Pre-analytical Laboratory

Errors
Tim Guirl MT (ASCP)
Phlebotomy Instructor
North Seattle Community College
Health & Human Services Division
 Objectives
 Identify the significant pre-analytical errors that
can occur during blood specimen collection and
transport
 Explain the various means of pre-analytical error
prevention
 List proactive steps to reduce potential pre-
analytical errors associated with blood collection
and transport
 Introduction
 Three phases of laboratory testing:
pre-analytical, analytical and post-analytical
 Pre-analytical—specimen collection, transport
and processing
 Analytical—testing
 Post-analytical—testing results transmission,
interpretation, follow-up, retesting.
 Phlebotomy Errors
 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.
 Phlebotomy errors may cause harm to patients
or result in needlestick injury to the
phlebotomist
 Pre-analytical 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 during the collection process are not
inevitable and can be prevented with a diligent
application of quality control, continuing
education and effective collection systems
 Types of Collection Errors
 Patient Identification

 Phlebotomy Technique

 Test Collection Procedures

 Specimen Transport

 Specimen Processing
 Patient Identification Errors
 Errors in correctly identifying the patient
are indefensible
 Reasons for patient identification errors
 Proper
positive patient identification
procedures not followed
 Patient identification from identification bracelet
(inpatients)
 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 Errors
 Specimen tubes unlabeled
 Requisition or collection tube labels not
affixed to tubes
 Requisition or collection tube labels in bag
containing collection tubes
 Requisition or collection tube labels rubber-
banded to 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
 Patient Identification Errors
 Collection tubes labeled with the wrong
patient
 Wrong computerized labels affixed to
collection tubes at bedside
 Collection tubes not labeled at the time of
collection
 Collection tubes incorrectly labeled by
someone other than the phlebotomist who
collects the specimen
 Patient Complications
 Some patient variables that affect blood
specimens
 Diet
 Fasting
 Exercise
 Obesity

 Allergies to alcohol or iodine used to clean

venipuncture site
 Use alternative cleanser such as chlorhexidine
 Phlebotomy Technique Errors
 Phlebotomy technique is important
 Ensures test result validity
 Minimizes trauma to patient

 Minimizes potential for phlebotomist injury

 Reduces recollections

 Vein selection essential for successful

venipuncture
 Three veins in antecubital fossa in order of selection
(1) median cubital (2) cephalic (3) basilic
 Phlebotomy Technique Errors
 Site Selection
 Avoid sites with IV
 Use alternative arm or draw below IV to avoid
contamination/dilution from IV
 Document arm if IV

 Mastectomy—avoid site due to lymphostasis

 Infection risk/alteration in body fluids and blood analytes
 Edematous areas —avoid due to accumulation
of body fluids
 Possible contamination/dilution of specimen
Phlebotomy Technique Errors
 Venous Access Difficulties
 Obstructed, hardened, scarred veins
 Veins difficult to locate
 Use of Alternative sites
 Top of hand/Side of wrist
 Areas to avoid

 Vein Collapse
 Useof appropriate needle size
 Smaller evacuated collection tube
 Phlebotomy Technique Errors
 Tourniquet Application
 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)
 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
 Phlebotomy Technique Errors
 Cleansing of venipuncture site
 Thorough cleaning with alcohol
 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
 Recollection rate for blood cultures ranges due to contamination is as
high as 50% in hospitals with increased costs, patient overtreatment
 Phlebotomy Technique Errors
 Correct collection system
 Evacuated tube system (Vacutainer) for large veins
in antecubital fossa
 Syringe for small, fragile veins or veins outside
antecubital fossa
 Venous access
 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
 Anchor vein to prevent movement during needle entry and to
reduce pain to patient
 Test Collection Errors
 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
 Hemolysis
 Blood collected insufficient to amount of additive in tube,
 Traumatic venipuncture
 Blood collected from area with hematoma
 Vigorous shaking of tubes after collection
 Milking the site when collecting capillary samples and blood
collected using a small diameter needle.
 Test Collection Errors
 Timing of Collection
 Timed Draws
 Therapeutic Drug Monitoring
 Peak and trough collection times
 Basal State Collections
 Fasting requirements—no food or liquid except water
 Specimens affected by time of day, for example,
cortisol
 Test Collection Errors
 Improper collection tube drawn for test ordered
 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.
 Test Collection Errors
 Capillary Collections—finger stick or heel stick
 Appropriate site
 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
 Warming—Warm before collection to increase
capillary blood flow near skin surface
 Cleaning—cleanse site with alcohol and allow to air
dry
 Capillary Collections
 Massaging site to increase blood flow
 Milking site can cause hemolysis or tissue fluid
contamination
 Finger sticks—roll fingers toward fingertip at 1st finger
joint several times
 Heel sticks—gently squeeze infant’s heel before
performing puncture.
 Perform puncture while firmly squeezing finger or
heel
 Wipe away first two drops of blood
 Ensure that full blood drop wells up each time
 Capillary Collections
 Avoid touching capillary collection tube or
micro collection tube to skin or scraping skin
surface
 Contaminatespuncture site
 Blood may become hemolyzed

 Mixing micro collection tubes with additive

frequently to avoid micro clots
 Collecting tubes with additives first
 Protecting tubes for bilirubin from light
Blood Specimen Transport Errors
 Transport of blood specimens in the proper
manner after collection ensures the quality of
the sample
 Timing
 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
 Transport Errors
 Temperature
 Specimens must be transported at the appropriate
temperature for the required test
 On ice—ABGs, Ammonia
 Warmed --98.6 degrees (37 C), cryoglobulins
 Avoid temperature extremes if transported from via
vehicle from other collection site
 Transport Container
 Some samples need to be protected from light, for example,
bilirubin
 Transport in leak-proof plastic bags in lockable rigid
containers
 Error Prevention
 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
 Continuing Education
 Phlebotomists should participate in regular educational competency
assessments (written and observational)
 Professional Licensure
 Phlebotomy Staffing
 Adequate staffing to maintain collection standards
 Technology
 Use of barcode scanners for patient identification
 Questions and Discussion
 How are pre-analytical errors prevented in your
laboratory?
 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 pro-active improvements would reduce
the number of pre-analytical errors?