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Challenged with persistent specimen labeling errors that were resistant to improvement efforts, our organization selected "reducing specimen labeling errors" as an indicator for a hospital-wide error reduction goal. Modeling quality improvement guidelines published in the institute of Medicine's report "To Err is Human, Building a Safer Health System," a multidisciplinary task force "error proofed" processes. The task force created new standards and crafted an implementation plan using an internal marketing strategy to change current practices and reinforce patient safety as a core value within our institution. This unique approach reduced errors by 41% and provided learning opportunities that will be valuable in more challenging patient safety initiatives such as medication error reduction. |
