Medical Assistant Prep / Unit 21 MAS 520 review, 2 to 3 minutes
A Labeling Near Miss
The idea
This case is constructed for this course. It shows how labeling at the point of collection catches an identity error that labeling the tubes ahead of time would have missed entirely.
In practice
Two patients with the same last name are scheduled for blood draws ten minutes apart. To save time, a coworker suggests printing both sets of labels at once and sticking them on the tubes ahead of time. The medical assistant declines, explaining that the practice labels tubes immediately after collection, in front of the patient. When the first patient sits down, she asks him to state his full name and date of birth. He gives a date of birth that does not match the label waiting on the printer. The label belongs to the second patient. She prints his correct labels, draws his blood, and labels each tube in front of him. She checks each label against his requisition before sending the specimens. Had the tubes been prelabeled, his blood would have gone to the laboratory under the other patient's name, and the error might never have been noticed. She reports the near miss through the practice's incident process, because two similar names on one morning's schedule is a known risk the team can plan for.
Where people slip
Labeling at the point of collection is not a formality. It is the moment when the identity check, the specimen and the label meet, in front of the patient. Any shortcut that moves labeling away from that moment removes the protection it provides. A wrong label is worse than no label, because nobody downstream has any reason to question it, and a provider could act on another patient's result.
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