1. Preanalytical variability: turning dark into bright.
Gian Luca Salvagno, Verona, Italy

3. Errors and patient’s outcome
1999 a.c.

5. Radiological mistakes 2001
Laboratory Errors 1997
Miss luggage in airport
Laboratory Errors 2007

6. The clinical perspective...

7. The economic perspective...
Sample recollection

8. The organizational perspective...

12. 1° 4° 2° 3° 5°

13. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

16. Fasting requirements

17. Fasting requirements

18. Fasting requirements

19. Fasting requirements

20. Fasting requirements

22. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

23. Posture
Inpatient Outpatient Just arrived in the ED

24. Posture

25. Posture X
DAY 1
DAY 2

26. Posture

27. Posture

28. Posture

29. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

30. Misidentification:
Relatively rare (2%), but the worst!

31. Healthcare institutions should have zero tolerance to patient identification errors;
A minimum two and preferably three unique patient identifiers (one of which is the full name of the patient) should be used for patient identification;
Patient and sample identity should always be checked in the presence of the patient;
The institution should have a policy and a written standard operating procedure defining the patient and sample identification, which is followed by all personnel;
The institution should have a system in place to continuous monitor and hopefully reduce the frequency of the identification error rate;
A system should be in place for a continuous education for all professions involved in phlebotomy;
EFLM member societies should adopt these recommendations and encourage their implementation among healthcare institutions at their national level;
Standard writing bodies (CLSI, ISO) are encouraged to consider the present recomendations

32. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

33. Blood drawing:
The leading source of “our” problems!

34. Blood drawing
-0.5
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
Median cephalic
Median basilic
Median anterobrachial
Cephalic
Basilic
Metacarpal plexus
Cell-free hemoglobin (g/L)
Blood collection from veins of the metacarpal plexus discouraged:
Hemolysis decreased by approx 30%

35. Tube validation

36. Tube validation

37. Tube validation

38. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

39. CONCLUSIONS: We suggest that, when a proper technique is used and within certain limitations, the butterfly device may be a reliable alternative to the conventional straight needles to draw blood for lab testing.

40. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

42. USE OF TOURNIQUET:
(a) The tourniquet should be applied to the area approximately 10 cm above the intended site of venipuncture.
(b) It should be tight enough to restrict venous flow but not tight enough to obstruct arterial circulation. The pulse should be palpable below the level of the tourniquet.
(c) The tourniquet should not be left in situ for >1 min (when more time is required to find a suitable vein or the venipuncture protracts, the tourniquet may be released and reapplied).
(d) When vein is selected, tourniquet is released, skin cleansed and allowed to dry, then tourniquet re-tightened to proceed with venipuncture.
(e) Once blood flow starts (or needle is safely in vein), tourniquet is released. Should flow diminish or cease before sufficient blood is obtained, the tourniquet may be reapplied lightly.
(f) Tourniquet should not cause pain or discomfort to patient.

43. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

44. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Wipe alcohol?
Fist clenching?
Underfilling?
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

47. (Avoiding fist clenching)

49. Underfilling

50. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

51. Is cross-contamination of blood tubes a significant cause of bias?

53. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

54. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

55. Spoke
Spoke
Spoke
HUB
Spoke
Spoke
Spoke
Spoke
Spoke

57. The 13 commandments: Separate serum or plasma from blood cells ASA but not later than 4 h Use tube separators or aliquot serum and plasma ASAP Keep tubes and aliquots safely capped Keep tubes in vertical position during transport Use validated biohazard containers for transport Use first/second/third level containers Ensure stable conditions of temperature (i.e., 18-25°C) and humidity Avoid light exposure Prevent trauma of specimens Deliver to the corelab as ASAP Record transportation time (from start to arrival to the lab) Monitor conditions throughout transportation Reject samples with unsuitable conditions of transport

58. Data relating to sample stability may strongly depend on the tube type used for blood collection, (including any separation gels, anticoagulants and other additives present), the temperature of storage prior to testing, and the laboratory method used for determination. The mode of transporting samples to the laboratory may be relevant, as well.

59. Patient preparation Sample collection Sample transport Sample storage
Biological variability
Posture
Patient identification
Sample collection
Collection system
Needle
Venous stasis
Order of draw
Phlebotomy procedure
Contamination
Tube mixing
Sample transport
Transport condition
Pneumatic tube systems
Sample storage

60. The conclusions of some papers show no preanalytical errors in samples transported for analysis of routine hematology, coagulation parameters and platelet function with the PFA-100. But, putting together the data, current evidence on the effects of PTS on the quality of patient samples is not satisfactory.

62. Pre-analytical Processes Quality Indicators…
A long and winding road ahead.

63. THE LABORATORY IN DIAGNOSIS

65. Sten Westgard,
January