FACTORS AFFECTING

LABORATORY RESULTS –
ANALYTICAL & NON-
ANALYTICAL

1
Bridging

■ A blood specimen was taken from a 65-year-old woman to

check her serum potassium concentration as she had been on
thiazide diuretics for some time.
■ The GP left the specimen in his car and dropped it off at the
laboratory on the way to the surgery the next morning.
■ Immediately after analysing the sample, the laboratory
personnel was on the phone to the GP. Why?

11/27/2023 2
FACTORS THAT MAY INFLUENCE LABORATORY RESULTS

 Classified into:
 Pre-analytical factors
 Analytical factors
 Post-analytical factors

Process/ sequence of events in laboratory results production

Patient preparation -> sample collection -> transportation -> receipt and
registration in the lab -> sample preparation and analysis -> results
transmission/ manual entry into a computer -> verification & authorisation
-> printing

11/27/2023 3
 Please indicate possible pre-analytical factor that might be
responsible for each of the following pattern of results
(N=normal, ↑=high, ↓=low, - = not done)

Analyte Patient A Patient B Patient C Patient D

(Serum)
Na+ N N N ↑
K+ ↑↑ ↑ ↑ ↓
Cl- N N N ↑
Urea N N N ↓
LDH N ↑ - -
ALP ↓ - - -
TP N - ↑ ↓
Calcium ↓↓ N ↑ -
Mg ↓ N - -
PO4 N ↑ - -

11/27/2023 4
Pre-analytical
Non-modifiable biological factors
■ Biologic rhythms
■ Age
■ Sex
■ Physiological changes during pregnancy

11/27/2023 5
■ These factors may be controlled for, e.g. by selecting the most
appropriate time in the day, month or year for a test, or may be taken
into consideration in the interpretation of results
ALP and Age
■ Upper reference limit ↑↑ increased during puberty - time of maximum
bone remodeling.
■ Levels fall to a new upper limit through younger adult life, rise again in
females around the time of perimenopause, largely reflecting an increase
in bone turnover at that time.
■ Marked increases in serum ALP may also occur in women in late
pregnancy (due to production of ALP by the placenta), and during other
times such as in the weeks after healing of a fracture.

11/27/2023 6
Biological rhythms
■ Hormone production (e.g. cortisol, testosterone) follow a circadian (24
hour) rhythm
■ Tests are recommended at specific times of the day, e.g. testosterone
should be sampled between 7 am – 10 am.
- Peak testosterone levels usually occur in the early morning;
■ serum cortisol should preferably be sampled in the early morning as
there is marked diurnal variation

11/27/2023 7
Pregnancy
■ Alterations in many laboratory parameters, such as blood volume,
liver and renal function and hormone levels
■ Alterations in binding proteins, can affect assays differently, e.g.
free hormone levels can be assay dependent

11/27/2023 8
11/27/2023 9
Modifiable biological factors
Individual variations
■ A patient’s diet, health status and lifestyle factors can all have
a pre-analytical influence on laboratory parameters.
■ Diet and nutritional status
• Creatinine; a recent meal with high meat content can have a
significant influence on serum creatinine
• Sustained low caloric intake and starvation can result in numerous
changes to laboratory parameters such as glucose, thyroid function,
electrolytes, liver function, renal function and lipids.

11/27/2023 10
■ Malnutrition
■ Dehydration
■ Caffeine
■ Tobacco smoking
■ Exercise
■ Medicines
■ Alcohol

11/27/2023 11
Chronic effects of alcohol consumption on laboratory investigations
include:
 Elevated gamma glutamyl transferase (GGT) and mean cell volume
(MCV) which are commonly used to test for excessive alcohol
consumption
 Elevated aspartate aminotransferase (AST), alanine aminotransferase
(ALT) and AST/ALT ratio
 Elevated triglyceride levels
 Elevated uric acid and ferritin levels due to fatty liver and alcoholic
hepatitis
 Elevated creatine kinase due to alcoholic myopathy
 Haematological abnormalities, e.g. anaemia and thrombocytopenia
11/27/2023 12
11/27/2023 13
11/27/2023 14
 The Pre-Analytical process

■ Patient Identification

■ Sampling Technique

■ Test Collection Procedures

■ Specimen Transport

■ Specimen Processing

11/27/2023 15
Test Collection
■ Timing of Collection

– Therapeutic Drug Monitoring

■ Peak and trough collection times
– Basal State Collections
■ Fasting requirements—no food or liquid
except water(10-12h)
■ 2h postprandial, from the start of food .
– Specimens affected by time of day, for example,
cortisol, iron and TSH.

