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Mislabled lab specimens

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  • April 8, 2008 at 4:05 pm #25619

    sue
    ★ 10 Years ★
    Member

    Has anyone done a recent Lean or Six Sigma proejct looking at mislabled lab specimens?  One of our Black Belts did a PDCA in 2005 related to mislabeling of specimens and our numbers are creepping up and many of the processes have changes.  We are at the early stages of reveiwing data.  Any feedback or assistance would be greatly appreciated.
    Thank you!

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    April 9, 2008 at 7:49 pm #61942

    sixsigma78
    ★ 10 Years ★
    Member

    I was involved with a similar project and we have the same problem creep every once in a while. Is your problem related to new people or new hires coming in and causing mis-labeling? that was one of the factors for us
     

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    April 10, 2008 at 1:28 pm #61945

    sue
    ★ 10 Years ★
    Member

     Our lab folks are looking at the data, I am not sure at this point if it is realted to new hires.  If you have any action plans that you put in place,  we would greatly appreciate  the  help.
    Thank you!

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    April 23, 2008 at 5:27 pm #61963

    Kate Gillespie
    ★ 10 Years ★
    Participant

    We are starting a DFSS around phlebotomy model of Care due to our % of mislabeled specimens and specimen integrity.  Data shows us that the highest percent of occurances are specimens drawn by nursing and non lab assistants. We are kicking off this project in the next couple of weeks.   

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    April 23, 2008 at 6:13 pm #61964

    mark palmer
    ★ 10 Years ★
    Participant

    I did an FMEA on this a few years ago. We had a significant drop in mislabeled specimens and continue to hold down errors. Please call me sometime and i can explain. 773 880 3079

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    April 26, 2008 at 1:49 am #61966

    Clowers
    ★ 10 Years ★
    Participant

    There is technology out there to help you with your efforts.  Check out http://www.lattice.com.  This technology works with your IS to print specimen labels at the bedside to prevent any possibility of labeling errors.  The system can also be used for med adminstration and transfusion services. 

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    April 28, 2008 at 2:19 am #61969

    annon
    ★ 10 Years ★
    Participant

    I would start be reviewing the control plan in the original CI effort and determine if has been followed and appropriate metrics monitored and controlled.  If none is in place, I would go back to root cause analysis  before implementing someome’s action/control plan that is not specific to your investigative efforts.  Good luck.
     
     
     
     
     
     

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