Preanalytical venous blood sampling practices demand improvement — A survey of test-request management, test-tube labelling and information search procedures

Compliance with the clinical laboratory quality protocol in public primary healthcare centres

The clinical and economic relevance of the clinical laboratories procedures in Andalusia (Spain) have led the Regional Department of Health to focus attention on their improvement. A unified laboratory protocol was implemented that consisted of the unification of criteria in the handling and processing of samples, and report of results. The objective of this study is to describe the degree of compliance with the clinical laboratory protocol in the preanalytical phase, which includes the analytical request and up to the delivery in the laboratory, as well as the influencing factors. Cross-sectional descriptive study with a sample of 214 healthcare professionals involved in the preanalytical phase of laboratory procedures in primary care. A self-reported questionnaire with 11 items was used for data collection. Each item was assessed separately with a scale from 0 to 10. A 5 points score was considered as the cutoff point. Descriptive analysis was conducted and Mann-Whitney U test was used to determine differences between subgroups. Internal consistency of the questionnaire was considered. The best rated item was verifying the correspondence between the request form and identity of the patient. Each item scored from 3 to 10, and the mean for each item ranged from 6.40 (standard deviation = 3.06) to 8.57 (standard deviation = 2.00). Values above or equal to 8 were obtained, for 63.6% of them. Statistically significant differences between accredited and nonaccredited centres were found. Differences were not noteworthy regarding centres with a teaching activity or those without it. All the items were measured separately. The compliance with the protocol was adequate among primary healthcare professionals, who have a strategic position in the sample collection and its transport during the preanalytical phase. Being so, standardisation should be a priority to reduce errors and improve clinical safety and results.

Prevention of extra-analytical phase errors by non-analytical automation in clinical laboratory

During previous decades, significant improvements in laboratory errors have become a substantial part of reducing preventable diagnostic errors. In clinical laboratory practice, the errors in the testing process are primarily associated with extra-analytical phase error sources, influencing the test result quality profoundly. Thus, the management of these critical error sources makes their effects preventable thanks to automation and computer sciences. The implementation of non-analytical automated systems requires a risk management strategy based on laboratory’s workflow and bottlenecks. Then, the improvements can be measured and evaluated by the usage of quality indicators (QI). Consequently, the total quality of laboratory diagnostics and higher patient safety is closely dependent on this type of automation. This review will help laboratory professionals, managers, and directors improve the total testing processes (TTP). The automation technologies have added a serious impact on the proficiency of laboratory medicine. Several instrumentations have now partially or entirely automated many manual tasks to improve standardization, organization, efficiency, and TTP quality. The implementation of non-analytical automation has made them manageable. As a result, non-analytical automation within and outside the clinical laboratory will necessarily lessen the error sources’ effect on the total test process, enhancing the quality of the test results.

A portable droplet microfluidic device for cortisol measurements using a competitive heterogeneous assay

Point-of-care monitoring of chemical biomarkers in real-time holds great potential in rapid disease diagnostics and precision medicine. However, monitoring is still rare in practice, as the measurement of biomarkers often requires time consuming and labour intensive assay procedures such as enzyme linked immunosorbent assay (ELISA), which pose a challenge to an autonomous point-of-care device. This paper describes a prototype device capable of performing ELISA autonomously and repeatedly in a high frequency using droplet microfluidics. Driven by a specially designed peristaltic pump, the device can collect liquid samples from a reservoir, produce trains of droplets, complete magnetic bead based ELISA protocols and provide readouts with colourimetric measurement. Here, cortisol was chosen as a target analyte as its concentration in the human body varies on a circadian rhythm which may be perturbed by disease. The prototype device draws in and analyses 350 nL of the sample containing free bioactive cortisol every 10 seconds, with a sample-to-signal time of 10 minutes, and measures favourably in the analytical range of 3.175-100 ng ml-1, with reliably lower variability compared with the well plate based assay. As most ELISA type assays share similar procedures, we envisage that this approach could form a platform technology for measurement or even continuous monitoring of biomarkers in biological fluids at the point-of-care.

Improving diagnostic specimen management systems in an oral medicine department

Histological, haematological and microbiological investigations are essential in the field of oral medicine and are a crucial adjunct to clinical findings, often being relied on to obtain a definitive diagnosis. Importantly, in some cases, these investigations can help exclude or confirm the presence of malignancy. This project highlighted some problems regarding labelling and recording of specimens in an oral medicine department and a lack of clear specimen management processes. It aimed to improve specimen management by reducing reported incidents surrounding diagnostic tests. Quality improvement methods such as process mapping were key to understanding the journey of specimens and the departments involved at each stage of the system. Initiatives included a recording log book, staff training, information signage around the clinic and delegation of responsibilities, all of which were implemented over multiple plan, do, study, act (PDSA) cycles. The project was extremely successful and since implementation there has been a clear and sustained reduction in reported incidents. The small number of incidents which did occur all involved transportation of specimens and none involved labelling or recording. One can conclude that the change in test management systems in terms of recording and labelling of specimens in the department has been sustained. Ongoing engagement with stakeholders and senior leaders is the priority to ensure further reduction in incidents in the future and that the improvements are maintained. This project demonstrates how simple, realistic, cost-effective, quality improvement initiatives can have a significant positive impact on patient care and hospital management systems.

