How Much Do Your Mistakes Cost?

2718 Words Nov 22nd, 2014 11 Pages
How Much Do Your Mistakes Cost?
Brittney Roper, R.N.
Southwestern Oklahoma State University

Introduction

Proper patient identification in hospitals has been an issue for many years, especially when it comes to blood specimen collection. Laboratory specimens being mislabeled are a everyday cause of harm to patients including repeat diagnostic procedures; repeat phlebotomy; delays in necessary surgical procedures; a performing unnecessary surgical procedures (Dunn and Moga, 2010). This is not only costly, but it is very stressing to patients and medical staff. The biggest concern is the possibility of making a fatal error when it comes to specimen collection. Without proper patient identification this risk
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This is one of the most creative aspects of the job of the change agent by being sensitive to the change forces and forces of resistance continuously throughout the change process (Yoder-Wise, 2011). According to Mitchell (2013), Lippitt’s theory is similar to the nursing process of assessment, planning, implementation, and evaluation. The first three phases of Lippitt’s theory are essentially the assessment phase; the next two are the planning phase; the next is the implementation phase; and the last is the evaluation phase of the implemented change (Mitchell, 2013).
Assessment
The need for this change was recognized when the unit would receive numerous calls per shift about mislabeled or unlabeled lab specimens. Some mislabeled labs would not be caught until the lab had already been run and the results were not consistent with the patient’s previous labs. Nurses would then be required to recollect these labs taking more time out of their shift, and delaying any needs the patient may have due to the labs. Even though not all mislabeled specimens lead to adverse effects for the patient, it is very costly for the hospital to run the mislabeled specimens. For example, a Complete Blood Count (CBC) cost $300, a Complete Metabolic Panel (CMP) costs $500,
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