Project Scope and Plan (PSP)

General Information:
Project name: Mislabeled Specimens: Managing and decreasing mislabeling events in the
Emergency Department.
Project Manager name: Ashlee Knoll
Site: Ascension St. Mary’s Emergency Department (Main and Towne Centre)
Location: Saginaw, MI

A. Project Overview:
According to Rodziewicz & Hipskind (2018), medical errors remain a serious public health
problem and are a leading cause of death in the United States. The purpose of this project is to
identify system issues initially focusing in the emergency department that can then be pushed
out to the rest of the hospital. In Fiscal year-to-date 2019 (FYTD19), 38 mislabeled specimens
have been reported in ERS (Event Reporting System) at Ascension St. Mary’s (Main and Towne
Centre). All have the potential to cause serious harm. These events are reported daily at safety
huddle by all departments. As an institution, we have been unsuccessful at maintaining more
than 5 days without a specimen labeling issue. Although majority of these events have not led
to serious safety issues, the risk is always present and patient satisfaction is in jeopardy. ERS
reporting for specimen mislabeling has also increased over the last three fiscal years. Fiscal Year
2017 (FY17) ghad 13 reported events, FY18 had 72, and FYTD19 has already experienced 38
events. The Joint Commission (TJC) has consistently included identifying patients correctly as a
Hospital National Patient Safety Goal. TJC has specifically dedicated chapters to using two ways
to identify patients to ensure each patient gets the correct medicine and treatment as well as a
chapter specifically focusing on the correct identification of patients for blood transfusions (TJC,
2019). By recognizing how events occur, learning from them, and working toward preventing
them, patient safety can be improved.
References

[Quantros Error Reporting System]. (2019, January 27). Unpublished raw data. Mislabeled

Specimen Data entered into the safety reporting system.

Rodziewicz, T. L., & Hipskind, J. E. (2018, October 27). Medical Error Prevention. Stat Pearls.

Retrieved from PubMed.

The Joint Commission. (2018, October 16). Hospital: 2019 National Patient Safety Goals. In The

Joint Commission . Retrieved from

https://www.jointcommission.org/assets/1/6/2019_HAP_NPSGs_final2.pdf
B. Project Goal(s):
By February 17, 2019, visual education tools will be created and presented to the
Emergency Departments demonstrating proper labeling techniques on specimen collection
containers.
By April 1, 2019, Ascension St. Mary’s Emergency Department (Main and Towne Centre)
will have 3 or less specimen mislabeling issues per month. (This is a 70% reduction from current
run rate in FY19, 50% reduction from FY18 run rate).
C. Project Objectives/Deliverables:
1. Review ERS events to determine commonalities among events.
2. Review specimen labeling policy and corrective action process related to specimen
mislabeling.
3. Form committee with necessary members present (lab, nursing, education, risk
management).
4. Discuss with nursing staff the barriers they have related to specimen labeling.
5. Create educational materials for nursing.
6. Begin staff education on policy review and proper labeling of specimens.
7. Create audit process to evaluate daily compliance.
8. Enforce corrective action and follow up measures according to policy.
9. Evaluate effectiveness of education and proper labeling practices as evidence by
decreased number of mislabeling events.