Transcultural Adaptation and Piloting of the "Regarding Blood-Sampling Practices at Primary Health Care Centres" Questionnaire

Preanalytical errors account for up to 70% of the total potentially detectable errors in the laboratory. The main problems detected are related with procedures associated with Primary Care nursing practices that are directly involved in the preanalytical phase. The objective of this study is to carry out a transcultural adaptation and piloting of the "Regarding Blood-Sampling Practices at Primary Health Care Centres" questionnaire as regards blood sampling in Primary Care. For this, a cross-sectional descriptive study has been developed within the Primary Care area of the Andalusian Public Health System. The venous blood sampling questionnaire was translated into and adapted to Spanish by qualified professionals and expert translators. The questionnaires were then delivered to all staff nurses from the health districts involved. The total sample consisted of 224 primary care nursing professionals. The factors that showed statistically significant relationships were identification and sample collection, management with information search, storage and labelling of samples, and reporting of errors. A lack of global relationship between factors makes it impossible to find a global quality factor in the sampling process. The process of translation, adaptation, and piloting of the questionnaire from its original version to the Spanish one has proven to be understandable by professionals in its entirety and to offer data similar to the original version.

Evaluation of the clinical implementation of a large-scale online e-learning program on venous blood specimen collection guideline practices

BACKGROUND

When performed erroneously, the venous blood specimen collection (VBSC) practice steps patient identification, test request management and test tube labeling are at high risk to jeopardize patient safety. VBSC educational programs with the intention to minimize risk of harm to patients are therefore needed. In this study, we evaluate the efficiency of a large-scale online e-learning program on personnel's adherence to VBSC practices and their experience of the e-learning program.

METHODS

An interprofessional team transformed an implemented traditional VBSC education program to an online e-learning program developed to stimulate reflection with focus on the high-risk practice steps. We used questionnaires to evaluate the effect of the e-learning program on personnel's self-reported adherence to VBSC practices compared to questionnaire surveys before and after introduction of the traditional education program. We used content analysis to evaluate the participants free text experience of the VBSC e-learning program.

RESULTS

Adherence to the VBSC guideline high-risk practice steps generally increased following the implementation of a traditional educational program followed by an e-learning program. We however found a negative trend over years regarding participation rates and the practice to always send/sign the request form following the introduction of an electronic request system. The participants were in general content with the VBSC e-learning program.

CONCLUSIONS

Properly designed e-learning programs on VBSC practices supersedes traditional educational programs in usefulness and functionality. Inclusion of questionnaires in the e-learning program is necessary for follow-up of VBSC participant's practices and educational program efficiency.

Pre-analytical phase management: a review of the procedures from patient preparation to laboratory analysis

The pre-analytical phase encompasses all the procedures before the start of laboratory testing. This phase of the testing process is responsible for the majority of the laboratory errors, since the related procedures involve many sorts of non-laboratory professionals working outside the laboratory setting, thus without direct supervision by the laboratory staff. Therefore, either correct organization or management of both personnel and procedures that regard blood specimen collection by venipuncture are of fundamental importance, since the various steps for performing blood collection represent per se sources of laboratory variability. The aim of this (non-systematic) review addressed to healthcare professionals is to highlight the importance of blood specimen management (from patient preparation to laboratory analyses), as a tool to prevent laboratory errors, with the concept that laboratory results from inappropriate blood specimens are inconsistent and do not allow proper treatment nor monitoring of the patient.

Efficiency of an automated reception and turnaround time management system for the phlebotomy room

BACKGROUND

Recent advances in laboratory information systems have largely been focused on automation. However, the phlebotomy services have not been completely automated. To address this issue, we introduced an automated reception and turnaround time (TAT) management system, for the first time in Korea, whereby the patient's information is transmitted directly to the actual phlebotomy site and the TAT for each phlebotomy step can be monitored at a glance.

METHODS

The GNT5 system (Energium Co., Ltd., Korea) was installed in June 2013. The automated reception and TAT management system has been in operation since February 2014. Integration of the automated reception machine with the GNT5 allowed for direct transmission of laboratory order information to the GNT5 without involving any manual reception step. We used the mean TAT from reception to actual phlebotomy as the parameter for evaluating the efficiency of our system.

RESULTS

Mean TAT decreased from 5:45 min to 2:42 min after operationalization of the system. The mean number of patients in queue decreased from 2.9 to 1.0. Further, the number of cases taking more than five minutes from reception to phlebotomy, defined as the defect rate, decreased from 20.1% to 9.7%.

CONCLUSIONS

The use of automated reception and TAT management system was associated with a decrease of overall TAT and an improved workflow at the phlebotomy room.

