During a busy day in Duke Clinic 3K (Dermatology) in January 2010, specimen labels for two patients were inadvertently swapped.

Though a DNA-based test was able to confirm which specimen went with which patient, the patient safety event triggered a root cause analysis to identify the factors that contributed to the event and establish steps to avoid similar events in the future.

Kelly Nelson, MD, medical director of Clinic 3K, and the PDC Accreditation and Patient Safety group looked for opportunities to improve specimen labeling within the clinic. She answers questions related to how they've improved labeling.

Describe how you approached the analysis of the labeling process.

Nelson: During the root cause analysis, we mapped out all of the steps that take place every time a provider in our clinic decides to perform a skin biopsy.

We then identified “forced functions” to remind team members about essential safety events; for example, before we put a patient label on the specimen bottle, we ask the patient to tell us their name and date of birth, and we double-check the accuracy of their label.

The Safety Committee for the Department of Dermatology, made up of medical assistants, registered nurses, nurse managers, and resident physicians, refined the essential steps and discussed our recommendations at a Grand Rounds presentation. The department faculty, residents, and nursing staff provided us with critical feedback and suggestions for improvement.

Once we developed a plan that everyone felt was suitable, we trialed and refined the new labeling process in my clinic before launching it to the department as a whole, which happened about eight weeks after the originating specimen labeling event. 

What were some of the goals you had in mind with this project?

Nelson: Our first (and largest) goal was to improve the specimen labeling process, but we have since identified other areas for improvement within the department.

We have created an environment where discussing opportunities for continuous improvement is “safe.” The entire faculty and staff have observed our open, respectful, and collaborative discussions about high-quality and safe patient care, which has empowered all members of our care team to speak up with concerns about patient safety.

Could you describe the feedback thus far?

Nelson: The feedback has been profoundly positive. We have seen a significant decline in the number of specimen labeling events, despite adding a new off-site clinic (Duke Dermatology at Patterson Place), hiring four providers, and generating over 6,400 specimens per year.

Dr. Sean Thomas, one of our senior residents, and I presented our specimen labeling initiative and preliminary data at the Duke Medicine Patient Safety and Quality Conference and were very honored to be recognized as an outstanding Patient Safety presentation. It has also been very rewarding to share our straightforward, low-cost initiative with other Duke departments.