Running head: FAILURE TO LABEL

Failure to Label Patient Specimens and Medications

Chantell Copeland
Santa Fe College: Fundamentals of Health Research Methods (HSA 4700) Prof. Steven Arnett
August 11, 2015

Running head: FAILURE TO LABEL

Abstract
This paper provides an assessment of the effects of improperly labeling patient specimens and
medications. This paper provides scenarios as well as examples of how to properly implement
the success of an almost error free labeling system. In healthcare, human error is very likely due
to people being imperfect. In regards to labeling patient specimens and medications, studies have
indicated that this can affect health outcomes, cause death and put patients as well as healthcare
facilities at risk. in order to ensure satisfactory patient care, healthcare facilities have protocols
and procedures set in place to produce safe effective healthcare. Identifying the correct patient,
taking the right specimens and correctly labeling patient specimens are key factors in the
execution of satisfactory patient care. Between July 2011 and December 2011, 813 wrong-patient
medication errors were reported to the Pennsylvania Patient Safety Authority. With labeling
being a key factor in identifying and treating a patient, the large amount of errors contributes to
the amount of negative healthcare outcomes.

Keywords: satisfactory patient care, label and specimens, outcomes, affect

Running head: FAILURE TO LABEL

The purpose of this paper is to explore the various affects that incorrect patient specimen
and medication labeling can have in healthcare as well as describe solutions to limit such errors.
The articles selected state facts about the effects on these types of errors as well as present real
life situations that have occurred and their outcomes.
In order to ensure satisfactory patient care, healthcare facilities have protocols and
procedures set in place to produce safe effective healthcare. Identifying the correct patient, taking
the right specimens and correctly labeling patient specimens are key factors in the execution of
satisfactory patient care. Mislabeled specimens is a frequent source of harm to patients.
Examples include repeat specimen samples, wrongful diagnoses, execution of an unnecessary
procedure or a delay in a necessary procedure (Dunn & Moga, 2010).
Incorrect patient specimen labeling and wrongful administration of medication is
researched majorly based off of real life cases that have had a huge adverse affect which caused
harm to patients. Reported cases involving these issues proves a wide variety of potential
scenarios and how they can be prevented and handled in case they reoccur again in the future. In
healthcare, research is constantly being conducted in various areas to simply improve healthcare
overall. No matter how small the increase or improvement, it can have a large impact on
healthcare quality.
In the year 2011, within 6 months, 813 wrong-patient medication errors were reported to
the Pennsylvania Patient Safety Authority (Grissinger, 2013, p.1). These reports were examined
to organize the events by related processes, possible causes, and contributing factors and to
determine patterns and noteworthy cases (Grissinger, 2013, p. 1). Majority of the errors occurred
during transcribing, which means when the doctor writes out the prescription. The errors least

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occurred during dispensing meaning when the medications were disbursed to the patients, it
usually went to the correct patient. Antibiotics, pain relievers, and blood thinners were the most
common types of medications associated with wrong-patient events (Grissinger, 2013, p. 1). A
lot of things can contribute to this type of event happening. Healthcare facilities can be hectic
work environments which can cause a lot of distractions and leave room for error. Many
healthcare workers say being over worked or understaffed contributes to the amount of errors
that take place in patient care. The most common mistakes are two similar patients being
prescribed the same medication either because they have similar names or similar conditions
however different allergen lists. Improper verification of patient identification; being unaware of
if the person is the correct patient, and similar room numbers (Grissinger, 2013, p. 1). Strategies
use to lower the risk production in a healthcare facility include ensuring proper storage of
medications and patient-specific documents, utilizing healthcare technology fully, for example
electronic healthcare records, limiting verbal orders, and improving patient verification
throughout the medication-use process (Grissinger, 2013, p. 1).
Ethically speaking labeling patient specimens and or administering the wrong medication
due to improper labeling is indeed a form of negligence even if it is unintentional. Healthcare
facilities have to maintain and improve protocols in order to limit human error. Although it is
almost impossible to insure mistakes like these will not happen, there are strategies and
procedures that can contribute to lessoning the amount.
According to Lee Moran from the New York Daily News, a brain tumor patient died
suddenly in an Oregon hospital's emergency room (ER) after she was mistakenly given the
wrong drug through her IV supply. The name of the patient was Loretta Macpherson whom died
at St. Charles Medical Center after she was accidentally given a paralyzing drug normally, used

