# An RN has just completed venipuncture for blood specimens on four assigned patients during morning rounds and brings the unlabeled tubes to the nursing station to label them all together. Which is the safest action?

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> subject: Performance Improvement  
> category: MOC

## Question

An RN has just completed venipuncture for blood specimens on four assigned patients during morning rounds and brings the unlabeled tubes to the nursing station to label them all together. Which is the safest action?

## Option

1. Take the unlabeled tubes to the clinical laboratory and label them there using the printed laboratory requisitions.
2. Label the four sets of tubes at the nursing station, double-checking each against the printed orders before pickup.
3. Have a second RN at the nursing station witness each label to reduce specimen mix-up.
4. Take the tubes back to each patient's bedside and label them at the point of care after re-verifying two patient identifiers. **✔ Correct answer**

**Correct answer: 4**

## Explanation

The Joint Commission National Patient Safety Goal NPSG.01.01.01 (improve the accuracy of patient identification) and CLSI GP33 require that specimen tubes be labeled at the bedside, immediately after collection, after verifying two unique patient identifiers (such as full name and date of birth) against the patient's wristband and the patient's self-stated identifiers when possible. Carrying unlabeled specimens to a central area is a leading cause of mislabeling sentinel events that result in transfusion of incompatible blood, missed diagnoses, and treatment of the wrong patient. Choices 1, 2, and 3 violate point-of-care labeling by moving specimens to a location distant from the patient before labeling. Choice 1 sends unlabeled tubes to the laboratory, where staff cannot verify from which patient each tube was drawn; even with printed orders, the chain of identification is broken. Choice 2 attempts labeling at the nursing station with order cross-checking, but this still breaks the bedside labeling requirement. Choice 3 adds a witness at the nursing station, which does not correct the fundamental error of labeling away from the patient. Only choice 4 rectifies the breach by returning to the bedside, re-verifying two identifiers, and labeling at the point of care.

## In-depth explanation

Specimen mislabeling is one of the most preventable causes of harm in hospitals. The principle is "label the tube in the presence of the patient, immediately after collection, before leaving the room." Two-identifier verification must occur at the point of labeling, not at the nursing station — otherwise the chain of identification is broken. Bringing unlabeled tubes to a central area, even with a witness, is the precise scenario described in multiple Joint Commission sentinel event alerts on wrong-blood-in-tube events. The right corrective action is to take the tubes back to each bedside, re-verify identity, and label there.

## Clinical scenario

An RN has just completed **venipuncture for blood specimens** on **four assigned patients** during morning rounds. The unlabeled tubes are in a tray at the nursing station, and the printed laboratory orders are laid out next to them.

## Key concepts

- **Two-Identifier Verification** — Joint Commission NPSG.01.01.01 standard requiring two unique patient identifiers (commonly full name and date of birth, or medical record number) to be confirmed before any specimen, medication, treatment, or transfusion. Identifiers must be verified at the point of care, not at a central station.
- **Point-of-Care Labeling** — Practice of labeling specimens at the bedside, in the presence of the patient, immediately after collection. Required by CLSI GP33 and Joint Commission to prevent specimen mix-ups, particularly for blood bank samples where mislabeling can cause fatal hemolytic transfusion reactions.
- **Wrong-Blood-in-Tube (WBIT) Error** — A specimen labeled with the identity of a different patient than the source of the blood. A leading cause of fatal ABO-incompatible transfusion. Almost always preventable by strict point-of-care labeling and two-identifier verification.

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