Pre-analytical

Laboratory Errors
Forte Diagnostics – Main Laboratory
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 (skill in performing tasks,
especially with the hands) and critical judgment
 Phlebotomy errors may cause harm to patients or result in
needle stick injury to the phlebotomist
Pre-analytical errors
 Pre- analytical errors are estimated to constitute 70% 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
 Sample Collection Procedures
 Specimen Transport
 Specimen Processing
Patient Identification Errors
 Errorsin correctly identifying the patient are indefensible
 Reasons for patient identification errors
 Proper positive patient identification procedures not followed

 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

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

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
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
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

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
Transport Container
 Temperature
Specimens must be transported at the appropriate temperature for
the required test

On ice—ABGs, Ammonia

Warmed 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
• 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?