11/27/2023 16
 Sample collection

a) Posture
- Based on Starlings law of capillary exchange:
Haemodynamic adaptation to postural change (e.g. lying to
sitting and vice versa).
- postural changes will affect proteins & protein bound
analytes e.g. Ca²˖, Fe²˖, Cholesterol, Triglycerides, etc.
b) Prolonged application of tourniquet - ↑ Protein & protein
bound analytes
c) IV solutions - e.g. NaCl drip: ↑Na & Cl (other analytes ±↓)
d) Hemolysis
- narrow bore needle, tight tourniquet, sample clotting
during
collection→↑K, Mg, PO3, AST, LDH
11/27/2023 17
 e) Sample tubes
- e.g. K-EDTA will influence the following analytes: K(↑),
Ca(↓),
Mg(↓), Zn(↓), ALP(↓)
f) Sequence of sample collection (multiple tubes)
- tubes without preservatives 1st
g) Sample volume & mixing where necessary
h) Type of sample
- e.g. arterial vs venous blood: PCO2, PO2
i) Mislabeling of sample tubes
j) Exercise
- e.g. ↑ CK, AST, LDH etc.
k) Sex - e.g. ↑ PSA
11/27/2023 18
 Sample collection

Recommended order of draw (CLSI):

1. Blood Culture Bottles (Aerobic-Anaerobic)
2. Coagulation Tube
3. Serum Tube with or without clot activator, with or
without gel separator
4. Heparin Tube with or without gel plasma separator
5. EDTA
6. Glycolytic Inhibitor

11/27/2023 19
11/27/2023 20
11/27/2023 21
 Sample transportation
a) Improper preservation e.g. ice or not
e.g. ACTH, ammonia, lactate, etc.
b) Delayed transportation to the lab
e.g. K, AST, ALT etc.

Sample receipt and registration

a) Transcription or sample labelling error

11/27/2023 22
 Problem Cause(s) Aff ects

overnight storage
Increases potassium, &
Delay in processing
delay in transit phosphate

Increases potassium
storage of samples
Incorrect storage
overnight in fridge
Decreases bicarbonate

Forcing blood through Increases potassium,

needle into tube phosphate, bilirubin.

Diffi cult to bleed

patients (e.g. paeds)

Haemolysis Storage frozen

Very delayed samples

Also increases AST, LDH, CK

and decreases Troponin T &
glucose

Increased drip analytes e.g.

glucose, potassium etc.
Sample taken from drip
Incorrect sample site
arm
Dilutional eff ect lowers
other analyte concentrations

Increased potassium

Contamination of red/
yellow top tubes with
Incorrect sample tube
blood containing EDTA Decreased calcium, alkaline
(from purple top tube) phosphatase, iron,
magnesium

Decreases sodium
Lipaemia (fatty Sample taken shortly
sample) aft er fatty meal
Aff ects other analytes if
severe

11/27/2023 23
 Analytical Factors

■ Calibration
■ Internal quality control
■ Assay (method) characteristics
■ Reagents integrity & preparation
■ Instrument maintenance
■ Dilution and pipetting techniques

11/27/2023 24
 Analytical Factors

■ Accuracy
■ Imprecision
■ Sensitivity & specificity
■ Linearity

11/27/2023 25
 Post-Analytical Factors

■ Transcription errors in reporting

■ Reference intervals used
■ Report sent to the wrong location
■ Report illegible
■ Report not sent

11/27/2023 26
 ERRORS IN LABORATORY
MEDICINE :
DETECTION & PREVENTION

11/27/2023 27
Definitions

A laboratory error may be defined as:

 Any failure to meet the required output quality necessary for
optimum patient care anywhere in the pathway from test
selection to the return of an appropriately interpreted report to
requesting clinician’.
 ‘Failure of planned action to be completed as intended, or use a
wrong plan to achieve an aim, occurring at any part of the
laboratory cycle, from ordering tests to reporting results and
appropriately interpreting and reacting to them’.

