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

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Presentation on theme: "Pre-analytical Laboratory Errors Tim Guirl MT (ASCP) Phlebotomy Instructor North Seattle Community College Health & Human Services Division."— Presentation transcript:

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

2 Objectives Identify the significant pre-analytical errors that can occur during blood specimen collection and transport Identify the significant pre-analytical errors that can occur during blood specimen collection and transport Explain the various means of pre-analytical error prevention Explain the various means of pre-analytical error prevention List proactive steps to reduce potential pre- analytical errors associated with blood collection and transport List proactive steps to reduce potential pre- analytical errors associated with blood collection and transport

3 Introduction Three phases of laboratory testing: pre-analytical, analytical and post-analytical Three phases of laboratory testing: pre-analytical, analytical and post-analytical Pre-analytical—specimen collection, transport and processing Pre-analytical—specimen collection, transport and processing Analytical—testing Analytical—testing Post-analytical—testing results transmission, interpretation, follow-up, retesting. Post-analytical—testing results transmission, interpretation, follow-up, retesting.

4 Phlebotomy Errors Phlebotomy is a highly complex skill requiring expert knowledge, dexterity and critical judgment Phlebotomy is a highly complex skill requiring expert knowledge, dexterity and critical judgment It is estimated that one billion venipunctures are performed annually in the U.S. It is estimated that one billion venipunctures are performed annually in the U.S. Phlebotomy errors may cause harm to patients or result in needlestick injury to the phlebotomist Phlebotomy errors may cause harm to patients or result in needlestick injury to the phlebotomist

5 Pre-analytical errors Pre- and post-analytical errors are estimated to constitute 90% of errors Pre- and post-analytical errors are estimated to constitute 90% of errors Errors at any stage of the collection, testing and reporting process can potentially lead to a serious patient misdiagnosis Errors at any stage of the collection, testing and reporting process can potentially lead to a serious patient misdiagnosis Errors during the collection process are not inevitable and can be prevented with a diligent application of quality control, continuing education and effective collection systems Errors during the collection process are not inevitable and can be prevented with a diligent application of quality control, continuing education and effective collection systems

6 Types of Collection Errors Patient Identification Patient Identification Phlebotomy Technique Phlebotomy Technique Test Collection Procedures Test Collection Procedures Specimen Transport Specimen Transport Specimen Processing Specimen Processing

7 Patient Identification Errors Errors in correctly identifying the patient are indefensible Errors in correctly identifying the patient are indefensible Reasons for patient identification errors Reasons for patient identification errors Proper positive patient identification procedures not followed Proper positive patient identification procedures not followed Patient identification from identification bracelet (inpatients) Patient identification from identification bracelet (inpatients) Patient identification by asking patients to state or spell their full name (inpatients/outpatients) Patient identification by asking patients to state or spell their full name (inpatients/outpatients) Patient identification by staff or family member if patient unable to identify him/herself Patient identification by staff or family member if patient unable to identify him/herself

8 Patient Identification Errors Specimen tubes unlabeled Specimen tubes unlabeled Requisition or collection tube labels not affixed to tubes Requisition or collection tube labels not affixed to tubes Requisition or collection tube labels in bag containing collection tubes Requisition or collection tube labels in bag containing collection tubes Requisition or collection tube labels rubber- banded to tubes Requisition or collection tube labels rubber- banded to tubes Collection tube labels not affixed to all tubes Collection tube labels not affixed to all tubes Specimen collection tubes labeled insufficiently with at minimum patient’s full name, date/time of collection, phlebotomist’s initials Specimen collection tubes labeled insufficiently with at minimum patient’s full name, date/time of collection, phlebotomist’s initials

9 Patient Identification Errors Collection tubes labeled with the wrong patient Collection tubes labeled with the wrong patient Wrong computerized labels affixed to collection tubes at bedside Wrong computerized labels affixed to collection tubes at bedside Collection tubes not labeled at the time of collection Collection tubes not labeled at the time of collection Collection tubes incorrectly labeled by someone other than the phlebotomist who collects the specimen Collection tubes incorrectly labeled by someone other than the phlebotomist who collects the specimen

10 Patient Complications Some patient variables that affect blood specimens Some patient variables that affect blood specimens Diet Diet Fasting Fasting Exercise Exercise Obesity Obesity Allergies to alcohol or iodine used to clean venipuncture site Allergies to alcohol or iodine used to clean venipuncture site Use alternative cleanser such as chlorhexidine Use alternative cleanser such as chlorhexidine

