Butterworth Hospital Emergency Department – Misidentification of Specimens

The rate of misidentification of specimens had more than doubled over the course of 6 months in the Butterworth Emergency Department. The Spectrum Health definition of a specimen identification error is “one nurse collecting one or more specimens from the same patient at the same time that does not include two patient identifiers on the container or that has wrong patient identification on the container.” Lack of a standardized process for identification of specimens resulted in adverse patient safety events, increased cost, unnecessary inconvenience to the patient, decreased patient satisfaction, and increased length of stay (LOS). On average, the Butterworth Emergency department collects approximately 19,000 specimens per month. Of those, approximately 15,000 are collected by staff in the emergency department.

A team was formed in February 2016 with the intent to determine current state surrounding the process for labeling of specimens, identification of gaps within the current process, and to develop a strategy to decrease misidentification of specimens.

A lack of standard work surrounding the process for specimen collection and labeling was identified. This included multiple means of collecting specimens, many individuals handling collected specimens, as well as a lack of a double check process. In an already chaotic environment, full of many distractions, employees were looking in numerous places to find patient and lab labels. The team determined that the implementation of a standardized process for obtaining and labeling of specimens, handling of the specimens and double checking of specimens with a peer would improve the misidentification of specimen rate.

In March 2016, specific interventions were developed and implemented as part of the standard work for RN, Nurse Technician and the Unit Secretary. This included:

  • Hanging 4 patient labels in the patient room.
  • The individual collecting the specimen placing their Cerner ID on the specimen label after verifying 2 patient identifiers with patient.
  • A peer double check of the specimen and the placement of the peers Cerner ID on the specimen label.

Since implementation, the Butterworth Emergency Department has seen a 72% decrease in the number of misidentified specimens from 49 in the five months prior to interventions (Oct15-Feb16) to 14 in the five months post interventions (Jun16-Oct16).

This decrease in number of misidentified specimens results in a cost reduction as well, with an estimated monthly cost reduction of $364.00.


Team Members:

Jeff Skinner MHA, BSN, RN, CEN
Allison Gillett BSN, RN, CEN
Carrie Grassley RN, CEN
Tonja Moyer BSIE, SSMBB
April Serne BSN, RN, CEN, EMT-P
Katie Johnson BSN, RN
Ben Vairet NT
Jason Holtof BSN, RN
Jorge Zamuido-Mora BSN, RN
Raquel Martinez NT
Andreas Roiniotis MD