Blood specimens are labeled at the time of acquisition in order to identify and match the specimen, label, and order to the patient. While the labeling process is not new, it is frequently laden with errors (Brown, Smith, & Sherfy, 2011). Wrong blood in tube (WBIT) poses significant risk. Multiple factors contribute to mislabeling errors, including lax policies, limited technological solutions, decentralized labeling processes, multi-tasking, distraction from the clinician, and insufficient education and training of staff. To reduce blood specimen labeling errors, a large academic medical center implemented an innovative technological solution for specimen labeling that integrates patient identification, physician order, and laboratory specimen identification through barcode technology that interfaces with the electronic medical record at the point of care. A failure mode, effects and critical analysis (FMECA) were completed to assess for system failure points, and to design workflow prior to training staff. Four failure points were identified and eliminated through workflow adjustments with the new system. Staff training utilizing simulation highlighted system safety points. This quality improvement process applied across adult and pediatric acute and critical care units provided dramatic reductions in blood specimen labeling errors pre/post intervention.
","abstract_html":"<p>Blood specimens are labeled at the time of acquisition in order to identify and match the specimen, label, and order to the patient. While the labeling process is not new, it is frequently laden with errors (Brown, Smith, & Sherfy, 2011). Wrong blood in tube (WBIT) poses significant risk. Multiple factors contribute to mislabeling errors, including lax policies, limited technological solutions, decentralized labeling processes, multi-tasking, distraction from the clinician, and insufficient education and training of staff. To reduce blood specimen labeling errors, a large academic medical center implemented an innovative technological solution for specimen labeling that integrates patient identification, physician order, and laboratory specimen identification through barcode technology that interfaces with the electronic medical record at the point of care. A failure mode, effects and critical analysis (FMECA) were completed to assess for system failure points, and to design workflow prior to training staff. Four failure points were identified and eliminated through workflow adjustments with the new system. Staff training utilizing simulation highlighted system safety points. This quality improvement process applied across adult and pediatric acute and critical care units provided dramatic reductions in blood specimen labeling errors pre/post intervention.</p>","abstract_has_math":false,"creators":["Hoiting, Traci"],"institution":null,"degree_name":"Doctor of Nursing Practice (DNP)","degree_level":"Project","degree_discipline":"Nursing","degree_department":null,"school":null,"contributors":["Dr. KT Waxman","Dr. Amy Nichols","Dr. Daphne Stannard"],"advisors":[],"committee_chairs":[],"committee_members":[],"year":2014,"date_issued":"2014-12-12T08:00:00Z","date_published":"2014-12-12T08:00:00Z","updated_at":"2026-07-24T05:42:56Z","subjects":["specimen labeling","error","failure modes","effects and critical analysis","(FMECA)","simulation","wrong blood in tube (WBIT)","patient safety.","Health Information Technology","Nursing Administration"],"languages":[],"rights":[],"rights_urls":[],"identifier_entries":[]},"links":{"outbound_url":"https://repository.usfca.edu/dnp/44","outbound_label":"Repository record","outbound_source":"dc:identifier"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:contributor","label":"Contributor","values":["Dr. KT Waxman","Dr. Amy Nichols","Dr. Daphne Stannard"]},{"key":"dc:creator","label":"Author","values":["Hoiting, Traci"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date.available","label":"Dc Date Available","values":["2015-12-02T08:00:00Z"]},{"key":"thesis:degree_discipline","label":"Discipline","values":["Nursing"]},{"key":"thesis:degree_level","label":"Degree Level","values":["Project"]},{"key":"thesis:degree_name","label":"Degree Name","values":["Doctor of Nursing Practice (DNP)"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["specimen labeling","error","failure modes","effects and critical analysis","(FMECA)","simulation","wrong blood in tube (WBIT)","patient safety.","Health Information Technology","Nursing Administration"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier","label":"Identifier","values":["https://repository.usfca.edu/dnp/44"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description.abstract","label":"Abstract","values":["Blood specimens are labeled at the time of acquisition in order to identify and match the specimen, label, and order to the patient. While the labeling process is not new, it is frequently laden with errors (Brown, Smith, & Sherfy, 2011). Wrong blood in tube (WBIT) poses significant risk. Multiple factors contribute to mislabeling errors, including lax policies, limited technological solutions, decentralized labeling processes, multi-tasking, distraction from the clinician, and insufficient education and training of staff. To reduce blood specimen labeling errors, a large academic medical center implemented an innovative technological solution for specimen labeling that integrates patient identification, physician order, and laboratory specimen identification through barcode technology that interfaces with the electronic medical record at the point of care. A failure mode, effects and critical analysis (FMECA) were completed to assess for system failure points, and to design workflow prior to training staff. Four failure points were identified and eliminated through workflow adjustments with the new system. Staff training utilizing simulation highlighted system safety points. This quality improvement process applied across adult and pediatric acute and critical care units provided dramatic reductions in blood specimen labeling errors pre/post intervention.
"]},{"key":"dc:title","label":"Title","values":["SPECIMEN LABELING IMPROVEMENT PROJECT: SLIP"]}]}],"canonical_facts":{"dc:contributor":["Dr. KT Waxman","Dr. Amy Nichols","Dr. Daphne Stannard"],"dc:creator":["Hoiting, Traci"],"dc:date.available":["2015-12-02T08:00:00Z"],"dc:description.abstract":["Blood specimens are labeled at the time of acquisition in order to identify and match the specimen, label, and order to the patient. While the labeling process is not new, it is frequently laden with errors (Brown, Smith, & Sherfy, 2011). Wrong blood in tube (WBIT) poses significant risk. Multiple factors contribute to mislabeling errors, including lax policies, limited technological solutions, decentralized labeling processes, multi-tasking, distraction from the clinician, and insufficient education and training of staff. To reduce blood specimen labeling errors, a large academic medical center implemented an innovative technological solution for specimen labeling that integrates patient identification, physician order, and laboratory specimen identification through barcode technology that interfaces with the electronic medical record at the point of care. A failure mode, effects and critical analysis (FMECA) were completed to assess for system failure points, and to design workflow prior to training staff. Four failure points were identified and eliminated through workflow adjustments with the new system. Staff training utilizing simulation highlighted system safety points. This quality improvement process applied across adult and pediatric acute and critical care units provided dramatic reductions in blood specimen labeling errors pre/post intervention.
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