In light of the current JCAHO focus to improve the process of patient identification (including the use of two identifiers), a Michigan blood banker's risk management department wonders how phlebotomists in other facilities identify patients and label specimen tubes for inpatient and outpatient collections. The inquiring blood banker's policy/procedure is to identify inpatients using the name and medical record number on the patient identification wristband. If the patient is alert, the patient is asked to state what his/her name is. It is not uncommon, however, for wristband identification to be removed to allow access for certain treatments, and the inquiring blood banker requests example procedures to guide the process of 'rebanding'. In other words, what procedure is followed to assure that the correct information is placed onto the patient whose ID band has been removed, while the patient is in the hospital? The inquiring blood banker is also interested in example procedures for identifying outpatients, or for verifying the identity of patients who are being admitted to the hospital. The inquiring blood banker has observed resistance by nursing staff to do any active patient identification in clinics where a patient is seen frequently, since the nurses say "they know their patients". Some nursing areas use patient name plus a second identifier such as birth date or home town. The specimen identification policy for the inquiring blood banker's institution can be found at their web site. In addition to the above questions, the inquiring blood banker requests input and/or example procedures for the following:

• How does a phlebotomist assure that the correct label is on a specimen tube?
• How does a hospital document the identity of a phlebotomist who draws a specimen, as well as the date/time of the draw?
• What is a reasonable mislabel policy and what is reasonable discipline associated with mislabels?
• Is the exact time of collection documented in the system?

Editor's NOTE: The following links to previous discussions on this site may be of interest in regard to the above query:

• Review calls for improved patient identification systems for blood
• What is an appropriate way for institutions to assure patient identification?
• Are two people needed to verify that the correct blood products are issued and transfused?
• Prevention of Mislabelling of Pre-transfusion Compatibility Specimens
• Who should draw blood specimens for compatibility testing?

The following responses have been received.

ADDENDA Sept. 25, 2002

1. A blood banker from the Pacific Northwest reports the following:

"With regard to the removal of armbands, this practice is discouraged, but realistically in some situations it cannot be avoided. They have written instruction in their procedure for Patient Identification that when an armband needs to be removed the person removing the band must reapply the band to another extremity by reattaching the ends of the band with tape. This is for bands associated with blood products. If that is not done, then sample collection and compatibility testing is repeated. In her hospital, a bar code band is used for all routine admits. Patients admitted in emergency situations are identified with a band (usually associated with blood products) created so that the patient can be immediately identified and procedures and tests performed without delay. When the bar code band is removed another one is generated. When that is applied the patient is asked to recite and spell their name to the person applying the band. For unresponsive patients, a relative may verify the patient's identity or the identity can be verified using accompanying documentation. Patients who have no relative or accompanying documentation are designated as John/Jane Doe until identification can be accomplished. They are currently in the process of requesting budget approval for a commercial system of patient identification for compatibility testing.

With regard to how the phlebotomist assures a sample is correctly labeled, they ask the patient to recite their name while examining the collection label , the collection label is checked against the armband attached to the patient , and after blood collection the label is applied to the tube at the bedside. To monitor compliance with these key elements of the identification procedure, periodic direct observation audits of the phelbotomists are performed.

With regard to how the date, time and collector ID information is captured, they require that the collector writes the date and time of collection on the tube label in addition to the collector ID.

With regard to their specimen rejection policy, they reject all samples with missing or incorrect name and ID number and missing date, time or collector ID. They accept the sample after correction if the date, time or collector ID are incorrect. This requires a signature on a rejection policy form. An occurrence report is completed for every mislabeled sample.

With regard to documenting 'time', they do require the time of collection on the sample label. The collection time is entered into the computer system when the sample is received in the laboratory.

The responding blood banker reports that in 1999 a hospital-wide process improvement project addressed sample labeling and patient identification. To make a long story short, they had nursing support, they developed a competency, had a skills fair, etc. Marketing got involved and made posters illustrating the labeling requirements, they published stories that illustrated the consequences of not identifying the patient etc., etc. They tried extending the strict labeling policy to the whole lab and all samples for consistency - they re-educated techs in all parts of the lab, provided feedback to all collectors whenever a sample was mislabeled. It was a success and the number of mislabeled samples decreased. However, the number of mislabeled samples began to increase after 1.5 years, the main lab lightened up on their rejection policy, they lost consistency, so they are now back at the drawing board but this time have drawn interest from upper hospital administration due to pressures from JCAHO. The responding blood banker laments that they have a long way to go, but with JCAHO focus it is bound to have a larger and lasting impact and will force managers in all areas to be continuously vigilant. They are currently working with marketing once again. The marketing campaign will be called "Wrist Watch". They have developed a logo and they will use this as a continued awareness for patient identification in their hospital. Their focus is not just on sample labeling but on patient identification for all areas of the hospital i.e. transportation of correct patient, etc."

ADDENDA Sept. 26, 2002

2. An Illinois blood banker reports that her hospital's mislabel policy requires discipline as part of the corrective action for mislabeling a specimen. Specifically, she reports that if a phlebotomist draws an incorrect patient or places an incorrect label on a tube, the phlebotomist is subject to receive a "decision day" which is a paid day off to think about the error and to present an Impact Report which consists of a written and oral report of the clinical, personal and organizational impact of the error. A second mislabel event requires an Impact Report and 5 days of retraining during which time the phlebotomist cannot draw or label specimens. A third mislabel event is subject to termination. The responding blood banker says that she personally thinks the above disciplinary approach is too strict. What do others think?

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator