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Publication Date



2021 prov rn wa; 2021 prov rn poster; washington; spokane; pshmc




Background: Mislabeled specimen can cause patient harm by delaying treatment or by inappropriately administering treatment based on incorrectly assigned results. National patient safety goals have consistently called for a reduction of these errors in the hospital setting to zero. The specimen labeling errors on one inpatient department (IPD) at an acute care hospital in Eastern Washington were noted to be elevated from 2019 to 2020, potentially threatening patient safety. An evidence-based technique called the Red Rule has been linked to an improvement in lab labeling performance in the hospital setting.

Purpose/aims: The primary purpose of the QI project was to reduce specimen labeling errors in the identified IPD. The clinical question was, "In an IPD at a large acute care hospital, does implementing a standardized specimen labeling workflow, nursing education on the Red Rule, and updating monthly performance data with nursing staff, compared to usual care, reduce the occurrence rate of specimen labeling errors over 3-month period of implementation?"

Methods/Approach: The project lead collaborated with the Red Rule Advisory Committee to implement a Doctor of Nursing Practice (DNP) project focusing on the selected IPD. Interventions and data collection consisted of the following: (1) Standardizing workflow of specimen labeling process by the end of September 2020, (2) Formulating nursing education on the Red Rule by the end of October 2020, (3) Assigning nursing education to all RNs through an online learning platform to complete by the end of December 2020, (4) Sharing monthly data on specimen labeling errors from November 2020 to January 2021, and (5) Administering Pre- and post-interventions surveys in September 2020 and in February 2021 respectively to assess nursing staff perspectives on the new lab labeling process. Descriptive statistics was used for data analysis.

Results: A total of 32 nurses took the pre-intervention survey and indicated a low level of awareness and confidence on using the new Red Rule and lab labeling process. The biggest barrier on the new labeling compliance was lack of a pen in each patient room. A total of 41 nurses completed postintervention survey and reported increased confidence in using Red Rule and applying the new labeling process. Furthermore, the majority of nurses rated the pen placement in each workstation as moderately to extremely helpful for improving adherence. Following the intervention, the incidence of lab mislabeling errors on the IPD reduced significantly.

Conclusion: On the IPD, the implementation of an evidence-based Red Rule program was effective in reducing specimen labeling errors. The identification of the nursing-reported need for a pen in each patient room in order to effectively implement the new labeling process was a surprisingly simple yet powerful gap that was easily filled by this project.

Implications for practice: This project highlights the importance of assessing nursing perspectives on barriers to implementing change and supports that the Red Rule may be helpful in reducing lab labeling errors. Opportunities exist for future work to address gaps in following the new lab labeling process.




Pathology & Laboratory Medicine

Conference / Event Name

2021 Providence RN Conference


Virtual Conference

Reducing Specimen Labeling Errors to Promote Patient Safety: A Quality Improvement Project at an Inpatient Department in a Regional Acute Care Hospital

Included in

Nursing Commons