Factors associated with nursing students' adherence to venous blood collection practice guidelines - A cross sectional study

Venous blood specimen collection is a common procedure that nursing students perform during pre-registration courses, and training for such collections takes place on campus as well as at clinical placements. However, levels of adherence to practice guidelines are still suboptimal among both nursing students and healthcare staff. We aimed to explore nursing students' adherence to the Swedish national venous blood specimen collection practice guidelines regarding patient identification and test request management and how this adherence is related to clinical experience, capability beliefs, research use, and the perceived social climate in clinical contexts. A survey with a cross-sectional design was conducted among 305 nursing students at a medium-sized university in Sweden. Descriptive statistics and logistic regression were used for data analysis. The survey showed that 82% of the students adhered to patient identification guideline practices and 80% to test request management practices. Factors associated with correct patient identification procedures were semester and frequency of research use. Factors associated with correct test request management were previous healthcare work experience, semester, and capability beliefs regarding academic abilities and evidence-based practice. We conclude that there is a need to develop educational tools to train students in research use and evidence-based practice in order to enhance guideline practice adherence and improve patient safety.

Intensive educational efforts combined with external quality assessment improve the preanalytical phase in general practitioner offices and nursing homes

Background:

Errors in the preanalytical phase in clinical laboratories affect patient safety. The aim of this study was to evaluate the effect of intensive educational efforts together with external quality assessment (EQA) of the preanalytical phase from 2013 to 2015 to improve patient identification in primary health care in Norway. In addition, routines for venous and capillary blood sampling were investigated.

Methods:

A preanalytical EQA was circulated in 2013 by the Norwegian Quality Improvement of Laboratory Examinations (Noklus) to general practitioner offices and nursing homes (n=2000) to obtain information about important issues to focus on before launching an intensive educational program with courses, posters and visits in 2013–2015. Preanalytical EQA surveys were further circulated in 2014 and 2015.

Results:

The response rate varied between 42% and 55%. The percentages of participants asking for the patients’ name and the Norwegian identification number increased from about 8% in 2013 to about 35% in 2015. The increase was similar for those participating in only one EQA survey and for those who participated in EQA surveys both in 2013 and 2015. Guidelines for venous and capillary blood sampling were not always followed.

Conclusions:

Educational efforts more than the preanalytical EQA influenced the actions and resulted in an increase in the percentages of participants that followed the guidelines for patient identification. Some aspects of blood sampling routines need improvement.

Targeting Rejection: Analysis of Specimen Acceptability and Rejection, and Framework for Identifying Interventions in a Single Tertiary Healthcare Facility

OBJECTIVES

Assessment of specimen rejection rates is an important laboratory quality measure for laboratories because of a potential negative impact on patient care. Here, we examined reasons for specimen rejection at a single, tertiary care healthcare institution and propose a framework for designing an efficient intervention.

METHODS

During a 1-year period, we identified all specimens rejected at our hospital and performed an analysis of a wide range of associated variables: reason for rejection, patient location, type of phlebotomist, tests ordered, priority status, collection container used, transport time.

RESULTS

Clotted and hemolyzed specimens accounted for the majority of rejected specimens, but significant differences in reasons for specimen rejection existed between patient care areas. Eighty-five percent of rejected specimens came from the Emergency Department and eight other inpatient care areas. Registered nurses drew approximately 85% of rejected specimens, while laboratory phlebotomy staff drew only 4%.

CONCLUSIONS

While hemolysis and clotting are primary causes for specimen rejection, collection of all available data regarding specimen rejection data is essential for laboratories determining which factors are most significant causes of specimen rejection.

Findings of Phlebotomy Practices in Kenya in 2010: Need for Action

BACKGROUND

Phlebotomy, a commonly performed medical procedure in healthcare, is essential for disease diagnosis and patient management. However, poorly performed phlebotomy can compromise patient safety, healthcare worker (HCW) safety, and specimen quality. We carried out a study between June and July 2010 to assess knowledge, quality and safety of phlebotomy before implementation of a public-private partnership between Becton, Dickinson and Company and the US President's Emergency Plan for AIDS Relief.

METHODS

This was a cross-sectional observational study in 8 healthcare facilities within 4 regions of Kenya. HCWs were observed conducting venous and capillary blood collections, and pre- and posttests were offered during HCW training.

RESULTS

Of 283 blood samples obtained, 194 were venous draws conducted by 72 HCWs and 89 were capillary draws performed by 33 HCWs. Based on 12 preset quality-associated criteria, none of the 194 observed phlebotomies met the standard. In total, 91 HCWs were trained in phlebotomy. The mean knowledge increase between pre- and posttraining test was 41%, ranging from 39% to 45% (95% confidence interval, 29.3%-53.5%;P< .001).

CONCLUSIONS

Inadequate knowledge and imperfect phlebotomy procedures were noted. This formed the basis for the safe phlebotomy partnership to address these deficiencies. To ensure sustainability, safe phlebotomy practices were integrated into preservice training.

