with the CLSI H3-A6 guidelines: An observational study by the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) working group for the preanalytical phase (WG-PRE). Clin Chem Lab Med. 2015;53:1321–31. DOI: https://doi.org/10.1515/cclm-2014-1053

10. Österreichisches Normungsinstitut (ÖNORM). EN ISO 9001 - Quality management systems - Requirements (ISO 9001:2015). Austrian Standards Institute. 2015. (in German)

11. Lippi G, Plebani M. A Six-Sigma approach for comparing diagnostic errors in healthcare-where does laboratory medicine stand? Ann Transl Med. 2018;6:180. DOI: https://doi.org/10.21037/atm.2018.04.02

12. Sciacovelli L, Panteghini M, Lippi G, Sumarac Z, Cadamuro J, Galoro CAO, et al. Defining a roadmap for harmonizing quality indicators in Laboratory Medicine: a consensus statement on behalf of the IFCC Working Group “Laboratory Error and Patient Safety” and EFLM Task and Finish Group “Performance specifications for the extra-analytical phases”. Clin Chem Lab Med. 2017;55:1478–88. DOI: https://doi.org/10.1515/cclm-2017-0412

13. Cadamuro J, Mrazek C, Wiedemann H, Felder TK, Oberkofler H, Haschke-Becher E, et al. Effectiveness of a Laboratory Gate-Keeping Strategy to Overcome Inappropriate Test Utilization for the Diagnosis of Heparin-Induced Thrombocytopenia. Semin Thromb Hemost. 2017;43:645–8. DOI: https://doi.org/10.1055/s-0037-1604054

14. Lippi G, Blanckaert N, Bonini P, Green S, Kitchen S, Palicka V, et al. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med. 2009;47:143–53. DOI: https://doi.org/10.1515/CCLM.2009.045

15. Delanghe J, Speeckaert M. Preanalytical requirements of urinalysis. Biochem Med (Zagreb). 2014;24:89–104. DOI: https://doi.org/10.11613/BM.2014.011

16. Referenzinstitut für Bioanalytik: Preanalyical Benchmark Database. Available at: https://www.rfb.bio/cgi/haemolysisLogin. Accessed February 17th 2020.

17. Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196–205. DOI: https://doi.org/10.1016/j.annemergmed.2006.06.035

18. Plebani M. Towards a new paradigm in laboratory medicine: the five rights. Clin Chem Lab Med. 2016;54:1881–91. DOI: https://doi.org/10.1515/cclm-2016-0848

19. Lippi G. The irreplaceable value of laboratory diagnostics: four recent tests that have revolutionized clinical practice. EJIFCC. 2019;30:7–13.

20. Coskun A, Oosterhuis WP, Serteser M, Unsal I. Sigma metric or defects per million opportunities (DPMO): the performance of clinical laboratories should be evaluated by the Sigma metrics at decimal level with DPMOs. Clin Chem Lab Med. 2016;54:e217–9. DOI: https://doi.org/10.1515/cclm-2015-1219

21. Cadamuro J, Ibarz M, Cornes M, Nybo M, Haschke-Becher E, von Meyer A, et al. Managing inappropriate utilization of laboratory resources. Diagnosis (Berl). 2019;6:5–13. DOI: https://doi.org/10.1515/dx-2018-0029

22. Cornes M. Case report of unexplained hypocalcaemia in a slightly haemolysed sample. Biochem Med (Zagreb). 2017;27:426–9. DOI: https://doi.org/10.11613/BM.2017.046

23. Da Rin G. Pre-analytical workstations: a tool for reducing laboratory errors. Clin Chim Acta. 2009;404:68–74. DOI: https://doi.org/10.1016/j.cca.2009.03.024

24. Buchta C, Coucke W, Mayr WR, Muller MM, Oeser R, Schweiger CR, et al. Evidence for the positive impact of ISO 9001 and ISO 15189 quality systems on laboratory performance - evaluation of immunohaematology external quality assessment results during 19 years in Austria. Clin Chem Lab Med. 2018;56:2039–46. DOI: https://doi.org/10.1515/cclm-2018-0482

25. Dikmen ZG, Pinar A, Akbiyik F. Specimen rejection in laboratory medicine: Necessary for patient safety? Biochem Med (Zagreb). 2015;25:377–85. DOI: https://doi.org/10.11613/BM.2015.037

26. Laposata M, Dighe A. “Pre-pre” and “post-post” analytical error: high-incidence patient safety hazards involving the clinical laboratory. Clin Chem Lab Med. 2007;45:712–9. DOI: https://doi.org/10.1515/CCLM.2007.173

27. Plebani M, Laposata M, Lundberg GD. The brain-to-brain loop concept for laboratory testing 40 years after its introduction. Am J Clin Pathol. 2011;136:829–33. DOI: https://doi.org/10.1309/AJCPR28HWHSSDNON

28. Plumelle D, Lombard E, Nicolay A, Portugal H. Influence of diet and sample collection time on 77 laboratory tests on healthy adults. Clin Biochem. 2014;47:31–7. DOI: https://doi.org/10.1016/j.clinbiochem.2013.11.002

29. Bucurescu S. Pre-analytical Laboratory Error in a Stroke Patient due to Blood Collection from another Stroke Patient: A Case Report. J Neurol Neurophysiol. 2013;4:178. DOI: https://doi.org/10.4172/2155-9562.1000178

30. Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006;82:823–9. DOI: https://doi.org/10.1136/pgmj.2006.049551

31. Verna R, Velazquez AB, Laposata M. Reducing Diagnostic Errors Worldwide Through Diagnostic Management Teams. Ann Lab Med. 2019;39:121–4. DOI: https://doi.org/10.3343/alm.2019.39.2.121

32. De Plato F, Fontana C, Gherardi G, Privitera GP, Puro V, Rigoli R, et al. Collection, transport and storage procedures for blood culture specimens in adult patients: recommendations from a board of Italian experts. Clin Chem Lab Med. 2019;57:1680–9. DOI: https://doi.org/10.1515/cclm-2018-1146

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Published

2024-08-30

How to Cite

Adel Mohammed Abdullah Altheeb, Reem Arif Khalaf Almuhawish, Alenezi Maha Abbas S, Alanazi, Nader Basheer M, Talal Muneer M Alsirhani, Abdullah Hasan Alnakhli, … Mohammed Osaylan Shutayt Alanazi. (2024). Sample Identification and Labeling Errors in Clinical Settings: A Review of Prevention Strategies Involving Nursing and Laboratory Practice. International Journal of Computational and Experimental Science and Engineering, 10(4). https://doi.org/10.22399/ijcesen.4417

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Research Article