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Pre-Analytical Variation

The Leading Cause of Error in Laboratory Medicine

Author: Mahboobe Ghaedi, PhD, and Joe M. El-Khoury, PhD, DABCC,

FACB
 //
Date: JUL.1.2016
 //
Source: Clinical Laboratory News

Topics: Lab Management,

Patient Safety,
Preanalytical Factors,
Sample Collection/Sample Type

In a recent report, researchers from Johns Hopkins University School of

Medicine in Baltimore made headlines when they estimated that medical
error is the third leading cause of death in the U.S. (1). While patient
safety remains a struggle in many areas of healthcare, laboratory
medicine has been a leader in reducing error, with an estimated total
error rate of 0.33%, the lowest in diagnostic medicine (2). Major
advancements in automation and analytical instrumentation have helped
reduce laboratory-associated errors over the last decade, but with pre-
analytical errors currently accounting for up to 75% of all mistakes (3),
laboratory medicine professionals must keep expanding their focus to
what is happening outside of the lab.

The classic paradigm for a wider view of errors is the total testing
process (TTP). Beginning with test ordering and ending with result
reporting, TTP encompasses the pre-analytical, analytical, and post-
analytical phases of testing (Figure 1). Pre-analytical variation includes
all the steps that occur from test ordering until right before sample
analysis. While the likelihood of variation in any of the three phases is
not negligible, the vast majority of laboratory variation emerges from the
many factors affecting laboratory specimens prior to testing. These
activities include test ordering, patient preparation, specimen collection,
transportation, preparation, and storage.

Since activities in the pre-analytical phase are neither performed entirely

in the clinical laboratory nor under the control of laboratory personnel,
they are harder to monitor and improve. Consequently, labs often have
focused on improving areas under their direct control while leaving pre-
analytical activities to healthcare professionals who have little to no
formal training in laboratory medicine.

Recognizing the magnitude of errors associated with the pre-analytical

phase, regulatory agencies and laboratory medicine associations have
dedicated more resources to developing focused checklists and quality
guidelines. The revised international standard ISO 15189:2012, Medical
Laboratories: Requirements for Quality and Competence, has expanded
its pre-examination procedures section to require laboratories to include
collection and pre-collection activities, specific instructions to patients
and users, and sample transportation, processing, and storage (4). In
addition, the International Federation for Clinical Chemistry and
Laboratory Medicine (IFCC) has established a working group,
Laboratory Errors and Patient Safety (WG-LEPS), with the goal of
reducing laboratory medicine-associated errors. The WG-LEPS’s most
promising initiative has been establishing standardized quality indicators
(QIs) to help labs monitor all three phases of testing.

QIs measure how well the laboratory meets the needs and requirements
of users and the quality of all operational processes. Monitoring the total
number of samples lost or not received normalized to the total number
of samples received is an example of a QI for the pre- analytical phase.
Adopting QIs to track and improve performance is essential: what a
laboratory does not measure, it cannot improve. Only by monitoring the
performance of the TTP can labs reliably identify and manage these
potential variations.

Sources of Pre-Analytical Variability

There are four general categories of pre-analytical variability, including:

test ordering, patient preparation, specimen collection, and specimen
processing, transportation, and storage (5). In this article, we discuss for
each category the sources of variation, potential solutions, and
appropriate QIs.

Test ordering

Test ordering, the first step of the pre-analytical process, is often

referred to as the pre-pre-analytical phase. Ordering the wrong test not
only is wasteful but also potentially harmful to patients. Providers order
inappropriate tests for a variety of reasons, including confusion over
tests with similar names (such as 25-hydroxyvitamin D versus 1,25-
dihydroxyvitamin D), unnecessary duplicate orders, transcription errors
during order entry, and misinterpreted verbal orders, which occur when
physicians do not place test orders themselves.

To deal with problems in this phase of testing, labs must engage hospital
staff to promote appropriate test utilization. This is typically done through
a laboratory formulary committee or test utilization committee that draws
from hospital-wide resources and influences physicians’ test ordering
behavior. Institutions lacking the resources or structure to set up a
formulary committee should focus on areas that will have the biggest
impact, such as monitoring expensive sendouts and duplicate orders.
Labs must ensure that such efforts are data driven and closely
monitored with QIs that can track inappropriate test orders, duplicate
orders, and errors in test input (Table 1).

Patient preparation

Patient preparation is one of the most challenging among the pre-

analytical phases because it encompasses variables that typically occur
before the individual arrives for his or her sample collection. Patient
preparation factors include:
Diet: Food ingestion is a significant source of pre-analytical variability.
This effect varies based on the analyte and the time between meal
ingestion and blood collection. For example, glucose and triglycerides
significantly increase after meals with high carbohydrates and fat,
respectively. An overnight fasting period of 10 to 14 hours prior to blood
collection is optimal for minimizing variations. However, some meals
may have longer-lasting effects and particular foods should be
prohibited before performing certain tests. For example, bananas are
high in serotonin and can affect 5-hydroxyindoleacetic acid excretion
testing. Caffeine, alcohol, vegetarianism, malnutrition, and starvation are
also known to have a significant impact on commonly measured
analytes. Communicating these requirements to patients is important to
ensure appropriate preparation for testing and has been recognized in
ISO 15189:2012.