11/27/2023 28
Definitions
■ Mistakes, blunders, defects, outliers, unacceptable results and quality
failure
■ - Have negative connotations of blame, individual failure and culpability

■ Errors in laboratory medicine are intrinsically obscure as they are

difficult to identify
■ Compared with adverse events related to surgery or other treatment errors
that are often glaring and obvious, laboratory errors tend to be more
insidious and difficult to pinpoint in time and place
Errors in laboratory medicine
 Firstly, there is a time lapse between laboratory testing, physicians’ action
and patient outcomes
 Secondly, the testing process is complex, consists of numerous steps and
stretches across multiple providers
 Thirdly, physicians responsible for making clinical decisions seldom
perceive laboratory errors as a harmful source of patient adverse events,
nor do they understand that most laboratory defects may arise from the
pre- and post-analytic steps
 Fourthly, laboratory professionals are reluctant to divulge data on the
frequency and types of errors observed in their own setting for fear of a
sense of blame, individual failure and culpability associated with these
events
Defect rates in laboratory medicine as compared with other sectors
Discourse

 Evidence demonstrates that pre- and post-analytical steps of the total

testing process (TTP) are more error-prone than the analytical phase
 In a patient centered approach to the delivery of health-care services,
there is the need to investigate, in the TTP, any possible defect that may
have a negative impact on the patient
 Any direct or indirect negative consequence related to a laboratory test
must be considered, irrespective of which step is involved and whether
the error depends on a laboratory professional (e.g. calibration/testing
error) or non-laboratory operator (e.g. inappropriate test request, error in
patient identification and/or blood collection)
11/27/2023 33
Discourse
■ Pre- and post-analytical phases
 The preanalytic phase had the highest error rate, the most
frequent problems arising from mistakes in tube filling,
inappropriate containers, and requesting procedures.
 The main reasons for errors in the postanalytic phase were an
excessive turnaround time in the later study, errors in keyboard
entry and missed correction of erroneous findings in the earlier
study
Discourse
Types and relative frequency of errors
Impact of errors

 The risk of adverse events and inappropriate care due to laboratory errors
ranges from 2.7% to 12%,
 In a larger percentage of cases (24.4% to 30%), the laboratory error
translates into a patient care problem
■ - further inappropriate investigations
■ - more invasive testing and additional consultations
 Creates discomfort and incurs higher costs for both patients and the
health-care system
Impact on patient outcome (Goldschmidt)

11/27/2023 38
Processes to address errors
1. Identify high-risk processes where the potential error could
lead to a safety risk for patients
2. Identifying actual incidents associated with deviations from
standard requirements
3. Estimating and evaluating the associated risks to patient safety
4. Controlling these risks and
5. monitoring the effectiveness of the control undertaken.
Processes to reduce errors in laboratory medicine

■ Developing guidelines and standard operating procedures for patient

identification, blood collection, sample handling and specimen acceptance
or rejection
■ Interfacing analyzers and laboratory information systems (avoids manual
entry &transcription errors)
■ Policies and procedures exist for reporting critical values
■ Test report delivery to requesting physicians improved
■ Other IT initiatives- e.g.
- Automatic computerized communication systems ;
- Automated procedures for data validation and reporting as well as the
implementation of systems which allows an effective knowledge
management to support data interpretation
 International initiatives to reduce errors
in laboratory medicine

Several initiatives
■ World Alliance for Patient Safety – critical values reporting
■ Joint Commission 2008 National Patient Safety Goals for
Laboratories – communication among care givers
■ Working Group on ‘Laboratory errors and patient Safety’-
‘Model of quality indicators’
- 25 quality indicators: 16 pre-analytic, 3 analytic and 6 for
the post-analytic phase
Cheese model

The presence of holes in any one defensive layer does not normally cause adverse events.
Usually this happens only when the holes in many layers line up to permit a trajectory of
accident opportunity
11/27/2023 44
 SPECIMEN REJECTION CRITERIA

Specimens to which the following conditions apply will be rejected, returned to the
originating site or specimen processing delayed. The physician office will be notified.

1. Specimen is submitted without a test request form.

2. Specimen is not labeled with the patient’s full name (for slides, the frosted end must
be labeled with the patient’s first and last name in pencil).
3. The patient name (or other identifying information) on the specimen and test request
form do not correspond.
4. The specimen is labeled appropriately, but the test request form is not labeled.
5. Specimen is submitted from an unauthorized source.
6. No source or test marked on the test request form.
7. Incorrect specimen submitted for test requested.

11/27/2023 45
■THANK YOU

11/27/2023 46