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"Pocono Medical Center uses their laboratory information system to specifically track mislabeling errors," Charney said. "Many events are most likely missed, especially near-miss events, in other facilities if they do not have a process to track these specific events. Existing processes within facilities need to be examined and changed, if necessary, to be able to track these events more thoroughly."

Charney added that the collaboration will help facilities track these events more carefully and then more process changes will occur to reduce the chances of a healthcare provider mislabeling a patient's lab specimen. Ten hospitals and one rehabilitation facility are participating in the collaborative. To ensure participating facilities will collect the correct events for analysis, they were encouraged to compare specimen mislabeling events submitted to the Authority to other data, such as the number of redraws per month and the number of specimens wasted per month.

Two key elements were identified by the participants for this purpose: 1) the definition of phlebotomy specimen mislabeling and 2) the list of questions (taxonomy) under which these events will be reported to the Authority.

"It is so important for facilities to work together to solve problems, particularly in regard to this project," Charney said. "We must ensure that the data we are collecting for the project is standardized so we can analyze the loopholes in processes that are causing the mislabeling to occur and thereby provide guidance to prevent any future mislabeling of lab specimens."

Charney said the Authority will provide education, technical assistance, tools, resources and an interactive forum to facilitate participants' efforts to improve patient safety with phlebotomy specimen mislabeling prevention. She added th
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