PROCESSING OF CLINICAL SAMPLES

I. Observation/Results
A. Blood Specimen Processing and Transport

Figure 1. Sanitizing and Wearing PPE Figure 2. Putting and balancing of Specimens
and Dummy Balanced tubes in the Centrifuge

Figure 3. Operation of Centrifuge Figure 4. Matching of Bar Code &

Client details with referral, and Placing
specimen in bags

Figure 5. Placing of specimen bags Figure 6. Certificate for Completion

into the courier bag of Centrifugation from
NCBioNetwork.org
 B. Urine Specimen Processing and Transport

Figure 7. Urine sample cup with labels of name, Figure 8. Straw yellow and
date of birth, and date & time of collection Clear/Transparent urine

Figure 9. Wearing PPE Figure 10. Urine Specimen

processing tools

Figure 11. Reading specific gravity Figure 12. Placing of reagent strip
from urine hydrometer into the urine
 Figure 13. Urinalysis test strip color Figure 14. Placing of specimen in
chart the biohazard bag

Figure 15. Discard gloves and sanitize Figure 16. Fill, fold, and put the
requisition in the outer pocket
II. Discussion
Chawla et al. (2010) claim that today's diagnosis is highly reliant on accurate laboratory results.
As a result, it is critical to ensure that the clinical laboratory results are trustworthy. All the operations
that occur before the sample is processed in the autoanalyzer are included in the preanalytical phase. In
this phase, pre-analytic errors are errors that occur during specimen preparation—which includes all
activities that are performed to make a sample suitable for analysis (Naz et al. 2012). Pre-analytical
errors may include incorrect or incomplete laboratory request forms, patient misidentification,
mislabeling of the containers, collection errors, specimen transportation problems, specimen
preparation errors, some biological variations, exercise, coordination of treatments and conditions,
vascular access devices, and posture.
First, incorrect or incomplete laboratory request forms can result in laboratory service misuse,
which further increases injuries and medical costs (Silverstein, 2003). Moreover, incomplete laboratory
request forms and labels can be placed in the wrong container or be lost. This causes rejection and
missing important data entered by unwitting reception laboratory staff. Misidentification presents to be
the most important concern; thus, one should prioritize efforts to guarantee adherence to standardized
identification procedures such as the use of two unique patient identifiers (Schulmeister, 2008). Patient
misidentification can lead to medication and transfusion errors, unnecessary testing and procedures,
and even death in rare situations. When nurses mispronounce patients' names, refer to them solely by
their first or last names, become complacent and fail to check armbands, or meet language or
communication challenges, patients may be mistaken. Third, Valenstein et al. (2016) implied that
labeling specimen containers should always be done before sample collection, as labeling them after the
fact increases the chance of collecting specimens from the wrong patient. Errors in specimen labeling
resulted in a larger number of erroneous test findings—wrong patient-wrong results—which can cause
delays in patient results and treatment alternatives. This is not only harmful to the patient's health, but
it affects their pleasure with the institution and their peace of mind. Next, Naz et al. also mentioned
that improper sample collection can cause delays in reporting, unnecessary re-draws/retests, poor
customer satisfaction, increased costs, wrong diagnosis/treatment, injuries, and even death. Specifically,
this improper collection can be caused by volume inadequacy, incorrect phlebotomy practices, lipemic
samples, and hemolysis. Thereafter, Felder (2011) said that sample transportation is one of the biggest
problems contributing to delays in getting high-quality clinical laboratory findings to the patient's
bedside. During delays and disturbances in transportation, variations in temperature and physical forces
might damage sample quality. Afterward, specimen preparation errors contribute to 19% of costs
regarding a single specimen, increase in time spent on results by 37%, rejection of samples due to
underfilling; HIL; clots; or air bubbles, inaccurate aspiration, malfunction of analyzing equipment due to
fibrin strands clogging the pipetting needle, and other preventable analyte inaccuracies that can affect
patient diagnosis (Naz et al. 2012). Then, Kouri et al. (2005) pointed out that biological variations
primarily result in variation of analytes, which can affect patient diagnosis. These errors from biological
variations include stress, diet, exercise, and chronobiological variations of blood levels from the
biological clock. Specifically, exercise can significantly affect test results, and patients are advised to
avoid collecting specimens right after strenuous activity. Exercise can temporarily increase ACTH,
bilirubin, CK, cortisol, creatinine, HDL, LDH, neutrophils, uric acid, and WBC count. Outpatients are
mostly affected because of their work outside the health facility than the inpatients. Furthermore,
pumping one’s hand before collection can change potassium and ionized calcium levels—affecting
specimen quality. Subsequently, Hvas et al. (2017) inferred that miscoordination of treatments and
conditions can have a dramatic effect on test results, as well as over-medication or under-medication.
The therapy that affects collecting quality specimens primarily is the infusion of intravenous fluids
because it can falsely decrease analyte concentration through dilution or falsely increase analyte
