Pre-analytical Laboratory Errors Tim Guirl MT (ASCP) Phlebotomy Instructor North Seattle Community College Health & Human Services Division

Pre-analytical Pre-analytical Laboratory ErrorsLaboratory Errors

Tim Guirl MT (ASCP)Tim Guirl MT (ASCP)Phlebotomy InstructorPhlebotomy Instructor

North Seattle Community North Seattle Community CollegeCollege

Health & Human Services Health & Human Services DivisionDivision

ObjectivesObjectives

Identify the significant pre-analytical Identify the significant pre-analytical errors that can occur during blood errors that can occur during blood specimen collection and transportspecimen collection and transport

Explain the various means of pre-Explain the various means of pre-analytical error preventionanalytical error prevention

List proactive steps to reduce List proactive steps to reduce potential pre-analytical errors potential pre-analytical errors associated with blood collection and associated with blood collection and transporttransport

IntroductionIntroduction

Three phases of laboratory testing: Three phases of laboratory testing: pre-analytical, analytical and pre-analytical, analytical and post-analyticalpost-analytical

Pre-analytical—specimen collection, Pre-analytical—specimen collection, transport and processingtransport and processing

Analytical—testingAnalytical—testing Post-analytical—testing results Post-analytical—testing results

transmission, interpretation, follow-transmission, interpretation, follow-up, retesting.up, retesting.

PhlebotomyPhlebotomy ErrorsErrors

Phlebotomy is a highly complex skill Phlebotomy is a highly complex skill requiring expert knowledge, requiring expert knowledge, dexterity and critical judgmentdexterity and critical judgment

It is estimated that one billion It is estimated that one billion venipunctures are performed venipunctures are performed annually in the U.S.annually in the U.S.

Phlebotomy errors may cause harm Phlebotomy errors may cause harm to patients or result in needlestick to patients or result in needlestick injury to the phlebotomistinjury to the phlebotomist

Pre-analytical errorsPre-analytical errors Pre- and post-analytical errors are Pre- and post-analytical errors are

estimated to constitute 90% of errorsestimated to constitute 90% of errors Errors at any stage of the collection, Errors at any stage of the collection,

testing and reporting process can testing and reporting process can potentially lead to a serious patient potentially lead to a serious patient misdiagnosismisdiagnosis

Errors during the collection process are Errors during the collection process are not inevitable and can be prevented with not inevitable and can be prevented with a diligent application of quality control, a diligent application of quality control, continuing education and effective continuing education and effective collection systemscollection systems

Types of Collection Types of Collection ErrorsErrors

Patient IdentificationPatient Identification

Phlebotomy TechniquePhlebotomy Technique

Test Collection ProceduresTest Collection Procedures

Specimen TransportSpecimen Transport

Specimen ProcessingSpecimen Processing

Patient Identification Patient Identification ErrorsErrors

Errors in correctly identifying the Errors in correctly identifying the patient are indefensiblepatient are indefensible

Reasons for patient identification errorsReasons for patient identification errors Proper positive patient identification Proper positive patient identification

procedures not followedprocedures not followed Patient identification from identification Patient identification from identification

bracelet (inpatients)bracelet (inpatients) Patient identification by asking patients to Patient identification by asking patients to

state or spell their full name state or spell their full name (inpatients/outpatients)(inpatients/outpatients)

Patient identification by staff or family member Patient identification by staff or family member if patient unable to identify him/herselfif patient unable to identify him/herself


Specimen tubes unlabeledSpecimen tubes unlabeledRequisition or collection tube labels Requisition or collection tube labels not affixed to tubesnot affixed to tubes

Requisition or collection tube labels in Requisition or collection tube labels in bag containing collection tubesbag containing collection tubes

Requisition or collection tube labels Requisition or collection tube labels rubber-banded to tubesrubber-banded to tubes

Collection tube labels not affixed to all Collection tube labels not affixed to all tubestubes

Specimen collection tubes labeled Specimen collection tubes labeled insufficiently with at minimum patient’s full insufficiently with at minimum patient’s full name, date/time of collection, phlebotomist’s name, date/time of collection, phlebotomist’s initialsinitials


Collection tubes labeled with the Collection tubes labeled with the wrong patientwrong patient Wrong computerized labels affixed Wrong computerized labels affixed

to collection tubes at bedsideto collection tubes at bedside Collection tubes not labeled at the Collection tubes not labeled at the

time of collectiontime of collection Collection tubes incorrectly labeled Collection tubes incorrectly labeled

by someone other than the by someone other than the phlebotomist who collects the phlebotomist who collects the specimenspecimen

Patient ComplicationsPatient Complications

Some patient variables that affect Some patient variables that affect blood specimensblood specimens DietDiet

FastingFasting

ExerciseExercise ObesityObesity Allergies to alcohol or iodine used to Allergies to alcohol or iodine used to

clean venipuncture siteclean venipuncture site Use alternative cleanser such as Use alternative cleanser such as

chlorhexidinechlorhexidine

Phlebotomy Technique Phlebotomy Technique ErrorsErrors

Phlebotomy technique is importantPhlebotomy technique is important Ensures test result validityEnsures test result validity Minimizes trauma to patientMinimizes trauma to patient Minimizes potential for phlebotomist injuryMinimizes potential for phlebotomist injury Reduces recollectionsReduces recollections