Posture/exercise: A change from lying to standing can cause within 10

minutes an average 9% elevation in serum concentrations of proteins or
protein-bound constituents. This occurs because blood volume falls by
about 10% and only protein-free fluid passes through capillaries to the
tissue. Prolonged bed rest also sometimes dramatically affects
hematocrit, serum potassium, and protein-bound constituents. As a
result, some hospitalized patients should delay certain tests until after
they leave the hospital and resume normal activity.

On the opposite end of the activity spectrum, moderate and strenuous

exercise also deranges analytes like aspartate aminotransferase, lactate
dehydrogenase, creatinine kinase, and aldolase. This is due to skeletal
muscle release. Patients should be instructed to avoid moderate to
strenuous exercise prior to specimen collection for certain analytes.

Timing of sampling

Blood concentrations of various analytes change during the course of

the day. These cyclical variations can be significant, so the timing of
sample collection should be strictly controlled. For example, serum iron
increases by as much as 50% from morning to afternoon, and serum
potassium has been reported to decline from morning to afternoon by an
average of 1.1 mmol/L. Hormones such as cortisol, renin, aldosterone,
and corticotropin are especially impacted by this circadian variation.

Timing of sample collection is especially critical for therapeutic drug

monitoring, which requires trough levels for most analytes. Protocols
must specify an ideal time of sampling for each test and the actual time
of draw must be carefully documented. Draws that occur outside of the
specified time can be monitored as QIs (Table 1).

Strategies for detection

Clinical labs have several tools at their disposal to detect pre-analytical

errors. These include:

1. Erroneous result flags: These are analyte concentrations that do

not make physiologic sense, such as a potassium level of 20
mEq/L and calcium of 1.0 mg/dL, which is the typical pattern
 observed when a specimen drawn into a plasma EDTA tube is
transferred to a serum tube.
2. Critical result flags: These are results that are in the life-
threatening range, such as potassium of 6.5 mEq/L or glucose of
30 mg/dL, which also occur when there has been a significant
delay in sample processing.
3. Rules: This is when a combination of otherwise normal results
strongly indicates a problem with the specimen. A good example
is detection of intravenous line contamination using the “IF
Glucose > 800 mg/dL AND creatinine < 0.6 mg/dL” rule, among
others (7).
4. Delta checks: These help expose errors by calculating the
difference between a patient’s current results and previous
results based on a defined time window for certain analytes. If
the difference exceeds an acceptable threshold, the sample is
flagged for review. This is particularly useful for sample
misidentification, but is limited in application to patients with
previous results and specific tests.
5. Serum indices: Serum indices represent a spectrophotometric
estimate of the level of interference from hemoglobin (hemolysis
index), bilirubin (icterus index) and lipids and chylomicrons
(lipemia index). These are the most common type of
interferences to clinical chemistry tests and can serve as
indicators for pre-analytical errors related to inappropriate
fasting, sample processing, transportation, and storage.

Future Perspectives

The QIs shown in Table 1 have been adapted from Plebani et al. (8) and
represent an initial step toward monitoring and improving the pre-
analytical phase of testing. The WG-LEPS is also promoting anonymous
sharing of QI data by clinical labs worldwide through the IFCC WG-
LEPS website. The working group’s goal is to establish benchmarks so
labs can compare their performance on these metrics to other similar-
sized labs, enabling them to identify areas that require more attention
and resources for improvement.

Reporting specific QIs might one day become mandatory as part of an

external quality assessment program. Until then, labs must be proactive
in creating, collecting, and sharing QIs for the pre-analytical phase in an
effort to reduce laboratory medicine’s greatest contribution to medical
errors.

References

1. Makary MA, Daniel M. Medical error-the third leading cause of

death in the us. BMJ 2016;353:i2139.
2. Carraro P, Plebani M. Errors in a stat laboratory: Types and
frequencies 10 years later. Clin Chem 2007;53:1338-42.
3. Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory
medicine. Clin Chem 2002;48:691-8.
4. Standardization IOf. Iso 15189:2012: Medical laboratories:
Particular requirements for quality and competence. Vol.
Geneva, Switzerland, 2012.
 5. Nichols JH. Preanalytical variation. In: Clarke W, ed.
Contemporary practice in clinical chemistry, Vol. 2nd ed.
Washington, DC: AACC Press, 2010:1-12.
6. Young DS. Effects of preanalytical variables on clinical laboratory
tests. 3rd ed. Washington, DC: AACCPress, 2007.
7. Hernandez J. The Paradox of learning from errors. Clinical
Laboratory News 2011;37(4):15.
8. Plebani M, Sciacovelli L, Aita A, Chiozza ML. Harmonization of
pre-analytical quality indicators. Biochem Med 2014;24:105-13.

Joe El-Khoury, PhD, DABCC, FACB is co-director of clinical chemistry at

Yale New Haven Health and assistant professor of laboratory medicine
at Yale University in New Haven, Connecticut. Email: joe.el-
khoury@yale.edu

Mahboobe Ghaedi, PhD is an associate research scientist in the

departments of anesthesia and biomedical engineering at Yale
University in New Haven, Connecticut. Email:
mahboobe.ghaedi@yale.edu