concentration through direct interference—leading to negative patient outcomes. Besides, Ernst (2005)
indicated that Vascular Access Devices (VADs) such as IV lines, central venous catheters, and arterial
lines are tools to obtain blood specimens without venipuncture but their use can result in Likely
contamination of blood cultures; IV fluid contamination of specimens; Hemolysis is more common than
venipunctures; Possibility of causing an air embolism in the bloodstream; Line occlusion is a possibility;
and risks of Iatrogenic anemia—anemia caused by medical operations. Finally, posture affects test
results and reference ranges of patients, typically including the ambulatory patient population
(Narayanan, 2000). An upright position triggers an increase of some hormones to increase blood
pressure and decrease blood volume. Some cells, proteins, and compounds attached cannot pass from
capillary walls causing hemoconcentration and an increase of some analytes. Drawing specimens during
this transition yields a higher test result than drawing specimens when the patient is recumbent. When
a patient moves from an upright to a recumbent position, the blood becomes diluted due to water
moving from the tissue into the circulation. Patients whose blood was obtained after sitting recumbent
for 5 minutes had cholesterol levels up to 12% lower and triglycerides up to 17% lower.
Celik et al. (2018) expounded that sample rejection is a critical laboratory procedure that is
linked to patient safety. For a variety of reasons, clinical laboratory specimens may be rejected as unfit
for examination, and specimen rejection might have serious clinical consequences. Dikmen et al. 2015
enumerated situations that result in recollection or rejection of specimens which are: incorrect test
requests such as incomplete, duplicate, errors in test input, and inconsistent information; improper
transportation due to transport temperature, light exposure, and delayed transport time; specimens
with no or incompatible barcodes; misidentification such as unlabeled mislabeled or mismatched
samples; incorrect tube or container; inadequate specimen volume leading to abnormal
blood/anticoagulant ratio; improper preservation and storage; lipemic specimen; hemolyzed specimen;
and clotted samples with fibrin. However, Salinas et al. (2016) advised that the corresponding solutions
for incorrect test requests are: the determination over and under-requesting of laboratory tests;
correcting the errors through clinicians; monitoring the interventions; automation to remove human
error due to unnecessary repetitive testing; and by looking at the number of queries in the LIS patient
database in the past. Becan-McBride (2002) offered suggestions for preventing inappropriate
transportation by upholding OSHA and CDC standards; maintaining temperature through cold packs or a
heated vehicle; maintaining vertical positions; using of spill kit in the courier vehicle; specimen placed in
a lockable container; specimen shielded from lighting if photosensitive; specimen placed in a sealed
plastic bag with a pocket for requisition; and keeping a schedule for the time and location of specimen
collections and couriers. Specimens with no or incompatible barcodes can be prevented through
increasing contrast of barcodes, providing much space and less noise around barcodes, proper reading
position, having consistent print or mark, and protecting barcodes from abrasion, stain, excess material,
and environmental conditions (Koppel et al. 2008). To prevent misidentification resulting in rejection,
Hawker and Messinger (2014) recommend using barcode systems, bedside printers, practicing single
piece flow or avoiding having specimens from multiple patients in the active work area simultaneously,
destroying unused labels before the next patient, avoiding aliquot labels with limited identifiers, sample
relabeling, and avoiding format, layout and display inconsistency. Also, an incorrect tube must be
replaced by a correct tube type or in a correct transport material in a leak-proof container, unexpired,
correct tube for the test requested, and electronic labeling system (Proehl, 2016). Inadequacy of
specimen volume can be prevented by using syringes large enough for the requirement, drawing blood
into a discard tube to prevent dead space, and filling tubes with the recommended volume based on the
manufacturer as also stated by Proehl. Furthermore, rejection—caused by improper preservation and
storage—should be averted by proper container labels, sample storage under prescribed light and
temperature conditions, be sealed in a biohazard bag for courier pickup, be checked at frozen indication
if on the freezer, and serum/plasma tube be centrifuged before storage (Deepak, 2018). Lipemic
samples for rejection can be avoided by encouraging fasting collection, coordinating away from IV
infusion of lipid emulsion, use of lipid-clearing reagents, ultracentrifugation, and using of blood gas
analyzer quickly after collection (Krasowski, 2019). Krasowski further stated that hemolyzed samples can
be avoided by slowly pulling the syringe plunger, not using an IV catheter, not collecting sites other than
the antecubital area, not shaking the tube too much, not using needles smaller than gauge 21, not
squeezing the capillaries too much, filling enough to avoid sloshing while transporting, not extending
tourniquet time, allowing antiseptic to air dry, centrifugation speed, not pumping, and not taking from a
bruise. Lastly, clotting of samples can be avoided by filling the tube quick enough, not prolonging the use