11 Phlebotomy Technique Errors Phlebotomy technique is important Phlebotomy technique is important Ensures test result validity Ensures test result validity Minimizes trauma to patient Minimizes trauma to patient Minimizes potential for phlebotomist injury Minimizes potential for phlebotomist injury Reduces recollections Reduces recollections Vein selection essential for successful venipuncture Vein selection essential for successful venipuncture Three veins in antecubital fossa in order of selection (1) median cubital (2) cephalic (3) basilic Three veins in antecubital fossa in order of selection (1) median cubital (2) cephalic (3) basilic

12 Phlebotomy Technique Errors Site Selection Site Selection Avoid sites with IV Avoid sites with IV Use alternative arm or draw below IV to avoid contamination/dilution from IV Use alternative arm or draw below IV to avoid contamination/dilution from IV Document arm if IV Document arm if IV Mastectomy—avoid site due to lymphostasis Mastectomy—avoid site due to lymphostasis Infection risk/alteration in body fluids and blood analytes Infection risk/alteration in body fluids and blood analytes Edematous areas — avoid due to accumulation of body fluids Edematous areas — avoid due to accumulation of body fluids Possible contamination/dilution of specimen Possible contamination/dilution of specimen

13 Phlebotomy Technique Errors Venous Access Difficulties Venous Access Difficulties Obstructed, hardened, scarred veins Obstructed, hardened, scarred veins Veins difficult to locate Veins difficult to locate Use of Alternative sites Use of Alternative sites Top of hand/Side of wrist Top of hand/Side of wrist Areas to avoid Areas to avoid Vein Collapse Vein Collapse Use of appropriate needle size Use of appropriate needle size Smaller evacuated collection tube Smaller evacuated collection tube

14 Phlebotomy Technique Errors Tourniquet Application Tourniquet Application Tourniquet tied too close to the venipuncture site can cause hematoma Tourniquet tied too close to the venipuncture site can cause hematoma Veins may not become prominent if tourniquet is tied too high (more than 3 to 4 inches above venipuncture site ) Veins may not become prominent if tourniquet is tied too high (more than 3 to 4 inches above venipuncture site ) Tourniquet left on longer than one minute can result in hemoconcentration, affecting some test results Tourniquet left on longer than one minute can result in hemoconcentration, affecting some test results Tourniquet should be released as soon as needle is in the lumen of the vein and blood flow established Tourniquet should be released as soon as needle is in the lumen of the vein and blood flow established

15 Phlebotomy Technique Errors Cleansing of venipuncture site Cleansing of venipuncture site Thorough cleaning with alcohol Thorough cleaning with alcohol Allow alcohol to dry completely to avoid stinging sensation upon needle entry and hemolysis of sample Allow alcohol to dry completely to avoid stinging sensation upon needle entry and hemolysis of sample Samples such as blood cultures should be collected using iodine to cleanse site to ensure sterility of sample Samples such as blood cultures should be collected using iodine to cleanse site to ensure sterility of sample Recollection rate for blood cultures ranges due to contamination is as high as 50% in hospitals with increased costs, patient overtreatment Recollection rate for blood cultures ranges due to contamination is as high as 50% in hospitals with increased costs, patient overtreatment

16 Phlebotomy Technique Errors Correct collection system Correct collection system Evacuated tube system (Vacutainer) for large veins in antecubital fossa Evacuated tube system (Vacutainer) for large veins in antecubital fossa Syringe for small, fragile veins or veins outside antecubital fossa Syringe for small, fragile veins or veins outside antecubital fossa Venous access Venous access Needle entry should be at 15 to 30 degrees depending on depth of vein Needle entry should be at 15 to 30 degrees depending on depth of vein Needle entry should be in same direction as vein, centered over vein Needle entry should be in same direction as vein, centered over vein Anchor vein to prevent movement during needle entry and to reduce pain to patient Anchor vein to prevent movement during needle entry and to reduce pain to patient

17 Test Collection Errors Order of Draw Order of Draw Order of draw affects the quality of the sample and can lead to erroneous test results due to contamination with the additive from the previous blood collection tube Order of draw affects the quality of the sample and can lead to erroneous test results due to contamination with the additive from the previous blood collection tube Hemolysis Hemolysis Blood collected insufficient to amount of additive in tube, Blood collected insufficient to amount of additive in tube, Traumatic venipuncture Traumatic venipuncture Blood collected from area with hematoma Blood collected from area with hematoma Vigorous shaking of tubes after collection Vigorous shaking of tubes after collection Milking the site when collecting capillary samples and blood collected using a small diameter needle. Milking the site when collecting capillary samples and blood collected using a small diameter needle.

