This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.
This monthly commentary examines risks associated with mismanagement of IV tubing and ports, discusses a recent article regarding unintended consequences of computerized provider order entry (CPOE), and details recent changes to similarly named medications.
Skibinski KA, White BA, Lin LI-K, et al. Am J Health Syst Pharm. 2007;64:90-6.
The authors implemented technologies supporting safe medication use and observed improved patient identification, decreased turnaround time for orders, and increased accuracy of medication administration.
A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.
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