Vein selection essential for successful Vein selection essential for successful venipuncturevenipuncture Three veins in antecubital fossa in order of Three veins in antecubital fossa in order of

selection (1) median cubital (2) cephalic (3) selection (1) median cubital (2) cephalic (3) basilicbasilic


Site SelectionSite Selection Avoid sites with IVAvoid sites with IV

Use alternative arm or draw below IV to avoid Use alternative arm or draw below IV to avoid contamination/dilution from IVcontamination/dilution from IV

Document arm if IVDocument arm if IV

Mastectomy—avoid site due to lymphostasisMastectomy—avoid site due to lymphostasis Infection risk/alteration in body fluids and blood Infection risk/alteration in body fluids and blood

analytesanalytes

Edematous areasEdematous areas — —avoid due to avoid due to accumulation of body fluidsaccumulation of body fluids Possible contamination/dilution of specimenPossible contamination/dilution of specimen


Venous Access DifficultiesVenous Access Difficulties Obstructed, hardened, scarred veinsObstructed, hardened, scarred veins Veins difficult to locateVeins difficult to locate Use of Alternative sitesUse of Alternative sites

Top of hand/Side of wristTop of hand/Side of wrist Areas to avoidAreas to avoid

Vein CollapseVein Collapse Use of appropriate needle size Use of appropriate needle size Smaller evacuated collection tubeSmaller evacuated collection tube


Tourniquet ApplicationTourniquet Application Tourniquet tied too close to the venipuncture Tourniquet tied too close to the venipuncture

site can cause hematomasite can cause hematoma Veins may not become prominent if Veins may not become prominent if

tourniquet is tied too high (more than 3 to 4 tourniquet is tied too high (more than 3 to 4 inches above venipuncture siteinches above venipuncture site))

Tourniquet left on longer than one minute Tourniquet left on longer than one minute can result in hemoconcentration, affecting can result in hemoconcentration, affecting some test resultssome test results Tourniquet should be released as soon as needle is Tourniquet should be released as soon as needle is

in the lumen of the vein and blood flow establishedin the lumen of the vein and blood flow established


Cleansing of venipuncture siteCleansing of venipuncture site Thorough cleaning with alcohol Thorough cleaning with alcohol Allow alcohol to dry completely to avoid Allow alcohol to dry completely to avoid

stinging sensation upon needle entry and stinging sensation upon needle entry and hemolysis of samplehemolysis of sample

Samples such as blood cultures should be Samples such as blood cultures should be collected using iodine to cleanse site to collected using iodine to cleanse site to ensure sterility of sampleensure sterility of sample

Recollection rate for blood cultures ranges due to Recollection rate for blood cultures ranges due to contamination is as high as 50% in hospitals with contamination is as high as 50% in hospitals with increased costs, patient overtreatmentincreased costs, patient overtreatment


Correct collection systemCorrect collection system Evacuated tube system (Vacutainer) for Evacuated tube system (Vacutainer) for

large veins in antecubital fossalarge veins in antecubital fossa Syringe for small, fragile veins or veins Syringe for small, fragile veins or veins

outside antecubital fossaoutside antecubital fossa Venous accessVenous access

Needle entry should be at 15 to 30 degrees Needle entry should be at 15 to 30 degrees depending on depth of veindepending on depth of vein

Needle entry should be in same direction as Needle entry should be in same direction as vein, centered over veinvein, centered over vein

Anchor vein to prevent movement during Anchor vein to prevent movement during needle entry and to reduce pain to patientneedle entry and to reduce pain to patient

Test Collection ErrorsTest Collection Errors Order of DrawOrder of Draw

Order of draw affects the quality of the sample Order of draw affects the quality of the sample and can lead to erroneous test results due to and can lead to erroneous test results due to contamination with the additive from the contamination with the additive from the previous blood collection tubeprevious blood collection tube

HemolysisHemolysis Blood collected insufficient to amount of additive in Blood collected insufficient to amount of additive in

tube, tube, Traumatic venipunctureTraumatic venipuncture Blood collected from area with hematomaBlood collected from area with hematoma Vigorous shaking of tubes after collectionVigorous shaking of tubes after collection Milking the site when collecting capillary samples and Milking the site when collecting capillary samples and

blood collected using a small diameter needleblood collected using a small diameter needle. .

Test Collection ErrorsTest Collection Errors

Timing of CollectionTiming of Collection Timed DrawsTimed Draws Therapeutic Drug MonitoringTherapeutic Drug Monitoring

Peak and trough collection timesPeak and trough collection times Basal State Collections Basal State Collections

Fasting requirements—no food or liquid Fasting requirements—no food or liquid except waterexcept water

Specimens affected by time of day, for Specimens affected by time of day, for example, cortisolexample, cortisol

Test Collection ErrorsTest Collection Errors

Improper collection tube drawn for Improper collection tube drawn for test orderedtest ordered

Collection tube not completely filledCollection tube not completely filled Example—light blue top tube for Example—light blue top tube for

Coagulation Studies. Incomplete filling Coagulation Studies. Incomplete filling results in specimen dilution and results in specimen dilution and erroneous Prothrombin and aPTT test erroneous Prothrombin and aPTT test results. results.