Running head: FAILURE TO LABEL

during surgeries, instead of the anti-seizure medication that she needed, which is the standard
protocol. This error occurred because the pharmaceutical technician labeled the medication with
the wrong label, the nurse administered the drug and the patient died because she received the
wrong drug. The hospital takes full responsibility and acknowledges their error, but it can not
change the outcome of the situation. All of the parties involved in the case were suspended from
work with pay (Moran, 2014).
This article allows ethics issues to surface in a big way in regards to incorrect labeling in
healthcare. Questions such as should the employees involved be fired? Should the family of the
deceased sue the hospital for negligence? Why were there not any procedures already in place to
prevent something like this from happening to patients? Opinions vary on whether or not the
employees should have gotten fired but by law, the hospital can be sued for negligence.
Negligence is the failure or omission to perform professional duties to an accepted standard of
care which can involve doing something carelessly or failing to do something that should have
been done (Fremgen, 2013, p. 39). In this particular case, there may not have been any
intentional carelessness, but the actions displayed that not everything was carefully considered.
As I stated above, there can be many distractions in a busy healthcare facility and St. Charles
Medical Center feels as though this fact contributed to the error that was made. Amongst other
changes, the facility created a "safety zone" where pharmacists and technicians can work that has
a limited if not eliminated all distractions and the implementation of a new checking system for
paralytic and mislabeled drugs (Moran, 2014). The article does not state what previous
precautions the facility had in place to prevent such errors but they do reassure that they are on a
preventive path.

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Ethics in healthcare can be a very sensitive subject. The laws definition of ethics may
sometimes always go against someones personal beliefs which makes it vey difficult to make
certain decisions sometimes. The employees in the above example did recent leave with pay
which indicates that they still had jobs and the punishment was them being prohibited to work or
do their career choice of passion. Ethics, in this case raises questions such as was this the correct
repercussions for the actions taken? How many patient error mistakes can happen before
someone is reprimanded more? Ethically speaking in healthcare their is a huge line between
intent to harm and a very unfortunate mistake. Studies show that people are more likely to be
compassionate and understanding to a medical error that takes places in a facility that does not
have as many fatal mistakes.
The overall solution to this issue is following effective procedures and systems that
allows for people to double check and reassure that patient labeled specimens and medications
are properly labeled. A study was conducted on a new barcoding method using technology that
created a way to minimize labeling errors. Guaranteeing accurate patient recognition in
healthcare is essential to preventing medical errors and inaccurate specimen process, but it can
be challenging. The American Journal of Clinical Pathology executed a barcode based, positive
patient recognition system for use in inpatient blood and specimen collection as a test to see if
this method would be sufficient in lowering the rate of incorrect patient labeling. various
approaches were conducted to determine the impact of the patient recognition on the amount of
mislabeled and or unlabeled specimens that managed to make it through the laboratory. Labeling
errors fell from 5.45 in 10,000 before project execution to 3.2 in 10,000 afterward project
execution. approximate 108 improper labeling events were prevented by the improvement of the
patient recognition system in just one year. Through the research a manual step that technicians