Associations between workplace affiliation and phlebotomy practices regarding patient identification and test request handling practices in primary healthcare centres: a multilevel model approach

Background

Clinical practice guidelines aim to enhance patient safety by reducing inappropriate variations in practice. Despite considerable efforts to enhance the use of clinical practice guidelines, adherence is often suboptimal. We investigated to what extent workplace affiliation explains variation of self-reported adherence to venous blood specimen collection regarding patient identification and test request handling practices, taking into consideration other primary healthcare centre and individual phlebotomist characteristics.

Methods

Data were collected through a questionnaire survey of 164 phlebotomy staff from 25 primary healthcare centres in northern Sweden. To prevent the impact of a large-scale education intervention in 2008, only baseline data, collected over a 3-month period in 2006–2007, were used and subjected to descriptive statistics and multilevel logistic analyses.

Results

In two patient identification outcomes, stable high median odds ratios (MOR) were found in both the empty model, and in the adjusted full model including both individual and workplace factors. Our findings suggest that variances among phlebotomy staff can be largely explained by primary healthcare centre affiliation also when individual and workplace demographic characteristics were taken in consideration. Analyses showed phlebotomy staff at medium and large primary healthcare centres to be more likely to adhere to guidelines than staff at small centres. Furthermore, staff employed shorter time at worksite to be more likely to adhere than staff employed longer. Finally, staff performing phlebotomy every week or less were more likely to adhere than staff performing phlebotomy on a daily basis.

Conclusion

Workplace affiliation largely explains variances in self-reported adherence to venous blood specimen collection guidelines for patient identification and test request handling practices among phlebotomy staff. Characteristics of the workplace, as well as of the individual phlebotomist, need to be identified in order to design strategies to improve clinical practice in this and other areas.

Preanalytic errors in anatomic pathology: study of 10,574 cases from five Portuguese hospitals

BACKGROUND

Identification of errors in anatomic pathology is an important issue in medical practice. The main objective of this study was to determine the prevalence and characterize preanalytic errors in surgical pathology and cytology samples. We also intended to explore associations between error prevalence and procedures implemented in hospitals concerning the type of requisition forms, use of guidelines for case acceptance and existence of error notification system.

METHODS

We analyzed 10,574 cases in five Portuguese hospitals. The pathology laboratories recorded during 20 days all cases submitted with preanalytic errors, using an input form that allowed the identification of sample type, error description, action taken before error, the professional who detected the fail and the test cycle segment where it was identified. Subsequently, particular procedures in use for preanalytic phase were characterized for each hospital.

RESULTS

The prevalence of cases with error was 3.1% (330/10,574), 95% confidence interval: 2.8%-3.5%. Errors occurred in 4.1% (250/6079) of histology specimens and 0.9% (40/4477) of cytology specimens, and included errors in the requisition forms (2.6% error rate) and in the sample container (1.5% error rate). Acceptance of cases with error was the most frequent action (66.9%), followed by rejection (24.4%) and retention (8.7%).

CONCLUSIONS

The existence of written norms for sample acceptance and error reporting systems to submitting services and patient safety department were proven to be associated to lower error prevalence.

External Quality Assessment Programs in the US with an emphasis on urinary sediment testing: the College of American Pathologists experience

The College of American Pathologists (CAP) has maintained the highest standards for laboratory medicine through education, evaluation, and certification. One form of External Quality Assurance - proficiency testing (PT) - is the centerpiece of that mission. Over 500 medical and scientific experts oversee CAP PT programs which include more than 600 tests performed by 22,000 laboratories in over 100 countries. It is the most comprehensive laboratory peer-review comparison program in the world. The CAP offers four urine sediment PT products tailored to the needs of different laboratories. Each includes three or four digital images, shipped twice a year. The program is overseen by the Hematology and Clinical Microscopy Resource Committee. Images are graded if there is 80% or greater consensus of either referee or participant laboratories. Failing laboratories must analyze the reasons for the failure, report the results, and initiate corrective action. Over the years, there has been a progressive decline in the number of errors, demonstrating that education and regulatory oversight are major contributors to improved PT performance and, by extension, patient care. The PT urine sediment image databank is a unique resource, representing the consensus of many laboratories. Participant and referee responses identify which morphologic variants are unambiguous and which are more difficult to classify. The PT challenges include discussions of disease pathophysiology and key morphologic features. This teaching component is what helps to set the CAP's program apart. The discussions formed the basis for the Color Atlas of Urinary Sediment published by the CAP in 2010.

Personnel's Experiences of Phlebotomy Practices after Participating in an Educational Intervention Programme

Background. Blood specimen collection is a common procedure in health care, and the results from specimen analysis have essential influence on clinical decisions. Errors in phlebotomy may lead to repeated sampling and delay in diagnosis and may jeopardise patient safety. This study aimed to describe the experiences of, and reflections on, phlebotomy practices of phlebotomy personnel working in primary health care after participating in an educational intervention programme (EIP). Methods. Thirty phlebotomists from ten primary health care centres participated. Their experiences were investigated through face-to-face interviews. Findings were analysed using qualitative content analysis. Results. The participants perceived the EIP as having opened up opportunities to reflect on safety. The EIP had made them aware of risks in relation to identification procedures, distractions from the environment, lack of knowledge, and transfer of information. The EIP also resulted in improvements in clinical practice, such as a standardised way of working and increased accuracy. Some said that the training had reassured them to continue working as usual, while others continued as usual regardless of incorrect procedure. Conclusions. The findings show that EIP can stimulate reflections on phlebotomy practices in larger study groups. Increased knowledge of phlebotomy practices improves the opportunities to revise and maximise the quality and content of future EIPs. Educators and safety managers should reflect on and pay particular attention to the identification procedure, distractions from the environment, and transfer of information, when developing and implementing EIPs. The focus of phlebotomy training should not solely be on improving adherence to practice guidelines.

