At Mayo Clinic, RFID Slashes Error Rate

Prior to employing the RFID tags and database, she notes, the endoscopy unit used only paper labels affixed to the bottles. In addition to having human-readable printed text, the labels also typically contained handwritten patient information and lab instructions. But such manual procedures were prone to errors. "The RFID system has allowed the practice to step away from an old habit of adding handwriting to the printed labels," Sanderson states. "All of that information—any that may have been added to the printed label, after the fact—is now managed by the RFID system."

The endoscopy unit sent 8,231 specimen bottles to the pathology lab for evaluation during the first three months of 2007, and 8,539 in the first three months of 2008. The specimen-labeling errors were categorized as Class 1 (only typographical, with no potential patient-care consequences), Class 2 (minor errors, unlikely to have patient-care consequences) and Class 3 (significant errors with the potential to detrimentally impact patient care, such as a bottle with no specimen label, or one containing a label printed with information pertaining to the wrong patient).

Dr. Dawn Francis

Compared with a total of 765 errors (a rate of 9.29 errors per 100 bottles) during the 2007 evaluation, only 47 errors (an error rate of 0.55 per 100 bottles) were noted in the same period this year. In the first quarter of 2007, 646 (7.85 percent) of the errors were Class 1; 112 (1.36 percent) were Class 2; and seven (0.09 percent) were Class 3. In the first quarter of 2008, 35 (0.41 percent) were Class 1; 10 (0.12 percent) were Class 2; and two (0.02 percent) were Class 3.

"Class 2 errors are unlikely a problem, but there is the potential," Francis says. "An example is if the specimen bottle label said 'stomach,' but what the nurse entered into the database was a certain part of the stomach. How that might occur is that, at the time the biopsy was taken, the nurse entered into the computer 'stomach,' and printed out the label, at which time the doctor said the biopsies were taken from the stomach. Then the doctor later might be more specific and say the biopsies are from the antrum of stomach, and while the nurse made the change in the computer, a new label wasn't printed out."

Regarding the two Class 3 errors found in the first quarter of 2008, workers caught the mistakes in both instances and used the RFID system to rectify them.

Francis says she and her colleagues weren't surprised with the study's findings. "We certainly were pleased," she says. "We had to do something that eliminates human error, and [RFID] was our best option. RFID offers a redundancy mechanism."