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 preanalytical 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 postanalytical
Pre-analyticalspecimen collection,
transport and processing
Analyticaltesting
Post-analyticaltesting 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 patients full name, date/time
of collection, phlebotomists 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

Mastectomyavoid

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

Use

of 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

Basal State Collections

Peak and trough collection times

Fasting requirementsno 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

Examplelight blue top tube for

Coagulation Studies. Incomplete filling
results in specimen dilution and
erroneous Prothrombin and aPTT test
results.

Test Collection Errors

Capillary Collectionsfinger stick or heel

stick

Appropriate site
Heel sticksides of the bottom surface of the heel
Finger stickthird or fourth fingers,
perpendicular to fingerprint lines on fleshy pads
on finger surface

WarmingWarm before collection to increase

capillary blood flow near skin surface
Cleaningcleanse 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 sticksroll fingers toward fingertip at
1st finger joint several times
Heel sticksgently squeeze infants 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
Contaminates

puncture 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 iceABGs, 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

Continuing Education

Phlebotomists should participate in regular educational

competency assessments (written and observational)
Professional Licensure

Phlebotomy Staffing

Phlebotomists should have completed a standard

academic course in phlebotomy and undergo
thorough on-the-job training under the supervision
of a senior phlebotomist

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?