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had to take to reprint multiple labels was eliminated. Eliminating this step also helped to
decrease errors by one fourth. This contributes to the conclusion that human error is a
contributing factor to the overall numbers. After executing the system, a higher number of
patients reported having their wristband checked before they had their blood drawn. Bar code
technology significantly reduced specimen identification errors by eliminated small manual steps
that left room for much human error.
This study that was conducted made a huge impact on patient labeling errors, therefore it
can be considered to be a reliable solution to the problem. The barcode system allows technicians
to print the labels, scan them and the computer is able to double check and assist in identify if the
label matches. This system isnt just computerized, technicians and healthcare workers still have
to check who the patient is and what exactly is supposed to be taken. The bar-coding system just
makes it easier to keep track of every specimen that is attached to one patient.
The bar-coding system, 2-person check and a safety zone are all methods that can be used
to solve the issue of improper patient and medication labeling. There is enough information to
find this study effective simply because it is such an easy error to make. There are tons of stories
and real life events that take place every year that contribute to being able to research into the
elimination of this type of error. Healthcare will always be hands on so there will always be room
for human error however, there have been proven ways to lesson the amount. The methods that
have been created to limit this error rely solely on the execution of the procedures by the
healthcare providers. Statistics show in the bar-coding system that the execution of the program
cut errors in almost half in just a year. This shows promise that after years of execution and
perfection, this error can be reduced to small minimum. Conclusions that can be drawn from the
research is that this is a human error that wont be completely eliminated as long as humans are

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working on other humans in healthcare. It does indicate that through better working conditions,
proper protocols, and execution of programs, this problem can be minimized drastically.
From the ethical point of view, this study did not violate any ethic issues or laws. The
study was conducted through observing the events at a healthcare facility with and without the
implementation of the patient recognition system. This means that statistics derived from real life
events that would have otherwise taken place regardless of the study. The positive effects of the
study can argue that the study prevented a large amount of potential labeling errors while
successfully implementing a new system. From this study alone, enough evidence was provided
to display the errors in the healthcare system as it relates to patient labeling, create an effective
method that would lower the amount of errors as well as create room for other ideas to surface.
Technology provides a consistency that humans cannot. limiting the amount of information that a
person has to put or the amount of steps that they have to go through to label a specimen
automatically lowers the risk of mistake. making the process completely electronic almost makes
in error proof. The increase in the technology supports the increase in the success of the
implemented project.
Failure to label patient specimens and medications is a common mistake in todays
American healthcare system. Specimens can include blood draws, urine and fecal samples and
biopsies. Each example respectively being significant because of the need for the specimen. How
do these mistakes happen? is a question that is presented and answered along with various
studies, ideas, analysis on the causes and the effects of improper labeling. Medications have a
large effect on the number of mislabeled items in healthcare. Providing the patient with the
wrong type of medication such as a paralytic can ultimately be fatal for the patient. The
healthcare system is currently aiming to perfect the misuse and inaccuracy of patient specimen

Running head: FAILURE TO LABEL

and medication labeling. With the efforts to eliminate this issue along with the increased amount
of technology, the United States healthcare system is moving towards safer more efficient care
provision.

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10

References
Dunn, E. J., & Moga, P. J. (2010). Patient misidentification in laboratory medicine. Archives of
Pathology & Laboratory Medicine, 134(2), 244-255. Retrieved from
http://eds.a.ebscohost.com.ezproxyprod.sfcollege.edu/ehost/detail/detail?
Fremgen, B. F. (2012). Medical law and ethics (4th ed.). Upper Saddle River, NJ:Pearson.
Lippi, G., Sonntag, O., & Plebani, M. (2011). Appropriate labelling of blood collection tubes: a
step ahead towards patient's safety. Clinical Chemistry & Laboratory Medicine, 49(12),
1921-1923. doi:10.1515/CCLM.2011.7361. Retrieved from:
http://eds.a.ebscohost.com.ezproxyprod.sfcollege.edu/ehost/detail/detail?
vid=6&sid=504b978c-50ac-404d-a343cf7a0c94a534%40sessionmgr4004&hid=4111&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY
29wZT 1zaXRl#db=a9h&AN=75212309"
Moran, L. (2014). Oregon brain surgery patient dies after being given wrong drug. Retrieved
from: http://www.nydailynews.com/news/national/brain-surgery-patient-dies-wrongdrug-article-1.2038982