Friday, 21 August 2009

Clinical samples 'wrongly labelled'

Tens of thousands of clinical samples were wrongly labelled when they arrived at NHS pathology laboratories, an investigation has found.

A further 11,712 specimens were incorrectly labelled by lab staff, according to information reportedly obtained under the Freedom of Information Act. The survey of every NHS trust, of which 120 replied, found 365,608 specimens were mislabelled before they arrived at laboratories.

More4 News, who obtained the information, also reported 46 cases had been recorded where mislabelling was found to be related to delays in patients' treatment and even deaths...
Source: The Metro


Witterings From Witney said...

This was in the Telegraph too. Have been a tad busy today and was going to send you the t'graph link now that I have got round to the blogging bit of the day!

Prisoner of Hope said...

A few years back while I was still an optimistic Patient Governor at the local Acute Foundation Trust one (of the very few) examples of good clinical audit and of staff still exercising local initiative was a "Get It Write" exercise to improve the accuracy of specimin labelling.

With all the auto analysers in use in the centralised city wide path lab, apparantly it was possible to detect some individual markers among discrete samples and identify (with a high degree of accuracy) if they were from the same individual. So by comparing a sample of these and recording the actual patient ID on the labels (not all hand-written btw - sometimes the wrong pre-printed label can get attached!) it was possible to identify the error rate among individual wards, departments and clinics. This was reported back and comparison bar charts used to show where each collection area fell. When repeated ater reporting back on this performance the error rate everywhere had fallen significantly.

For me this remains an example of how to improve quality and patient safety - by unstifling staff and letting them exercise some degree of local initiative.

The trouble occurs when good ideas like this are then foisted on to everyone from above (albeit with the best of intentions) when they are seen as interference and become a chore with no real commitment. Far better for such ideas to be disseminated as good practice and not imposed, monitored and then punished for non-compliance.

That way lies gaming, costly form filling, waste and demoralisation - in fact the essence of why Nu Labour has succeeded in "Putting Patients Last" as described in the Civitas essay by Peter Davies & James Gubb.