Deviations from venous blood specimen collection guideline adherence among senior nursing students

BACKGROUND

Despite considerable efforts to increase patient safety by supporting the use of best practice medical and nursing guidelines by healthcare staff, adherence is often suboptimal. Swedish nurses often deviate from venous blood specimen collection (VBSC) guideline adherence. We assessed the adherence to national VBSC guidelines among senior nursing students.

METHODS

We conducted a cross-sectional, self-reported questionnaire survey among 101 out of 177 senior nursing students consisting of web-based students in their fifth semester and campus-based students in their fifth or sixth semester out of six. In regard to the VBSC procedures, we asked about adherence to the patient identification, test request handling, and test tube labelling protocols that the students had learned during their second semester and practiced thereafter.

RESULTS

Guideline adherence to patient identification was reported by 81%, test request handling by 74%, and test tube labelling by 2% of the students. Students with no prior healthcare education reported to a higher extent that they operated within the guidelines regarding labelling the test tube before entering the patient's room compared to students with prior healthcare education. Using multiple logistic regression analysis, we found that fifth semester web-based program students adhered better to VBSC guidelines regarding comparing patient ID/test request/tube label compared to campus-based students.

CONCLUSIONS

Senior nursing students were found to adhere to VBSC guidelines to a similar extent as registered nurses and other hospital ward staff in clinical healthcare. Thus student adherence to VBSC guidelines had deteriorated since their basic training in the second semester, and this can impact patient safety during university/clinical studies. The results of our study have implications for nursing practice education.

Impact of a large-scale educational intervention program on venous blood specimen collection practices

BACKGROUND

Phlebotomy performed with poor adherence to venous blood specimen collection (VBSC) guidelines jeopardizes patient safety and may lead to patient suffering and adverse events. A first questionnaire study demonstrated low compliance to VBSC guidelines, motivating an educational intervention of all phlebotomists within a county council. The aim was to evaluate the impact of a large-scale educational intervention program (EIP) on primary health care phlebotomists' adherence to VBSC guidelines. We hypothesised that the EIP would improve phlebotomists' VBSC practical performance.

METHODS

The present study comprise primary health care centres (n = 61) from two county councils in northern Sweden. The final selected study group consisted of phlebotomists divided into an intervention group (n = 84) and a corresponding control group (n = 79). Both groups responded to a validated self-reported VBSC questionnaire twice. The EIP included three parts: guideline studies, an oral presentation, and an examination. Non-parametric statistics were used for comparison within and between the groups.

RESULTS

Evaluating the EIP, we found significant improvements in the intervention group compared to the control group on self-reported questionnaire responses regarding information search (ES = 0.23-0.33, p < 0.001-0.003), and patient rest prior to phlebotomy (ES = 0.27, p = 0.004). Test request management, patient identity control, release of venous stasis, and test tube labelling had significantly improved in the intervention group but did not significantly differ from the control group (ES = 0.22- 0.49, p = < 0.001- 0.006). The control group showed no significant improvements at all (ES = 0-0.39, p = 0.016-0.961).

CONCLUSIONS

The present study demonstrated several significant improvements on phlebotomists' adherence to VBSC practices. Still, guideline adherence improvement to several crucial phlebotomy practices is needed. We cannot conclude that the improvements are solely due to the EIP and suggest future efforts to improve VBSC. The program should provide time for reflections and discussions. Furthermore, a modular structure would allow directed educational intervention based on the specific VBSC guideline flaws existing at a specific unit. Such an approach is probably more effective at improving and sustaining adherence to VBSC guidelines than an EIP containing general pre-analytical practices.

A new device to relieve venipuncture pain can affect haematology test results

BACKGROUND

In vitro diagnostic tests play a key role in patients' management (e.g., guiding red blood cell transfusions). The aim of this study was to evaluate the impact of an innovative device (Buzzy®) which is claimed to be able to relieve venipuncture pain by means of cold and vibration. This device was applied during collection of venous blood by venipuncture for conventional haematology testing.

MATERIALS AND METHODS

Blood was drawn from 100 volunteers by a single, expert phlebotomist. A vein was located in the left forearm without applying a tourniquet but using a subcutaneous tissue transilluminator device, so that venous stasis was avoided. Blood samples were collected with a 20G straight needle directly into 4 mL K3EDTA vacuum tubes. In sequence, external cold and vibration was established by Buzzy® on the right forearm -5 cm above the venipuncture site- for 1 minute before venipuncture and continued until the end of the same procedure already performed in the left forearm. Conventional haematological tests were performed using the same instrument (Sysmex® XE-2100D) in all cases.

