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Preanalytical errors in hospitals: implications for quality improvement of blood sample collection
Umeå University, Faculty of Medicine, Department of Medical Biosciences.
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Most errors in the venous blood testing process are preanalytical, i.e. they occur before the sample reaches the laboratory. Unlike the laboratory analysis, the preanalytical phase involves several error-prone manual tasks not easily avoided with technological solutions. Despite the importance of the preanalytical phase for a correct test result, little is known about how blood samples are collected in hospitals.

Aim: The aim of this thesis was to survey preanalytical procedures in hospitals to identify sources of error.

Methods: The first part of this thesis was a questionnaire survey. After a pilot study (Paper I), a questionnaire addressing clinical chemistry testing was completed by venous blood sampling staff (n=314, response rate 94%) in hospital wards and hospital laboratories (Papers II–IV). The second part of this thesis was an experimental study. Haematology, coagulation, platelet function and global coagulation parameters were compared between pneumatic tube-transported samples and samples that had not been transported (Paper V).

Results: The results of the questionnaire survey indicate that the desirable procedure for the collection and handling of venous blood samples were not always followed in the wards (Papers II–III). For example, as few as 2.4% of the ward staff reported to always label the test tube immediately before sample collection. Only 22% of the ward staff reported to always use wristbands for patient identification, while 18% reported to always use online laboratory manuals, the only source of updated information. However, a substantial part of the ward staff showed considerable interest in re-education (45%) and willingness to improve routines (44%) for venous blood sampling. Compared to the ward staff, the laboratory staff reported significantly higher proportions of desirable practices regarding test request management, test tube labelling, test information search procedures, and the collection and handling of venous blood samples, but not regarding patient identification. Of the ward staff, only 5.5% had ever filed an error report regarding venous blood sampling, compared to 28% of the laboratory staff (Paper IV). In the experimental study (Paper V), no significant preanalytical effect of pneumatic tube transport was found for most haematology, coagulation and platelet function parameters. However, time-to-clot formation was significantly shorter (16%) in the pneumatic tube-transported samples, indicating an in vitro activation of global coagulation.

Conclusions. The questionnaire study of the rated experiences of venous blood sampling ward staff is the first of its kind to survey manual tasks in the preanalytical phase. The results suggest a clinically important risk of preanalytical errors in the surveyed wards. Computerised test request management will eliminate some, but not all, of the identified risks. The better performance reported by the laboratory staff may reflect successful quality improvement initiatives in the laboratories. The current error reporting system needs to be functionally implemented. The experimental study indicates that pneumatic tube transport does not introduce preanalytical errors for regular tests, but manual transport is recommended for analysis with thromboelastographic technique. This thesis underscores the importance of quality improvement in the preanalytical phase of venous blood testing in hospitals.

Place, publisher, year, edition, pages
Umeå: Medicinsk biovetenskap , 2008. , 64 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1177
Keyword [en]
medical errors, preanalytical, quality improvement, questionnaire, venous blood sampling
National Category
Other Clinical Medicine
Identifiers
URN: urn:nbn:se:umu:diva-1672ISBN: 978-91-7264-562-2 (print)OAI: oai:DiVA.org:umu-1672DiVA: diva2:141788
Public defence
2008-06-13, Hörsal Betula, Norrlands Universitetssjukhus, 901 85, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2008-05-21 Created: 2008-05-21 Last updated: 2011-01-25Bibliographically approved
List of papers
1. Patient-centred care - preanalytical factors demand attention: a questionnaire study of venous blood sampling and specimen handling
Open this publication in new window or tab >>Patient-centred care - preanalytical factors demand attention: a questionnaire study of venous blood sampling and specimen handling
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2007 (English)In: Scandinavian Journal of Clinical and Laboratory Investigation, ISSN 0036-5513, E-ISSN 1502-7686, Vol. 67, no 8, 836-847 p.Article in journal (Refereed) Published
Abstract [en]

Objective. Most mistakes in laboratory medicine are the result of human error occurring before the blood sample reaches the laboratory. This survey of preanalytical procedures was designed to identify sources of error and potential targets for quality improvement strategies.

Material and methods. The staff in a highly specialized surgical ward at a university hospital completed a questionnaire addressing the collection and handling of venous blood samples in plastic vacuum test‐tubes for general clinical chemistry testing.

