Three phases of laboratory testing:

 Pre-analytical:
Specimen collection, transport &
processing
 Analytical:
Testing
 Post-analytical:
Results transmission, interpretation, follow-
up, retesting
 Preanalytical variables can dramatically
affect the results of laboratory tests.
 Paying close attention to control the
preanalytical variables will help to
ensure accurate test results in clinical
laboratory.
No result is better than bad result.

Accurate result is the best of all.

Preparation prior to sampling

Sampling/Handling

Transport/Storage

Preparation prior to analysis

 Pre-& post-analytical errors: > 90% of
errors
 These potential errors are not inevitable
but could be prevented with an
accurate application of quality control,
continuing education and effective
collection systems.
 Patient Identification
 Sampling Technique
 Collection Procedures
 Specimen Transport
 Specimen Processing
 Attention to the preanalytical variables
associated with blood collection is
critical in ensuring accurate test results.
 Record significant variables on request
form.
Some patient variables that affect test results
 Age
 Genetic variation/ Race
 Sex
 Nutritional status
 Diet
 Exercise
 Pregnancy
 Timing
 Special habits
 Hemolysis, lipemia, Jaundice
When identifying the patient, get:
 Full name
 Age & sex
 Address/Nationality
 Identification number:
 Hospital No for inpatients,
 Identification band should contain the
above information (confirm before
venipuncture)
The highest frequency of errors occurs with
the use of handwritten labels & request
forms.
These can be eliminated by:
 Confirming patient’s identifiers (name,
medical record number, date of birth,
room location or address)
 Barcode technology.
 Locate Patient
 Label
 Prepare Patient
 Draw Sample
 Dispose of supplies
Timing of Collection:
 Therapeutic Drug Monitoring
-Peak and trough collection times
 Basal State Collections
-Fasting requirements: no food or liquid
except water (10-12h), (12-14 h for TG)
-2h postprandial, from the start of food .
 Specimens affected by time of day, for
example, cortisol, iron and TSH.
 Venipuncture requires expert knowledge
and critical judgment.
 Phlebotomy errors may cause harm to
patients or result in needle stick injury to
the phlebotomist.
 It could result in many preanalytical
errors in Lab results
 Phlebotomy Education
-Academic course and training under the
supervision of a senior phlebotomist.
 Continuous Medical Education
-Competency assessments (written and
observational).
-Professional License.
 Phlebotomy Staffing
-Adequate staffing to maintain collection
standards.
 Technology
-Use of barcode scanners for patient
identification.
1. Posture:
- Comfortably seated patient or supine for
20 min before sampling (not standing).
- The arm should be extended in a straight
line from the shoulder to the wrist.
2. Collection site:
- The median cubital vein is the preferred
site.
- Veins on the hand or at ankle may be
used.
 Cleaning of venipuncture site
-Thorough cleaning with alcohol
-Allow alcohol to dry completely to avoid
stinging sensation and hemolysis of sample
-Iodine for blood culture samples (sterile
sample)
 N.B: contamination occurs in 50% at some
hospitals with increased costs & patient
overtreatment.
Avoid the arm with:

- Extensive scarring, hematoma, infection,

edema or burn
-On the same side of mastectomy.
-I.V. infusion (Document if IV ).
3. Correct collection system :
-Vacutainers for large veins in antecubital fossa.
-Syringe for small, fragile veins or veins outside
antecubital fossa.

4. Venous access :
-Needle entry should be at 15-30o depending on
depth of 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.
 Tourniquet Application
-Tourniquet tied too close to venipuncture
site can cause hematoma.
 Veins may not become prominent if
tourniquet is tied too high (> 3-4 inches
above venipuncture site)
 Tourniquet left for > 1 min can result in
hemoconcentration, affecting some test
results.
 Tourniquet should be released as soon as
needle is in the lumen of vein and blood
flow is established.
Additives used:
 EDTA,
 Citrate,
 Lithium heparin,
 Fluoride/ Oxalate
 Typical errors :
Incorrect tube

• cannot be analysed
• risk of contamination

 Solution: New sample needs to be sent to lab.