RESULTS

When Buzzy® was applied before drawing blood, erythrocyte counts and associated parameters (i.e., haemoglobin and haematocrit) were higher, whereas platelet number, leucocyte count and differential were lower. Statistically and clinically significant differences (P<0.001) were observed for erythrocytes, haemoglobin and haematocrit.

DISCUSSION

From a practical perspective, cold-induced haemoconcentration promotes the efflux of water, diffusible ions and low molecular weight molecules from the vessel, thus increasing the concentration of other blood analytes at the puncture site. These variations may influence test results, especially for erythrocytes, haemoglobin and haematocrit. The novel Buzzy® device should, therefore, be used with caution when collecting blood for conventional haematological testing because of the observed bias introduced in some parameters.

Quantification of Hemodialysis Dose: What Kt/V to Choose?

Background

Quantification of hemodialysis became more accurate and easier after the advent of ionic dialysance and the use of methods for estimating urea distribution volume (V). The aim of this study was to compare different methods of hemodialysis dose assessment: Kt/VDau (Daugirdas 2nd generation), Kt/VOCM (Kt by OCM (Online Clearance Monitor) and V by Watson), and Kt/VBCM (Kt by OCM and V by bio-impedance); and to assess the dialysis adequacy, defined by a Kt/V≥1.4.

Design

Prospective, observational study.

Methods

35 hemodialysis sessions were evaluated in 35 chronic hemodialysis patients. During each session, we measured simultaneously, Kt/VOCM, Kt/VBCM and calculated Kt/VDau by performing blood samples before and after each session.

Results

35 patients, gender (M/F: 19/16), mean age of 50.49 years, were evaluated. We noted a difference between the three methods of evaluating Kt/V index: Kt/VDau, Kt/VOCM and Kt/VBCM (1.82 ± 0.29; 1.45 ± 0.23; 1.8 ± 0.33, p<0.001). Comparison of Kt/VOCM with Kt/VDau and Kt/VBCM leads to a significant systematic underestimate of Kt/V by 22% and 20.5% respectively. Better agreement between Kt/VDau and Kt/VBCM was observed. The adequate hemodialysis was achieved, according to three methods: Kt/VDau, Kt/VOCM and Kt/VBCM respectively in 100%, 57,1% and 88.6% of the cases.

Conclusions

The Kt/V index is different depending on the method used for its evaluation. The three methods can be used for quantification of hemodialysis with a better agreement between Kt/VDau and Kt/VBCM. In this study, Kt/VOCM results underestimate hemodialysis efficiency. This difference has to be considered when applying quantification of hemodialysis to clinical practice.

Short-term interventions on wards fail to reduce preanalytical errors: results of two prospective controlled trials

Background

Preventing laboratory errors promotes patient safety and reduces the cost of unnecessary processing. The aim of this study was to test the effectiveness of two short-term interventions at reducing errors in the preanalytical stage of laboratory testing.

Methods

Error data were reviewed from inpatient wards at Bradford Royal Infirmary (BRI), Leeds General Infirmary (LGI) and St James’ University Hospital (SJUH) for 22 weeks. Two separate interventions lasted for two weeks. The outcome measures were inadequate tube and form labelling, incorrect tube selection and insufficient sample volume. Posters targeting these errors were created and displayed on inpatient wards in SJUH ( n = 48). BRI and LGI were control hospitals. Qualitative interviews were held with clinical staff to raise awareness of common errors, give advice and discuss error reduction ( n = 37). Ten weeks later, screensavers warning against labelling errors were displayed (LGI and SJUH). Quantitative error data, routinely collected by the laboratory, were used for analysis.

Results

There was no change in error rate or type at the intervention site(s) compared with the control(s). There were 7058 reported errors across three sites, of which 6623 were errors targeted by the interventions. The overall error rate remained stable on all three sites (analysis of variance, P = 1.0). When interviewing clinical staff, 29% thought that equipment was the main contributing factor to errors while 23% struggled with tube selection.

Conclusions

Despite enthusiasm on the part of the ward-based staff, both short-term interventions had no significant impact on preanalytical error rates. Most errors are due to human factors. These may be reduced with the introduction of an electronic ordering system.

A content validated questionnaire for assessment of self reported venous blood sampling practices

BACKGROUND

Venous blood sampling is a common procedure in health care. It is strictly regulated by national and international guidelines. Deviations from guidelines due to human mistakes can cause patient harm. Validated questionnaires for health care personnel can be used to assess preventable "near misses"--i.e. potential errors and nonconformities during venous blood sampling practices that could transform into adverse events. However, no validated questionnaire that assesses nonconformities in venous blood sampling has previously been presented. The aim was to test a recently developed questionnaire in self reported venous blood sampling practices for validity and reliability.