Test Collection ErrorsTest Collection Errors Capillary Collections—finger stick or heel Capillary Collections—finger stick or heel

stickstick Appropriate siteAppropriate site

Heel stick—sides of the bottom surface of the heelHeel stick—sides of the bottom surface of the heel Finger stick—third or fourth fingers, perpendicular Finger stick—third or fourth fingers, perpendicular

to fingerprint lines on fleshy pads on finger surfaceto fingerprint lines on fleshy pads on finger surface Warming—Warm before collection to increase Warming—Warm before collection to increase

capillary blood flow near skin surfacecapillary blood flow near skin surface Cleaning—cleanse site with alcohol and allow Cleaning—cleanse site with alcohol and allow

to air dryto air dry

Capillary CollectionsCapillary Collections

Massaging site to increase blood flowMassaging site to increase blood flow Milking site can cause hemolysis or tissue Milking site can cause hemolysis or tissue

fluid contaminationfluid contamination Finger sticks—roll fingers toward fingertip at Finger sticks—roll fingers toward fingertip at

11stst finger joint several times finger joint several times Heel sticks—gently squeeze infant’s heel Heel sticks—gently squeeze infant’s heel

before performing puncture. before performing puncture. Perform puncture while firmly squeezing Perform puncture while firmly squeezing

finger or heelfinger or heel Wipe away first two drops of bloodWipe away first two drops of blood

Ensure that full blood drop wells up each Ensure that full blood drop wells up each timetime

Capillary CollectionsCapillary Collections

Avoid touching capillary collection Avoid touching capillary collection tube or micro collection tube to skin or tube or micro collection tube to skin or scraping skin surfacescraping skin surface Contaminates puncture siteContaminates puncture site Blood may become hemolyzedBlood may become hemolyzed

Mixing micro collection tubes with Mixing micro collection tubes with additive frequently to avoid micro clotsadditive frequently to avoid micro clots

Collecting tubes with additives firstCollecting tubes with additives first Protecting tubes for bilirubin from Protecting tubes for bilirubin from

lightlight

Blood Specimen Blood Specimen Transport ErrorsTransport Errors

Transport of blood specimens in the Transport of blood specimens in the proper manner after collection proper manner after collection ensures the quality of the sampleensures the quality of the sample

TimingTiming Some specimens must be transported Some specimens must be transported

immediately after collection, for immediately after collection, for example Arterial Blood Gasesexample Arterial Blood Gases..

Specimens for serum or plasma Specimens for serum or plasma chemistry testing should be centrifuged chemistry testing should be centrifuged and separated within two hoursand separated within two hours

Transport ErrorsTransport Errors TemperatureTemperature

Specimens must be transported at the Specimens must be transported at the appropriate temperature for the required appropriate temperature for the required testtest

On ice—ABGs, AmmoniaOn ice—ABGs, Ammonia Warmed --98.6 degrees (37 C), cryoglobulinsWarmed --98.6 degrees (37 C), cryoglobulins Avoid temperature extremes if transported Avoid temperature extremes if transported

from via vehicle from other collection sitefrom via vehicle from other collection site Transport ContainerTransport Container

Some samples need to be protected from light, for Some samples need to be protected from light, for example, bilirubinexample, bilirubin

Transport in leak-proof plastic bags in lockable Transport in leak-proof plastic bags in lockable rigid containersrigid containers

Error PreventionError Prevention Phlebotomy EducationPhlebotomy Education

Phlebotomists should have completed a standard Phlebotomists should have completed a standard academic course in phlebotomy and undergo academic course in phlebotomy and undergo thorough on-the-job training under the thorough on-the-job training under the supervision of a senior phlebotomistsupervision of a senior phlebotomist

Continuing EducationContinuing Education Phlebotomists should participate in regular educational Phlebotomists should participate in regular educational

competency assessments (written and observational)competency assessments (written and observational) Professional LicensureProfessional Licensure

Phlebotomy StaffingPhlebotomy Staffing Adequate staffing to maintain collection standardsAdequate staffing to maintain collection standards

Technology Technology Use of barcode scanners for patient identificationUse of barcode scanners for patient identification

Questions and Questions and DiscussionDiscussion

How are pre-analytical errors prevented How are pre-analytical errors prevented in your laboratory?in your laboratory?

What technology do you use to prevent What technology do you use to prevent human error?human error?

What systems does your hospital use to What systems does your hospital use to prevent errors by non-laboratory staff prevent errors by non-laboratory staff collecting blood?collecting blood?

What pro-active improvements would What pro-active improvements would reduce the number of pre-analytical reduce the number of pre-analytical errors? errors?

Documents

Pre-analytical Laboratory Errors Tim Guirl MT (ASCP) Phlebotomy Instructor North Seattle Community College Health & Human Services Division