D. Comprehensive List of Project Requirements/Activities/Tasks:

1. Review ERS events to determine commonalities among events.
1.1 Meet with Risk Management to access the ERS system. Completed 1/31/19
1.2 Search for similar circumstances within labeling occurrences. Completed 1/31/19
1.3 Determine target units that events occur more frequently. Completed 1/31/19
2. Review specimen collection policy and corrective action process related to specimen
mislabeling.
1.1 Obtain Ascension St. Mary’s specimen collection policies. Completed 1/31/19
1.2 Identify focus areas of current policy that are not currently enforced. Completed
2/4/19
1.3 Identify policy changes necessary to align with project goals. Completed 2/4/19
3. Form Committee with necessary members present (lab, nursing, education, risk
management).
1.1 Meet with committee to review ERS event findings. Completed 2/4/18.
1.2 Discuss observations of current specimen retrieval process. Completed 2/4/19
1.3 Verify label-printing capabilities. Complete by 2/7/19
4. Discuss with staff the barriers they have related to specimen labeling.
1.1 Meet with laboratory personnel to understand labeling expectation. Complete by
2/7/19
1.2 Meet with nursing leadership to discuss ERS findings. Complete by 2/7/19
1.3 Discuss process with nursing staff of identified target area (ED) to evaluate current
process understanding. Complete by 2/15/19
1.4 Review plans to proceed with nurse manager overseeing project. Complete by
2/10/19
5. Create educational materials for nursing.
1.1 Develop educational presentation board for ED nursing staff. Complete by 2/10/19
1.2 Request feedback from committee to ensure through education. Complete by 2/11/19
 1.3 Accommodate suggested alterations from committee. Complete by 2/12/19
1.4 Create daily tracking tool to be implemented within the Emergency Department to
track mislabeled specimens. Complete by 2/17/19
1.5 Review current specimen labeling myLearning module assigned for annual
mandatory
education with education department. Complete by 2/20/19
6. Begin staff education on policy review and proper labeling of specimens.
1.1 Determine dates and times to present educational tools. Complete by 2/17/19
1.2 Identify location to keep education materials for constant review. Complete by
2/17/19
1.3 Implement daily tracking tool as a check and balance system for nursing staff.
Complete by 2/18/19
1.4 Assess understanding of process among ED nursing staff. 2/20/19
7. Create audit process to evaluate daily compliance.
1.1 Create daily tracking tool to be implemented within the ED to track mislabeled
specimens.
Complete by 2/17/19
1.2 Implement daily tracking tool as a check and balance system for nursing staff.
Complete by
2/18/19
1.4 Integrate daily tracking tool into daily management system for nursing leadership in
ED. Complete by 2/18/19.
1.5 Compile findings weekly. Ongoing- Complete 4/1/19
1.6 Determine deviations from process on any reported specimen mislabeling events.
Ongoing- Complete 4/1/19
1.7 Make necessary adjustments as issues arise. Ongoing- Complete 4/1/19
1.8 Follow up with associates to determine causes related to event occurrences. Ongoing-
Complete 4/1/19
8. Enforce corrective action and follow up measures according to policy.
1.1 Ensure laboratory associates understand their role in reporting mislabeling events.
Complete
by 2/7/19.
1.2 Educate administrative managers regarding the reporting of mislabeled specimens on
after hours and weekend shifts. Complete by 2/7/19.
1.3 Distribute specimen mislabeling corrective action form to nurse managers. Complete
by 2/9/17.
9. Evaluate effectiveness of education and proper labeling practices as evidence by
decreased number of mislabeling events.
1.1 Collect data of mislabeled specimens weekly. Ongoing-Complete by 4/1/19
1.2 Interview ED staff to ensure they are following correct process. Ongoing-Complete
by 4/1/19
1.3 Integrate staff suggestions from the daily huddle to increase engagement. Ongoing-
Complete by 4/1/19
1.4 Continue to monitor ERS system for outlying events. Ongoing- Complete by 4/1/19
E. Timeline:
1. Review ERS events to determine commonalities among events. – 2 hours
 2. Review specimen labeling policy and corrective action process related to specimen
mislabeling.
– 2 hours
3. Form committee with necessary members present (lab, nursing, education, risk
management).
– 10 hours
4. Discuss with nursing staff the barriers they have related to specimen labeling. – 8 hours
5. Create educational materials for nursing. –15 hours
6. Begin staff education on policy review and proper labeling of specimens. –10 hours
7. Create audit process to evaluate daily compliance. – 20 hours
8. Enforce corrective action and follow up measures according to policy. – 10 hours
9. Evaluate effectiveness of education and proper labeling practices as evidence by
decreased number of mislabeling events. – 20 hours

F. Assumptions & Constraints:

The assumption of this project is that there is a need within the organization to re-align
the specimen labeling process. Evidence continues to show that patient safety should remain
every provider’s first priority, yet there are minor errors associated with lab errors that have
potential for serious injury. The assumption is that initiating the project within the Emergency
Department, data will show that that the project findings can then be cascaded throughout the
rest of the organization.
Project constraints include overall time to implement the project to obtain accurate
findings that positively impact patient safety. Associate compliance and willingness to adapt to
change will also be a constraint that will continually impact the success of the project. To create
a culture of high reliability, the staff must follow the appropriate steps (two patient identifiers,
affixing labels in appropriate places, labeling at the bedside, etc.), and accept accountability
when they fail comply. Financial constraints are also present in relation to technology/system
upgrades that are available but are not something the institution is in a position to invest in
currently.
G. Success Criteria:
This project is important because it is something that can be significantly impacted by
minor process evaluations. Lab work is obtained at least once; usually daily at minimum, on
almost every patient that enters the hospital. That creates an outstanding opportunity for errors
to occur based on volume of specimens alone. According to Novis, Lindholm, Ramsey, Alcorn,
Souers & Blond (2017), clerical errors such as specimen misidentification of blood type and
screens may lead to acute hemolytic transfusion reactions, resulting in serious morbidity and
death. Other potential harm based on misidentification of lab specimens includes ordering
wrong medications or procedures, or misdiagnosing patient conditions leaving the patient that
truly needs treatment without necessary intervention. The satisfaction and trust of the patient
is also at risk if they require their lab work to be redone due to mislabeling errors. Rodziewicz &
Hipskind (2018) explain that human factors are always a problem, identifying errors permits
improvement strategies to form. Health professionals working together can mitigate the cost
and injury associated with medical errors.
Success will be evident if healthcare providers understand the need for change and accept
the responsibility to reduce the risk of human error. By not allowing environmental
interruptions to distract them from the task at hand, they will be able to better serve the
patient population. This change in process and behavior will hopefully result in a decreased
number of specimen mislabeling events that occur in the emergency department.

References

Novis, D. A., Lindholm, P. F., Ramsey, G., Alcorn, K. W., Souers, R. J., & Blond, B. (2017,

February). Blood Bank Specimen Mislabeling. Archives of Pathology & Laboratory

Medicine, 141(2), 255-259. doi:http://dx.doi.org.ezproxy.ferris.edu/10.5858/arpa.2016-

0167-CP

Rodziewicz, T. L., & Hipskind, J. E. (2018, October 27). Medical Error Prevention. Stat Pearls.

Retrieved from PubMed.

H. Signatures: (no electronic signatures)

Project Manager__________________________________________________

Nurse Manager/Supervisor: ________________________________________

Phone: 989-714-3811 email: jill.loftus@ascension.org