NR 449 Week 5 Specimen Labeling Barrier Analysis Example

Labeling the Tube at the Bedside: A Barrier Analysis of Specimen Identification on a Medical Unit

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College of Nursing, Chamberlain University

NR 449: Evidence Based Practice

Instructor Name

Month Day, Year

Labeling the Tube at the Bedside: A Barrier Analysis of Specimen Identification on a Medical Unit

The Behavior and the Standard

The behavior analyzed here is labeling a blood specimen tube at the patient's bedside, in the patient's presence, immediately after the draw, after confirming two patient identifiers. The standard is not in dispute. The Joint Commission's national patient safety goals require at least two patient identifiers when collecting blood samples and labeling containers in the presence of the patient (The Joint Commission, 2024), and wrong blood in tube, a specimen drawn from one patient and labeled with another patient's details, is a recognized cause of incompatible transfusions and misdiagnosis (Bolton-Maggs et al., 2015). On a composite 30-bed medical unit, nurses draw about a third of blood specimens, mostly outside the phlebotomy team's morning round. In the past year the laboratory rejected 41 nurse-drawn specimens for labeling errors, and two wrong blood in tube events were caught when a blood type did not match the patient's historical type.

The approach here is to walk the task, record every move and its cost in time, and then sort each obstacle into one of three categories: a knowledge problem, meaning the nurse does not know what to do; a capability problem, meaning the nurse knows but the environment or the tools make it hard; and a cost problem, meaning the nurse can do it but it costs something the nurse is unwilling or unable to spend at that moment. The categories are close to the capability and opportunity components of the COM-B model of behavior, which holds that a behavior depends on capability, opportunity and motivation together (Michie et al., 2011).

Walking the Task

Move 1, print labels (1 to 4 minutes): The unit's label printer is at the nurses' station, not at the bedside. The nurse must print the labels at the station before or after the draw.

Move 2, carry labels to the room (30 seconds to 2 minutes): If labels are printed first, they are carried to the room, sometimes with labels for more than one patient.

Move 3, confirm two identifiers (20 seconds): Ask the patient's name and date of birth and compare with the wristband and the label.

Move 4, draw the specimen (3 to 8 minutes): Venipuncture or a draw from an existing line.

Move 5, label the tubes (30 seconds): Apply labels, write the time and initial them.

Move 6, scan and send (1 to 2 minutes): Scan the tube at the station and send it by pneumatic tube.

Walking the task on six draws across day and night shifts showed that the total time ranged from 7 to 16 minutes, and that the longest delays came from moves 1 and 2, when the printer was jammed, out of labels or already printing another nurse's job.

Obstacles, Sorted and Defended

Knowledge. Only one obstacle belongs here. Newer nurses were unsure whether a specimen drawn from a central line could be labeled after returning to the station if the patient was asleep, and the unit policy does not address it. Every nurse observed knew that two identifiers were required and that labeling should happen at the bedside. Education alone would therefore address a small part of the problem.

Capability. Most obstacles belong here. The printer is at the station, so the correct sequence, draw first and then label at the bedside, requires printing labels before the draw and carrying them in, which invites mixing labels for more than one patient. When the printer jams or runs out, a nurse who has already drawn the blood faces a choice between leaving the tubes unlabeled in the room and walking out with unlabeled tubes to print, both of which violate the standard. Asleep and confused patients cannot state their name and date of birth, and the policy gives no alternative for them other than the wristband, which some patients remove. At night, the room lights are off, and reading the small print on a label next to a wristband is hard without waking the patient.

Cost. Two obstacles belong here. At night, nurses avoid waking patients to state their names, trading patient sleep against a check the patient cannot always perform anyway. During busy periods, batching labels for several patients saves trips to the printer, and the minutes saved are real.

Workarounds as Evidence

Two workarounds were observed, and both are reports about obstacles rather than faults. First, some nurses print labels for all their morning draws at once and carry them in a pocket, sorted by room. This workaround exists because the printer is far away and often busy, and it is the workaround most likely to produce a wrong blood in tube error, because a pocket full of labels for several patients is exactly the situation in which a label is applied to the wrong tube. Second, some nurses at night label the tubes in the room by flashlight from their phones, which shows a determination to label at the bedside in spite of poor light. The first workaround points to where the unit's risk comes from; the second points to what nurses are already willing to do if the environment helps them.

The Version That Exists at Night

Night conditions change the task in three ways that the day version does not show: sleeping patients who cannot state identifiers, darkness in the room, and a single nurse for five or six patients with no one to fetch labels. Of the 41 rejected specimens last year, the laboratory's records show that 26 were collected between 2200 and 0600. The analysis would miss most of the problem if it described only the day routine.

What the Analysis Points To

Because most obstacles are capability problems, the solution is mainly a change to the environment, not to knowledge. A unit that moved label printing to the bedside with handheld scanners and small portable printers reported fewer mislabeled specimens after the change (Brown et al., 2011), which fits this analysis: the tool removes the move that creates the pocket of labels. Smaller changes would also help: a second label printer near the far end of the unit, a policy for identifying sleeping or confused patients using the wristband and a second staff member, and a clip-on light for night draws. Education should be brief and aimed at the one real knowledge gap, central line draws on sleeping patients. An in-service that tells nurses what they already know would add nothing.

References

Bolton-Maggs, P. H. B., Wood, E. M., & Wiersum-Osselton, J. C. (2015). Wrong blood in tube: Potential for serious outcomes: Can it be prevented? British Journal of Haematology, 168(1), 3-13. https://doi.org/10.1111/bjh.13137

Brown, J. E., Smith, N., & Sherfy, B. R. (2011). Decreasing mislabeled laboratory specimens using barcode technology and bedside printers. Journal of Nursing Care Quality, 26(1), 13-21. https://doi.org/10.1097/NCQ.0b013e3181e4e6dd

Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, Article 42. https://doi.org/10.1186/1748-5908-6-42

The Joint Commission. (2024). National patient safety goals effective January 2024: Hospital program. https://www.jointcommission.org/standards/national-patient-safety-goals/