FINDINGS

We developed a questionnaire to assess deviations from best practices during venous blood sampling. The questionnaire contained questions about patient identification, test request management, test tube labeling, test tube handling, information search procedures and frequencies of error reporting. For content validity, the questionnaire was confirmed by experts on questionnaires and venous blood sampling. For reliability, test-retest statistics were used on the questionnaire answered twice. The final venous blood sampling questionnaire included 19 questions out of which 9 had in total 34 underlying items. It was found to have content validity. The test-retest analysis demonstrated that the items were generally stable. In total, 82% of the items fulfilled the reliability acceptance criteria.

CONCLUSIONS

The questionnaire could be used for assessment of "near miss" practices that could jeopardize patient safety and gives several benefits instead of assessing rare adverse events only. The higher frequencies of "near miss" practices allows for quantitative analysis of the effect of corrective interventions and to benchmark preanalytical quality not only at the laboratory/hospital level but also at the health care unit/hospital ward.

Blood sample collection and patient identification demand improvement: a questionnaire study of preanalytical practices in hospital wards and laboratories

Scand J Caring Sci; 2010; 24; 581-591 
 Blood sample collection and patient identification demand improvement: a questionnaire study of preanalytical practices in hospital wards and laboratories

BACKGROUND

  Most errors in venous blood testing result from human mistakes occurring before the sample reach the laboratory.

AIMS

  To survey venous blood sampling (VBS) practices in hospital wards and to compare practices with hospital laboratories.

METHODS

  Staff in two hospitals (all wards) and two hospital laboratories (314 respondents, response rate 94%), completed a questionnaire addressing issues relevant to the collection of venous blood samples for clinical chemistry testing.

RESULTS

  The findings suggest that instructions for patient identification and the collection of venous blood samples were not always followed. For example, 79% of the respondents reported the undesirable practice (UDP) of not always using wristbands for patient identification. Similarly, 87% of the respondents noted the UDP of removing venous stasis after the sampling is finished. Compared with the ward staff, a significantly higher proportion of the laboratory staff reported desirable practices regarding the collection of venous blood samples. Neither education nor the existence of established sampling routines was clearly associated with VBS practices among the ward staff.

CONCLUSIONS

  The results of this study, the first of its kind, suggest that a clinically important risk of error is associated with VBS in the surveyed wards. Most important is the risk of misidentification of patients. Quality improvement of blood sample collection is clearly needed, particularly in hospital wards.

Pre-Analytical Workstations as a Tool for Reducing Laboratory Errors

Reducing errors and improving quality are an integral part of Laboratory Medicine. Laboratory testing, a highly complex process commonly called the total testing process (TTP), is usually subdivided into three traditional (pre-, intra-, and post-) analytical phases. A series of papers published from 1989 drew the attention of laboratory professionals to the pre-analytical phase, which currently appears to be more vulnerable to errors than the other phases. Consequently, the preanalytical phase should be the main target for further quality improvement. Therefore, identifying the critical steps in the pre-analytical phase is a prerequisite for continuous quality improvement, further error reduction and thus for improving patient safety. Use of automated systems where feasible, and use of error reduction/improved quality as a factor when selecting instrumentation are the main tools we have to insure high quality and minimize errors in the pre-analytical phase. The reasons for automation of the pre-analytical phase have become so compelling that it is no longer simply a competitive advantage for laboratories, but rather a competitive necessity. These systems can impact on the clinical/laboratory interface and affect the efficiency, effectiveness and quality of care.

Is the test result correct? A questionnaire study of blood collection practices in primary health care

RATIONALE, AIMS AND OBJECTIVES

Venous blood tests are important for clinical decision making. Most errors in blood testing are due to human errors before the blood samples reach the laboratory. The present study was designed to investigate venous blood sampling (VBS) practices in primary health care centres (PHCs) compared with clinical laboratory staff.

METHOD

A cross-sectional survey of 70 PHCs and two clinical laboratories is conducted. All staff responsible for VBS (317 respondents, response rate 94%) completed a questionnaire on VBS practices.

RESULTS

Instructions for VBS were not followed in the surveyed PHCs. For example, only 54% reported that they always identified the patient by using name/Swedish identification number and only 5% reported that they always used photo-ID, the two preferred means for patient identification. Only 12% reported that they always released venous stasis as soon as possible. Fewer PHC staff than clinical laboratory staff reported correct VBS practices. For example, 54% of the PHC staff reported that they always identified the patient by name and Swedish identification number, as compared with 95% of the clinical laboratory staff (P < 0.001). Documented VBS routines and re-education in VBS were not clearly associated with reported correct VBS practices.

CONCLUSIONS

In the surveyed PHCs, there are clinically important risks for misidentification of patients and erroneous test results, with consequences for the diagnosis and treatment of patients. Quality interventions, aimed at improving VBS practices, are needed to ensure patient safety.

Incident reporting practices in the preanalytical phase: Low reported frequencies in the primary health care setting

OBJECTIVE

Incident reporting is commonly used to improve patient safety. The preanalytical phase of laboratory testing contains several manual error-prone tasks where mistakes can affect patient outcomes. However, the practical use of incident reports in this area has not been previously investigated in the primary health care setting, where the majority of the patients come in contact with health care.

