College of American Pathologists
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Multilayered ID at Mass General

Rooting out ‘invisible’ blood collection errors

December 2003
Karen Lusky

At Massachusetts General Hospital, redundancies are built in to prevent patient misidentification. Errors that may be missed at the reception level can be discovered at the accessioning level. But "the final and ultimate responsibility remains with the phlebotomist who would be held responsible for an identification error," says George Souza, supervisor for clinical support services for the MGH laboratory.

The phlebotomist holds the order, a hospital-issued patient data card, and associated labels. The patient, who is prevented from seeing the materials, is asked to spell his or her last name. If done correctly, the phlebotomist asks for the first name and then the date of birth. The phlebotomist then makes sure all labels, orders, and patient card match. If a discrepancy is found, the procedure doesn’t continue and further inquiries are made of the patient and his or her provider. When the phlebotomy procedure is completed, the patient’s card is returned with one more request to ensure that the card belongs to the patient. Labeled tubes are checked again against the requisition.

Karen Lusky is a writer in Brentwood, Tenn.