Managing the quality of blood sampling: What are we missing?

Rosemary Cooper| National Chair Australian Pre-Analytical Network | BD ANZ Pre-analytical Advisory Board| RCPA KIMMS
Vacutainer - what was so special?
• Predetermined vacuum inside the tube
• The tube dictates the volume of blood collected
• Multiple tests could be done on one venipuncture
• Smaller volumes were required
• The predetermined lumen size of the needle, determines the speed
in which the blood is ‘pulled’ into the tube (less hemolysis)
• Additives preserved / enhanced the sample
• Tubes were made of hard plastic tubes that came in a variety of sizes.
• There was an exponential improvement in the quality of the samples.
Blood collection “systems”
 How should we collect blood samples?
• Needle and syringe – open system • Evacuated – closed system
 Open versus closed systems
• The WHO recommends closed systems over open systems because they have
been proven to be safer. 1

• The variety of products available make them suitable in almost all collection
situations.

• There is significantly less incidence of hemolysis in the evacuated system as well

as other advantages.2

• They also note that hypodermic needle and syringe is the most common means
of blood sampling.3

• Why?
1:Berkeris L, et al. Trends in blood culture contamination. A College of American Pathologist Q-tracks study of 356 institutions. Archives of Pathology and Laboratory
Medicine. 2005;123:1222–1226.
2: Ames A C, Bamford, E. An Appraisal of the vacutainer system for blood collection. Ann.Clin.Biochem. 12, 1975.
3: WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy 2010.
Closed system
Open system
Needle and syringe use
quotes from actual collectors

• “It’s easier”

• “I need to see the flashback so I know it is in the vein”

• “That’s how I was taught”

• “Vacutainers / butterflies are too expensive”

• “My company does not provide us with anything else”

Syringe collections- 2 big issues

Incorrect technique Incorrect blood transfer technique

Bernoulli's principle - collection
Bernoulli’s principle - transfer
Best practice standards
“... If drawing blood with a syringe is necessary, engineering
controls (engineered sharps injury protection) and safe work
practices (including mechanical means of removal if available)
must be used and needleless blood transfer devices must be
implemented.”

• Occupational Safety & Health Administration (OSHA), US Department of Labor

• June 12, 2002 OSHA Standard Interpretation letter on the Re-use of blood tube holders.
 Managing the quality of blood sampling:
what are we missing?
Let’s first look at what we know:

The vast majority of pre-analytical errors are attributable to

inappropriate procedures used for the collection of samples

and

the receipt of unsuitable samples is associated with diagnostic delay, missed or wrong diagnoses,

and also poses a considerable economic burden on the hospital and laboratory budgets.
Pre-analytical error (PAE)
• PAEs account for 70% of the errors in the blood collection process,
with haemolysis being the leading cause.4

• The cost of haemolysis is significant: 5

• Recollection costs
• Further stress to patient
• Delays results / treatment
• Extends time in hospital

4: Plebani, M. Pre-analytical Error and Patient Safety J.Med. Biochem. 31. 2012.
5: JACOBS, P.; COSTELLO, J.; BECKLES, M. Cost of haemolysis. Ann Clin Biochem, v. 49, Pt 4, p. 412, 2012
 Integrity of sample- syringe collections

Carraro, P., Servidio, G., Plebani, M. Hemolysed specimens: A reason for rejection or a clinical challenge? Clin. Chem. 46, 2000
Lippi et. al., 2019 reminds us:

Lippi, G., von Meyer, A., Cadamuro, J., Simundic, A. Blood Sample Quality. Diag. Berl. Mar 26-6, 2019
Pathology is heading towards the cosmos
What are we missing?

NHS Improvement- First Steps in improving phlebotomy: The challenge to improve quality, productivity and
patient experience. (2011).
 Education is the missing link!
To be effective , education, particularly ongoing professional development,
needs to be targeted and correct!

• Study what your collectors are doing

• Know the cause of your errors
• Develop a targeted learning strategy to address these
• Develop correct performance standards against best practice standards
and audit them – quality indicators
• Assess and re-assess

• Conferences, symposiums and visits can be powerful catalysts for change!

Needle and syringe use
quotes from actual collectors

• “It’s easier”

• “I need to see the flashback so I know it is in the vein”

• “That’s how I was taught”

• “Vacutainers / butterflies are too expensive”

• “My company does not provide us with anything else”

 Future- what will drive quality?
• Safety – for patient and phlebotomist
• ISO/ TS 22367: 2008- Medical laboratories -- Reduction of error through risk management and
continual improvement
• CLSI
• WHO
• OSHA
• National certification

• Specimen integrity and quality

• ISO 15189: 2012 Medical laboratories — Requirements for quality and competence
• ISO 17025: 2017 General requirements for the competence of testing and calibration
laboratories

• Reduced pain for patients

• Nanopathology
• Robotics
 Managing the quality of blood sampling
- what are we missing?

• We know what causes much of the pre-analytical error.

• We have the ability to reduce it.

• We know health care costs will be a driving factor.

• Do we have the commitment, leadership and the will?

It’s a poor sort of memory that only works backwards
The Queen to Alice in ‘Through the Looking Glass’. Lewis Carol. Ch 5; Wool and Water.
 Thank you
Rosemary Cooper| National Chair Australian Pre-Analytical Network |
BD ANZ Pre-analytical Advisory Board| RCPA KIMMS

http://www.apan.com.au/