F RO M T H E DATA B A S E Data Snapshot: Pediatric Laboratory Events Lea Anne Gardner, PhD, RN Specimen collection problems are costly in terms of the time required to secure a new Senior Patient Safety Analyst specimen, trauma inflicted on the patient, potential delay in diagnosis and treatment, Pennsylvania Patient Safety Authority and financial costs of additional resources used.1-3 The pediatric population has a heightened vulnerability to and fear of specimen collection, especially with venipunc- tures.4,5 For example, two events reported through the Pennsylvania Patient Safety Reporting System identified infants who needed additional services (i.e., blood transfu- sion and oxygen therapy, respectively) after repeat specimens were required. Typically, data and discussions related to laboratory-related errors combine pediatric and adult populations or tend to be adult-centric; however, this analysis focuses solely on the pediatric population and includes all types of specimen collection (e.g., blood, urine, biopsies). For the purposes of this study, "pediatrics" encompasses newborns through age 21, based on a 1988 American Academy of Pediatrics official statement.6 Between January 2010 and December 2012, the laboratory-related events that occurred accounted for 57.6% (n = 11,477 of 19,923) of the pediatric-related, procedural-error- related events reported and 14.0% (n = 11,477 of 81,701) of the total pediatric events reported by Pennsylvania children’s hospitals, acute care hospitals, community hospi- tals, rehabilitation hospitals, ambulatory surgical facilities, and birthing centers that provided care for pediatric populations. The Table shows a breakdown of the pediatric laboratory-related events. The categories (e.g., specimen mislabeled, specimen label incomplete or missing, specimen quality Table. Pediatric Laboratory Events Reported to the Pennsylvania Patient Safety Authority, January 1, 2010, through December 31, 2012 LABORATORY EVENT TYPE NO. OF % OF EVENTS EVENTS Specimen quality problems (e.g., wrong color 2,512 21.9 tubes used, blood hemolyzed) Specimen label incomplete or missing (e.g., 2,357 20.5 requisition missing hospital-specific information or label, requisition does not match specimen information) Specimen mislabeled (e.g., label missing 1,889 16.5 patient data) Results missing or delayed 1,093 9.5 Other (e.g., tourniquet left on, missing patient 907 7.9 identification bands, lab equipment failed) Tests ordered but not performed 858 7.5 Wrong patient (e.g., ordered on wrong patient, 503 4.4 performed test on wrong patient) Specimen delivery problem 408 3.6 Wrong result 342 3.0 Tests not ordered 299 2.6 Wrong test ordered 194 1.7 Wrong test performed 115 1.0 Total 11,477 100.1 Note: Total percentage does not equal 100 due to rounding. Page 140 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority problems) are defined according to involving specimens lacking the five mini- handling, and labeling of specimens; and descriptions provided in the literature3,7,8 mal data requirements and mismatches safe delivery of the specimens to the labo- and those used in the Pennsylvania between the specimen label information ratory can reduce patient stress, financial Patient Safety Authority’s collaborative and the requisition form (e.g., mis- costs, the use of additional resources, improvement project to reduce errors matched or missing patient identifiers). and the occurrence of delayed results, in blood specimen mislabeling.9-11 For As previously noted by the Authority delayed patient care, additional needle- example, the events found in the category and in the literature, ensuring proper sticks, and additional treatments (e.g., of mislabeled specimens include events patient identification; proper collection, transfusions).9,10,12,13 NOTES 1. Paxton A. Specimen rejection: what price 5. Duff AJA. Incorporating psychological AdvisoryLibrary/2011/jun8(2)/Pages/ for patient care? [online]. CAP Today approaches into routine paediatric veni- 47.aspx 2012 Jul [cited 2013 Oct 25]. http://www. puncture [online]. Arch Dis Child 2003 10. Shetterly M. Blood specimen labeling col- cap.org/apps/portlets/contentViewer/ [cited 2013 Oct 25]. http://www.ncbi. laborative: path to results. Pa Patient Saf show.do?printFriendly=true&contentRe nlm.nih.gov/pmc/articles/PMC1719315/ Advis [online] 2011 Jun [cited 2013 Aug ference=cap_today%2F0712%2F0712d_ pdf/v088p00931.pdf 28]. http://patientsafetyauthority.org/ specimen_rejection.html 6. American Academy of Pediatrics Council ADVISORIES/AdvisoryLibrary/2011/ 2. Latino RJ. Root cause analysis: investment on Child and Adolescent Health: age jun8(2)/Pages/53.aspx or expense? [online]. [cited 2013 Oct 29]. limits of pediatrics [online]. Pediatrics 11. Shetterly M. Collaborative patient safety http://reliability.com/industry/articles/ 1988 May [cited 2013 Nov 19]. http:// effort: addressing phlebotomy specimen RCA_Investment_or_Expense.pdf pediatrics.aappublications.org/content/ mislabeling. Pa Patient Saf Advis [online] 3. College of American Pathologists. When 81/5/736.full.pdf 2009 Sep [cited 2013 Aug 28]. http:// a rose is not a rose: the problem of mis- 7. Clinical and Laboratory Standards Insti- patientsafetyauthority.org/ADVISORIES/ labeled specimens [online]. 2010 Feb 23 tute (CLSI). Specimen labels: content and AdvisoryLibrary/2009/Sep6(3)/Pages/ [cited 2013 Aug 26]. http://www.cap.org/ locations, fonts, and label orientation; 107.aspx apps/cap.portal?_nfpb=true&cntvwrPtlt_ approved standard [online]. 2011 [cited 12. Wagar EA, Tamashiro L, Yasin B, et al. actionOverride=%2Fportlets%2Fcontent 2013 Aug 28]. http://www.readbag.com/ Patient safety in the clinical laboratory: Viewer%2Fshow&cntvwrPtlt%7Baction clsi-source-orders-free-auto12-a a longitudinal analysis of specimen iden- Form.contentReference%7D=practice_ 8. Wagar EA, Stankovic AK, Raab S, et al. tification errors [online]. Arch Pathol management%2Fdirectips%2Fmislabeled_ Specimen labeling errors: a Q-probes Lab Med 2006 Nov [cited 2013 Oct 25]. specimens.html&_pageLabel=cntvwr analysis of 147 clinical laboratories http://www.pathology.medsch.ucla.edu/ 4. Paxton A. Promise and provisos of pedi- [online]. Arch Pathol Lab Med 2008 downloads/06PatientSafety.pdf atric diagnostic testing [online]. CAP Oct [cited 2013 Aug 26]. http:// 13. The Joint Commission. National Patient Today 2010 Dec [cited 2013 Oct 25]. www.archivesofpathology.org/doi/ Safety Goals effective January 1, 2014: http://www.cap.org/apps/cap.portal?_ pdf/10.1043/1543-2165(2008)132%5B16 laboratory accreditation program [online]. nfpb=true&cntvwrPtlt_actionOverride=%2 17%3ASLEAQA%5D2.0.CO%3B2 2013 [cited 2013 Oct 25]. http://www. Fportlets%2FcontentViewer%2Fshow&_ 9. Reducing errors in blood specimen jointcommission.org/assets/1/6/LAB_ windowLabel=cntvwrPtlt&cntvwrPtlt%7B labeling: a multihospital initiative. Pa NPSG_Chapter_2014.pdf actionForm.contentReference%7D=cap_ Patient Saf Advis [online] 2011 Jun today%2F1210%2F1210d_pediatric. [cited 2013 Aug 28]. http://patient html&_state=maximized&_pageLabel=cntvwr safetyauthority.org/ADVISORIES/ Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 141 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 4—December 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. 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