1. This case was waiting for making decision in admission to the hospital. By the way, nurse had key lab of admission order in the system already but did not print lab episode number label.
2. Another nurse prepared tube lab without labeling and handed to nurse who was collecting the blood sample.
3. Not follow the identification policy when we will give various procedure.
4. Nurse who sent lab to laboratory department did not second verify again before sending tube lab.
5. The situation at that time we had many cases in Emergency department.