MATERIAL AND METHODS

All staff responsible for venous blood sampling in 70 primary health care centres and in two hospital clinical laboratories (317 respondents, response rate 94%) completed a questionnaire.

RESULTS

Of the primary health care staff, 69% reported that they had never filed an incident report regarding venous blood sampling. Barriers for not filing incident reports often/always included lack of time (44%) and a complicated reporting procedure (27%). A higher proportion of staff with re-education (43%) had filed at least one incident report as compared to those without re-education (20%, p < 0.001). No differences in incident reporting practices were found between primary health care and hospital clinical laboratory staff.

CONCLUSIONS

The investigated incident reporting system is likely to underreport incidents in the preanalytical phase. Therefore, the ability to discover preventable system vulnerabilities needs refinement.

Health-related information provided to patients attending a private clinic for laboratory tests in Spain

OBJECTIVE

The aim of this study is to analyze the health information received by a group of outpatients undergoing treatment and attending a private primary health care centre for blood and urine tests.

METHODS

We asked patients to report on whether they had been informed about the tests, about the information received on earlier occasions concerning analysis results and their understanding of their illness and prescribed treatment. The Chi-square test was used to assess the relation between the above and the patients socio-demographic characteristics.

RESULTS

Of the sample (n=309), 19.1% reported that they had not been given instructions on how to prepare themselves for the tests, 55% were unable to understand previous analytical results, 83.2% had asked for clarification and 82.5% had their doubts clarified. 41.4% did not understand what illness they had, while 32% and 17.7%, respectively, did not know how long to continue the treatment or the proper way to do so.

CONCLUSION

Immigrants, the elderly and those with a low level of formal education were the worst informed and had the lowest understanding of their illness, the results of previous analyses and the prescribed treatment.

PRACTICE IMPLICATIONS

The results underline the fact that doctors should properly communicate with patients and make sure they understand.

Preanalytical mistakes in samples from primary care patients

BACKGROUND

Preanalytical mistakes (PAMs) in samples usually led to rejection upon arrival to the clinical laboratory. However, PAMs might not always be detected and result in clinical problems. Thus, PAMs should be minimized. We detected PAMs in samples from Primary Health Care Centres (PHCC) served by our central laboratory. Thus, the goal of this study was to describe the number and types of PAMs, and to suggest some strategies for improvement.

METHODS

The presence of PAMs, as sample rejection criteria, in samples submitted from PHCC to our laboratory during October and November 2007 was retrospectively analysed.

RESULTS

Overall, 3885 PAMs (7.4%) were detected from 52,669 samples for blood analyses. This included missed samples (n=1763; 45.4% of all PAMs, 3.3% of all samples), haemolysed samples (n=1408; 36.2% and 2.7%, respectively), coagulated samples (n=391; 10% and 0.7%, respectively), incorrect sample volume (n=110; 2.8% and 0.2%, respectively), and others (n=213; 5.5% and 0.4%, respectively). For urine samples (n=18,852), 1567 of the samples were missing (8.3%).

CONCLUSIONS

We found the proportion of PAMs in blood and urine samples to be 3-fold higher than that reported in the literature. Therefore, strategies for improvement directed towards the staff involved, as well as an exhaustive audit of preanalytical process are needed. To attain this goal, we first implemented a continued education programme, financed by our Regional Health Service and focused in Primary Care Nurses.

Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling

: Most errors in laboratory medicine occur in the preanalytical phase and are the result of human mistakes. This study investigated information search procedures, test request management and test tube labelling in primary healthcare compared to the same procedures amongst clinical laboratory staff.

: A questionnaire was completed by 317 venous blood sampling staff in 70 primary healthcare centres and in two clinical laboratories (response rate = 94%).

: Correct procedures were not always followed. Only 60% of the primary healthcare staff reported that they always sought information in the updated, online laboratory manual. Only 12% reported that they always labelled the test tubes prior to drawing blood samples. No major differences between primary healthcare centres and clinical laboratories were found, except for test tube labelling, whereby the laboratory staff reported better practices. Re-education and access to documented routines were not clearly associated with better practices.

: The preanalytical procedure in the surveyed primary healthcare centres was associated with a risk of errors which could affect patient safety. To improve patient safety in laboratory testing, all healthcare providers should survey their preanalytical procedures and improve the total testing process with a systems perspective.

Clin Chem Lab Med 2009;47:195–201.

Pre-analytical issues for testosterone and estradiol assays

In order to standardize and harmonize testosterone measurement, it is vital to identify and minimize pre-analytical error as well as standardize them when developing reference intervals. These pre-analytic issues can be separated into technical and biological factors. Technical factors to address are the type of sample (serum vs. plasma), the type of collection tube, and the processing, storage, and handling of the samples. Biological issues include addressing the age of the subject, the time of day and month the sample is drawn, and all of the possible interfering drugs the subject may be taking. We recommend that great attention be paid to these pre-analytical issues before the assay methodologies are harmonized.