War on Errors
April 1, 2011 | In: I've Been Thinking
I’ve been thinking about pacifism, catechism, patient-recollection, and specimen-collection.
Unfortunately, it’s easy to become insensitive to statistics about lives taken by bullets and bombs. Similarly, it’s easy to grow numb to oft-rehearsed statistics like seven thousand patients dying each year from medication errors, which happens to be nearly seven times the U.S. troops we lost each year at the peak of the war in Iraq.
This is to say nothing of patients injured and lives lost from specimen-collection errors and laboratory mix-ups. Has anyone seen statistics on this? I’ve not been able to dig up the data, but the media has put a human face on the problem for us.
In July 2006, Darrie Eason, a 35-year-old New York patient, received a radical double mastectomy to save her from cancer that she never had. At the same time, another woman’s diagnosis and treatment were delayed—all because tissue samples got mixed up in the process.
While I don’t know all the details behind this tragedy, we all know it’s possible to mislabel specimens while collecting them at bedsides and to mix them up during testing in labs. We also know that clinicians and technicians do not deliberately misidentify specimens.
UPS and FedEx get the right packages to the right parties by utilizing bar-code technology from sending to receiving and at all points between—from label printing and pickups to transfers and drop-offs.
Given the state of technology, I’m convinced bar-code labels for specimens should be generated by scanning patient wristbands and immediately applied to vials at points of collection. Inside the lab, specimens should be scanned at all points of receipt, storage, and retrieval. When testing is completed, results should likewise be entered into patients’ medical records by scanning bar codes on the labels. And any hardcopy reports generated should be populated with bar codes for matching documents with patients during clinical activities.
In catechism many of us learned about sins of commission (forgive us for what we have done) and omission (forgive us for what we have left undone).
We are quick to blame people for what they have done in mislabeling specimens and misidentifying patients. Maybe we should think about the ramifications of dragging our feet when it comes to implementing readily available bar-code safety systems. By knowing such error-prevention technology exists and not implementing it, are we approaching guilt for leaving undone what ought to have been done?
We could argue over going to war, but properly matching patients with specimens is a matter of homeland security around which we all can rally. We may polarize over U.S. policy in the Middle East, but in our hospitals we all are on the same side—fighting to protect the lives of men and women, boys and girls. There is no place for pacifists in the war on medical errors.
We are fighting a good fight.
What do you think?
Mark Neuenschwander a.k.a. Noosh
Copyright 2011 The Neuenschwander Company
1 Response to War on Errors
Dennis Tribble
April 14th, 2011 at 11:56 am
Mark,
I find myself aghast that this could happen in this day and age. I worked in the HIS and LIS marketplace in the late 1980’s, and the use of bar codes for specimen tracking was known and commonplace in 1986. That something like this should have happened in 2006 seems nothing short of unforgivable, not for the people who were placed in harm’s way by lacking this support, but by the people whose sense of economy put those patient’s at risk.