Dome home blank
Search Dome


Reducing Mislabeled Specimens
Howard County General Hospital solves one of its most frequently reported problems.


Specimen labels

Specimen-labeling errors, which can sometimes lead to incorrect diagnoses, unnecessary treatments and extra work for staff, were the most frequently reported adverse events at Howard County General Hospital. The mistakes came in many forms: wrong patient or multiple names on specimen tubes, names for more than one patient in a specimen transport bag, and tubes without labels.

Several years ago, the hospital convened a group of patient care technicians and nurses to identify the causes of, and possible solutions to, the problem. Their input resulted in a number of changes, such as increasing the font size on labels, educating staff on proper patient-identification procedures, and disciplinary action for mistakes. Yet there was no decrease in errors.

About two years ago, the hospital formed a multidisciplinary team that sought a technological solution: a handheld barcode-scanning system that prints labels at the bedside. With representatives from Nursing, Clinical Education, Information Technology and Clinical Information Services, the group solicited proposals and selected the Mobilab system.

Connected by a wireless network to the hospital' patient record system, the handheld devices can display a list of the specimens that need to be taken on a floor. The caregiver scans his or her identification badge (to record who took the draws) and does the same with the patient' barcoded wristband. The user then collects samples in the order dictated by the device, which also tells them which color tube to use. Before a label will print from a small wireless printer, the system asks the user to confirm the patient' birth date—thus satisfying a Joint Commission requirement that two unique patient identifiers be matched.

The system went live on the first inpatient unit in October 2006 and was launched on five more units in the next two months. "This equipment really has been a dream," says Director of Nursing Nancy Smith, the team leader. "Our staff took to the technology very well."

On the six units that first adopted the technology, labeling errors went from 11 in October 2006 to zero in January—a number that has held. "It takes a lot of the stress out," says Jessica Prudencio, a patient care technician. "You can't take a sample on the wrong person. You just can't."

The devices bring other benefits. They give users specific instructions, such as placing certain specimens on ice and taking them immediately to the lab. And when users can't draw a specimen, the system forces them to enter a reason—which ensures that other caregivers know why a test result isn't available.

This summer, two intensive care units began using the system, and more services are in the expansion plans.

—Jamie Manfuso



Johns Hopkins Medicine

About Dome | Archive
© 2007 The Johns Hopkins University
and Johns Hopkins Health System