TY - JOUR T1 - Improving the Accuracy of Specimen Labeling JF - American Society for Clinical Laboratory Science JO - Clin Lab Sci SP - 210 LP - 212 DO - 10.29074/ascls.18.4.210 VL - 18 IS - 4 AU - Bobbi Dock Y1 - 2005/10/01 UR - http://hwmaint.clsjournal.ascls.org/content/18/4/210.abstract N2 - Accurate specimen identification is a challenge in all hospitals. A mislabeled specimen can lead to devastating consequences for a patient. In an effort to decrease the risk of potential harm caused by labeling errors, Children's Hospitals and Clinics of Minnesota successfully implemented a Zero Tolerance Laboratory Specimen Labeling process. After months of studying, charting, networking, and communicating with all stakeholders the new process led to a 75% reduction in laboratory specimen labeling errors.Over 70% of all information used by a clinician to diagnose and treat a patient comes from the laboratory.1 Ensuring that specimens are correctly identified at the point of collection is essential for accurate diagnostic information. Patient and/or specimen misidentification can be serious, resulting in misdiagnosis and mistreatment.2,3 A misidentification event creates multiple victims: the patient whose treatment was based on the provided results, the patient whose sample it actually was who may have gone untreated, and the healthcare workers who were directly involved with the patient or the specimen. There are also financial and emotional costs from this type of error. While the financial toll can be calculated, the emotional toll on the patients, their families, and healthcare workers who experience its impact is not easily quantifiable.METHOD In April 2003, a multidisciplinary team from Children's Hospitals and Clinics of Minnesota performed a Failure Mode and Effects Analysis (FMEA).4 The team was composed of representatives from the following departments: the clinical laboratory, pathology, process improvement, nursing, and risk management. FMEA analysis identifies potential flaws before an…ABBREVIATIONS: FMEA = Failure Mode and Effects Analysis. ER -