of the tourniquet, completely mixing the samples to its anticoagulant, not slowing the transfer of
samples, and collecting enough blood required in the tube (Lippi et al. 2019).
III. Guide Questions
1. List and explain pre-analytical errors that can occur with a specimen and how these
errors can affect patient’s outcome or result.
 Incorrect or incomplete laboratory request forms – This error can lead to laboratory service
misuse, increased injuries, costs, specimen in the wrong container, and lost specimen
(Silverstein, 2003).
 Patient misidentification – Misidentification can create medication and transfusion errors,
unnecessary procedures, and mortalities (Schulmeister, 2008).
 Mislabeling of the containers – Mislabeling can increase the chances of wrong patient
intervention and erroneous or wrong test findings which can lead to fatality and mortality
(Valenstein, 2016).
 Collection errors – This error can negatively affect the patient outcome by having delays in
reporting, wasted tests, poor patient experience, increased costs, wrong diagnosis and
treatment, injuries, and mortality (Naz et al. 2012).
 Specimen transportation problems – Transportation issues contribute to delays in giving
findings to the patient with the temperature and physical disturbance during transportation
causes sample damage (Felder, 2011).
 Specimen preparation errors – Preparation errors contribute to increased costs and time
spent on a specimen, rejection from underfilling; clots; or air bubbles, inaccurate aspiration,
analyzer malfunction, and other analyte inaccuracies (Naz et al. 2012).
 Biological variations – Errors due to biological variations can be caused by fluctuating body
analyte concentrations due to stress, diet, exercise, and time of the day (Kouri et al. 2005).
 Exercise – Exercise can elevate ACTH, bilirubin CK, cortisol, creatinine, HDL, LDH,
neutrophils, uric acid, and WBC of patients due to increased muscle and respiratory activity
(Kouri et al. 2005).
 Coordination of Treatments and Conditions – Miscoordination of treatments and
conditions can affect test results causing over-medication, under-medication, and IV
therapies can decrease results due to dilution or increase results due to added interference
(Hvas et al. 2017).
 Vascular access devices (VADs) – The use and invasive structure of VADs on patients can
explain the increased risks of contamination, hemolysis, air embolism, line occlusion, and
iatrogenic anemia on using it (Ernst, 2005).
 Posture – Posture falsely increases the patient’s analyte concentration when the patient
moves from recumbent to upright position due to hemoconcentration, but the opposite is
true when the patient moves from upright to recumbent position (Narayanan, 2000).
 2. What situations would result in recollection or rejection of specimen? Determine
corresponding solutions to avoid such conditions.
 Incorrect test requests – To avoid this, one can determine over and under-requesting,
checking through clinicians, monitoring interventions, automation, and reviewing queries in
the LIS patient database (Salinas et al. 2016).
 Improper transportation – The effect of sample transportation can be mitigated through
upholding OSHA and CDC standards, maintaining proper temperature, assuring verticality,
using a spill kit, use of lockable sealed bags, being shielded from environmental conditions,
having an attached requisition, and a schedule for time and location (Becan-McBride, 2002).
 No or incompatible barcodes of specimen – Rejection from improper specimen barcodes
can be avoided by having a great label contrast, removing clutter from sides and label,
proper reading position, and having uniform consistency of print (Koppel et al. 2008).
 Misidentification – Rejection from misidentification can be prevented by the use of
barcodes, bedside printers, single-piece workflows, removing unused labels before the next,
not limiting the identifiers, relabeling, and avoiding inconsistent prints (Hawker &
Messinger, 2014).
 Incorrect tubes – Rejection of samples in incorrect tubes can be curbed down by using
correct tubes for the test, correct transport material, using unexpired tubes, and an
electronic labeling system (Proehl, 2016)
 Inadequate specimen volume – Rejection of inadequate specimens can be mediated by the
right size of syringes, use of discarded tubes, and filling tubes properly (Proehl, 2016).
 Improper storage – Unusable samples from improper storage and preservation can be
reduced by having proper container labels, proper light and temperature regulation, sealed
in a bag, checked promptly in the freezer, and centrifugation of serum/plasma tubes before
storage (Deepak, 2018).
 Lipemic specimen – Lipemic samples should be rejected but can be reduced by having
fasting collection, being away at the site of lipid emulsion IV infusion, use of lipid-clearing
reagents, ultracentrifugation, and immediate blood gas analyzer use (Krasowski, 2019).
 Hemolyzed specimen – Hemolyzed samples should be rejected but can be decreased by
slowly pulling the plunger, not using IV lines, using the large median cubital vein, not shaking
vigorously, not using needles smaller than gauge 21, not squeezing, filling enough, limiting
tourniquet time, air-drying of antiseptic, not pumping, control of centrifugation, and not
using damaged skin conditions (Krasowski, 2019).
 Clotted samples with fibrin – Clotted samples in anticoagulant tubes are rejected but can be
reduced by filling the tube quick enough, proper mixing or inversions, proper time of
tourniquet, not slowing sample transfer, and collecting enough blood per tube (Lippi et al.
2019).

