Laboratory Label Printing Impacts Patient Safety and Throughput Time by Jeanne McGrayne, R.N.

Jeanne McGrayne, R.N.As an Emergency Department consultant for the past 18 years, I am continually seeking best practices that I can share with other organizations. One practice that I find frequently impacts both patient safety and throughput time is the process of labeling the blood specimen collected in the ED. I think the issue began when years ago when the laboratory used to provide phlebotomists to the ED in order to collect the specimen. With cost cutting and a greater move to speed ED processes, the phlebotomy process was delegated to the ED Nurse. This is typical of how nurses frequently assume responsibilities of other departments without additional resources, however in the case of phlebotomy it made sense, especially if the nurse was starting IV access and could minimize or eliminate the need for multiple IV sticks.

So, when the task of phlebotomy moved to the ED, so did the specimen label printer. Now, we often see these label printers in the ED where the label prints once the physician has ordered the test.
The problem with the laboratory order label printer in the ED is that there are multiple labels for numerous different patients printed simultaneously in a busy chaotic ED. The opportunity for the nurse to pick the wrong label from a batch increases the risk of mislabeling and ultimately treating the patient based on the wrong information.

Trying to explain this to administrators and Laboratory Directors begins with the explanation that the ED is a unique department where specimens are frequently collected before the order is placed. We want ED nurses to think proactively, to anticipate the worst, and to initiate IV access when warranted. If they collect blood specimens at this time, all the better. To meet patient safety goals, the nurse is expected to label the specimen at the bedside, therefore it is absolutely necessary to print out identification labels upon ED Registration and label the patient based on two unique identifiers. This is not the order label! Once the specimen is collected, and labeled with patient information appropriately, where is the specimen kept while waiting for the laboratory order label to be printed? Often it is the nurses pocket, or a “rack” in the ED. When the order label finally prints, the nurse will reconcile the order and the specimen and send it to the lab. If the nurse is tied up with other responsibilities, and does not see the order, the time from collection to specimen accession time is delayed. And if there is not an order for the specimen collected, where is the specimen stored in the ED?

I heard just recently of a deposition where the trial lawyer had many questions of the nurse about the "labs drawn" entry .. like why did you draw them, which did you draw, where did you put them, where did they get held/sent, etc. and what if no orders were written that would have "used" the tubes... "So, they were just floating around the hospital?" type of questions. Unfortunately, I frequently hear the Laboratory Director does not want the specimen sent to the lab unless it is accompanied by an order.

The best process that I have seen is neither costly nor will require additional staff. It is to merely to have the ED order print in the laboratory. When specimens are collected, they are labeled with a patient identification label printed upon patient registration, and sent to the lab for them to store. When the ED Physician orders the test, laboratory staff receiving the specimen reconciles the order and specimen and runs the test. If you have any questions, I can put you in touch with organizations that have adopted this practice and observed the positive results on mislabeling errors and turnaround times. Meet with your Nursing and Laboratory Directors to flow chart the process and identify delays and risks. Update your policy for managing blood specimen collection and labeling and agree upon where specimens are stored for safe keeping and for how long.

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