18 Test Collection Errors Timing of Collection Timing of Collection Timed Draws Timed Draws Therapeutic Drug Monitoring Therapeutic Drug Monitoring Peak and trough collection times Peak and trough collection times Basal State Collections Basal State Collections Fasting requirements—no food or liquid except water Fasting requirements—no food or liquid except water Specimens affected by time of day, for example, cortisol Specimens affected by time of day, for example, cortisol

19 Test Collection Errors Improper collection tube drawn for test ordered Improper collection tube drawn for test ordered Collection tube not completely filled Collection tube not completely filled Example—light blue top tube for Coagulation Studies. Incomplete filling results in specimen dilution and erroneous Prothrombin and aPTT test results. Example—light blue top tube for Coagulation Studies. Incomplete filling results in specimen dilution and erroneous Prothrombin and aPTT test results.

20 Test Collection Errors Capillary Collections—finger stick or heel stick Capillary Collections—finger stick or heel stick Appropriate site Appropriate site Heel stick—sides of the bottom surface of the heel Heel stick—sides of the bottom surface of the heel Finger stick—third or fourth fingers, perpendicular to fingerprint lines on fleshy pads on finger surface Finger stick—third or fourth fingers, perpendicular to fingerprint lines on fleshy pads on finger surface Warming—Warm before collection to increase capillary blood flow near skin surface Warming—Warm before collection to increase capillary blood flow near skin surface Cleaning—cleanse site with alcohol and allow to air dry Cleaning—cleanse site with alcohol and allow to air dry

21 Capillary Collections Massaging site to increase blood flow Massaging site to increase blood flow Milking site can cause hemolysis or tissue fluid contamination Milking site can cause hemolysis or tissue fluid contamination Finger sticks—roll fingers toward fingertip at 1 st finger joint several times Finger sticks—roll fingers toward fingertip at 1 st finger joint several times Heel sticks—gently squeeze infant’s heel before performing puncture. Heel sticks—gently squeeze infant’s heel before performing puncture. Perform puncture while firmly squeezing finger or heel Perform puncture while firmly squeezing finger or heel Wipe away first two drops of blood Wipe away first two drops of blood Ensure that full blood drop wells up each time Ensure that full blood drop wells up each time

22 Capillary Collections Avoid touching capillary collection tube or micro collection tube to skin or scraping skin surface Avoid touching capillary collection tube or micro collection tube to skin or scraping skin surface Contaminates puncture site Contaminates puncture site Blood may become hemolyzed Blood may become hemolyzed Mixing micro collection tubes with additive frequently to avoid micro clots Mixing micro collection tubes with additive frequently to avoid micro clots Collecting tubes with additives first Collecting tubes with additives first Protecting tubes for bilirubin from light Protecting tubes for bilirubin from light

23 Blood Specimen Transport Errors Transport of blood specimens in the proper manner after collection ensures the quality of the sample Transport of blood specimens in the proper manner after collection ensures the quality of the sample Timing Timing Some specimens must be transported immediately after collection, for example Arterial Blood Gases. Some specimens must be transported immediately after collection, for example Arterial Blood Gases. Specimens for serum or plasma chemistry testing should be centrifuged and separated within two hours Specimens for serum or plasma chemistry testing should be centrifuged and separated within two hours

24 Transport Errors Temperature Temperature Specimens must be transported at the appropriate temperature for the required test Specimens must be transported at the appropriate temperature for the required test On ice—ABGs, Ammonia On ice—ABGs, Ammonia Warmed degrees (37 C), cryoglobulins Warmed degrees (37 C), cryoglobulins Avoid temperature extremes if transported from via vehicle from other collection site Avoid temperature extremes if transported from via vehicle from other collection site Transport Container Transport Container Some samples need to be protected from light, for example, bilirubin Some samples need to be protected from light, for example, bilirubin Transport in leak-proof plastic bags in lockable rigid containers Transport in leak-proof plastic bags in lockable rigid containers

25 Error Prevention Phlebotomy Education Phlebotomy Education Phlebotomists should have completed a standard academic course in phlebotomy and undergo thorough on-the-job training under the supervision of a senior phlebotomist Phlebotomists should have completed a standard academic course in phlebotomy and undergo thorough on-the-job training under the supervision of a senior phlebotomist Continuing Education Continuing Education Phlebotomists should participate in regular educational competency assessments (written and observational) Phlebotomists should participate in regular educational competency assessments (written and observational) Professional Licensure Professional Licensure Phlebotomy Staffing Phlebotomy Staffing Adequate staffing to maintain collection standards Adequate staffing to maintain collection standards Technology Technology Use of barcode scanners for patient identification Use of barcode scanners for patient identification

26 Questions and Discussion How are pre-analytical errors prevented in your laboratory? How are pre-analytical errors prevented in your laboratory? What technology do you use to prevent human error? What technology do you use to prevent human error? What systems does your hospital use to prevent errors by non-laboratory staff collecting blood? What systems does your hospital use to prevent errors by non-laboratory staff collecting blood? What pro-active improvements would reduce the number of pre-analytical errors? What pro-active improvements would reduce the number of pre-analytical errors?


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