IV. Conclusion
 The preanalytical phase is critical to quality and accurate laboratory results (Naz et al. 2021).
Pre-analytical errors may include incorrect or incomplete laboratory request forms, patient
misidentification, mislabeling of the containers, collection errors, specimen transportation problems,
specimen preparation errors, some biological variations, exercise, coordination of treatments and
conditions, vascular access devices, and posture. All of the preanalytical errors can cause wrong,
erroneous, and rejectable specimens that can decrease patient experience and quality of healthcare,
increase medical costs and times, and cause wrong diagnosis, treatment, and maintenance that can
prove harmful to the patient, staff, and the healthcare institution (Schulmeister, 2008) (Silverstein,
2003).
Furthermore, sample rejection is very important to the critical laboratory procedure because it
is linked to patient safety and outcomes (Celik et al. 2018). Thus, some situations result in recollection or
rejection of specimens and they are: incorrect test requests such as incomplete, duplicate, errors in test
input, and inconsistent information; improper transportation due to transport temperature, light
exposure, and delayed transport time; specimens with no or incompatible barcodes; misidentification
such as unlabeled mislabeled or mismatched samples; incorrect tube or container; inadequate specimen
volume leading to abnormal blood/anticoagulant ratio; improper preservation and storage; lipemic
specimen; hemolyzed specimen; and clotted samples with fibrin. To infer, the overall trend of solutions
to these situations is to follow regulations and protocols, use automation such as barcoding systems,
maintain properly sealed containers and environmental conditions, have readable codes and
information, use proper and unexpired tools and equipment, and proper patient briefing, appropriate
venipuncture procedures, and settings, optimal pace—not too fast but not too slow—of collection and
transfer, and lastly, adequate and proper tubes as requested (Dikmen et al. 2015) (Salinas et al. 2016).
To derive, studying the appropriate processing of clinical samples is imperative in reducing the
chances of laboratory errors, rejection, and recollection that can negatively impact patient, health staff,
and health institution results and outcomes.

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