Reduction in specimen labeling errors after implementation of a positive patient identification system in phlebotomy

Am J Clin Pathol. 2010 Jun;133(6):870-7. doi: 10.1309/AJCPC95YYMSLLRCX.


Ensuring accurate patient identification is central to preventing medical errors, but it can be challenging. We implemented a bar code-based positive patient identification system for use in inpatient phlebotomy. A before-after design was used to evaluate the impact of the identification system on the frequency of mislabeled and unlabeled samples reported in our laboratory. Labeling errors fell from 5.45 in 10,000 before implementation to 3.2 in 10,000 afterward (P = .0013). An estimated 108 mislabeling events were prevented by the identification system in 1 year. Furthermore, a workflow step requiring manual preprinting of labels, which was accompanied by potential labeling errors in about one quarter of blood "draws," was removed as a result of the new system. After implementation, a higher percentage of patients reported having their wristband checked before phlebotomy. Bar code technology significantly reduced the rate of specimen identification errors.

MeSH terms

  • Academic Medical Centers
  • Boston
  • Electronic Data Processing
  • Humans
  • Medical Errors / prevention & control*
  • Patient Identification Systems*
  • Phlebotomy / methods*
  • Specimen Handling / methods
  • Workflow