Causes of Hemolysis
 Traumatic venipuncture
 Blood collected from area with hematoma
 Vigorous shaking after collection
 Milking the site when collecting capillary
samples
 Blood collected using a small diameter needle.
 High filling pressure through a narrow entrance
(e.g during too vigorous sample aspiration)
 Cooling down the sample < 0 °C.
 Affects analytes that are present at
higher concentrations in erythrocytes
than in plasma (K, LD, AST, Mg, P)
Capillary Collections:
 Appropriate site
-Heel stick: sides of bottom surface of the
heel (infants)
-Finger stick: third or fourth fingers,
perpendicular to fingerprint lines on
fleshy pads on finger surface.
 Warm before collection to increase
capillary blood flow near skin surface.
 Clean site with alcohol and allow to dry.
 Discard first drop of blood.
1.Blood Culture Bottles
2.Coagulation Tube
3.Serum Tube
4.Heparin Tube
5.EDTA
6.Glycolytic Inhibitor
Proper Tube Mixing:

All tubes with additives need to be

inverted (10 times) to mix the additive
evenly with the blood. Improper mixing
of the tube after venipuncture could
contribute to sample clotting.
 Typical errors Consequences
Trauma, strangulation, stasis hemolysis, hemoconcentration

IV contamination dilution, false results

Sample volume is insufficient incomplete lab results, repeat

sampling

Incomplete filling of tubes inappropriate anticoagulant:blood

ratio, false results

Inappropriate mixing clotted, hemolysed sample

Solution:
 Lab report with preanalytical comment
(if problem recognized).
 New sample is requested.
 Blood should never be collected proximal
to the infusion site.
 It is recommended that the laboratory be
informed of when and what type of infusion
were carried out and when blood samples
were taken.
 If samples are to be taken from catheters,
the cannula should be rinsed with isotonic
saline suitable for the volume of catheter.
The first 5 ml of blood should be discarded
before a blood sample is taken.
 Proper transport of specimens after
collection ensures quality of sample &
tests.
 Timing
-Some specimens must be transported
immediately (Arterial Blood Gases).
-Specimens for serum or plasma
chemistry testing should be centrifuged
and separated within 2 hs.
 Temperature
-On ice: ABGs, Ammonia
-Warmed (37 C): cryoglobulins
-Avoid temperature extremes if
transported via vehicle.
 Transport Container
-Some samples need to be protected
from light e.g. bilirubin.
-Transport in leak-proof plastic bags in
lockable rigid containers & avoid
agitation.
 Typical errors Consequences
Delay False results
sample stability deteriorates, (high K)
certain components break Delay in reporting
down Burden and harm to
Inappropriate storage patient

Solution: New sample is requested.

 Registration, identification
 Checking for clots
 Centrifugation
 Distribution
 Storage (non routine daily analysis , for
post-analysis if it is needed)
 Typical errors Consequences

Native blood centrifugated before Hemolysed sample, fibrin strand in

clotting serum, clogging

Inappropriate melting of frozen False concentration or

specimens precipitation, …… false result

Inappropriate storage of samples in False results

lab (sample ID lost, contamination, Contamination
break down of unstable
components … etc.)
Clots in anticoagulated blood False results
Cryoglobulins
 Clotted  Incorrect patient
 Hemolyzed  Incorrect specimen
 Underfilled, overfilled  Contaminated
 Insufficient quantity  Lost sample
 Incorrect labeling  Too old to process
 Unlabeled specimen  Broken and leaking
 The human role in sample collection
makes complete elimination of errors
associated with laboratory testing
unrealistic
 However, good practices and
compliance with strategies for error
prevention can lead to a substantial
reduction in pre-analytical errors.