Results. The results suggest that venous blood sampling instructions are not always followed. When uncertain about how a sample should be collected, the majority of respondents rely on potentially poor sources of information, such as out‐of‐date printed instructions or the advice of a colleague, rather than consult up‐to‐date electronic instructions. Furthermore, they do not always report errors and the referrals are not always handled according to sampling instructions. The respondents were highly motivated, however, and had a strong interest in receiving further education in, and assuming increased responsibility for, venous blood sampling procedures in the ward.

Conclusions. We believe that the introduction of standardized routines and regular staff training, combined with an exchange of the existing paper‐based referral management system with an electronic system for managing referrals, could increase safety in the preanalytical process, with positive effects on patient safety. Given the importance of venous blood samples in patient care, a more extensive study covering other hospital wards and primary health‐care centres is needed.

Read More: http://informahealthcare.com/doi/abs/10.1080/00365510701370675

Keyword
Blood specimen collection, guideline adherence, medical errors, patient-centred care, phlebotomy, quality of health care, questionnaires, safety management, specimen handling
National Category
Biomaterials Science
Identifiers
urn:nbn:se:umu:diva-6720 (URN)10.1080/00365510701370675 (DOI)17852838 (PubMedID)
Available from: 2008-01-10 Created: 2008-01-10 Last updated: 2017-12-14Bibliographically approved
2. Preanalytical venous blood sampling practices demand improvement: A survey of test-request management, test-tube labelling and information search procedures.
Open this publication in new window or tab >>Preanalytical venous blood sampling practices demand improvement: A survey of test-request management, test-tube labelling and information search procedures.
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2008 (English)In: Clinica Chimica Acta, ISSN 0009-8981, E-ISSN 1873-3492, Vol. 391, no 1-2, 91-97 p.Article in journal (Other academic) Published
Abstract [en]

BACKGROUND: Most errors in laboratory medicine are preanalytical in nature. In the present study, we aimed to survey preanalytical steps in venous blood sampling, prior to actual sample collection. These steps included test-request management and test-tube labelling, as well as information search procedures. METHODS: Venous blood sampling staff (n=314, response rate 94%) in hospital wards and laboratories completed a questionnaire related to clinical chemistry testing. RESULTS: Instructions for test-request management and test-tube labelling were not always followed. For example, only 66% of the ward staff reported always checking the test-request if someone else completed it, compared to 90% of the laboratory staff (p=0.003). As few as 16% of the ward staff reported desirable practices regarding test-tube labelling, compared to 100% of the laboratory staff (p<0.001). Furthermore, 18% of the ward staff reported always using online manuals (the only source of updated information), compared to 63% of the laboratory staff (p<0.001). CONCLUSIONS: Our results indicate a substantial risk of preanalytical error in test-request management, test-tube labelling, and information search practices, particularly in the wards. Our findings thus underscore the importance of quality control in venous blood sampling, in order to increase patient safety in modern health care.

Identifiers
urn:nbn:se:umu:diva-10008 (URN)10.1016/j.cca.2008.02.016 (DOI)18342012 (PubMedID)
Available from: 2008-06-09 Created: 2008-06-09 Last updated: 2017-12-14Bibliographically approved
3. Blood sample collection and patient identification demand improvement: a questionnaire study of preanalytical practices in hospital wards and laboratories
Open this publication in new window or tab >>Blood sample collection and patient identification demand improvement: a questionnaire study of preanalytical practices in hospital wards and laboratories
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2010 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 24, no 3, 581-591 p.Article in journal (Refereed) Published
Abstract [en]

Background:  Most errors in venous blood testing result from human mistakes occurring before the sample reach the laboratory.

Aims:  To survey venous blood sampling (VBS) practices in hospital wards and to compare practices with hospital laboratories.

Methods:  Staff in two hospitals (all wards) and two hospital laboratories (314 respondents, response rate 94%), completed a questionnaire addressing issues relevant to the collection of venous blood samples for clinical chemistry testing.

Results:  The findings suggest that instructions for patient identification and the collection of venous blood samples were not always followed. For example, 79% of the respondents reported the undesirable practice (UDP) of not always using wristbands for patient identification. Similarly, 87% of the respondents noted the UDP of removing venous stasis after the sampling is finished. Compared with the ward staff, a significantly higher proportion of the laboratory staff reported desirable practices regarding the collection of venous blood samples. Neither education nor the existence of established sampling routines was clearly associated with VBS practices among the ward staff.

Conclusions:  The results of this study, the first of its kind, suggest that a clinically important risk of error is associated with VBS in the surveyed wards. Most important is the risk of misidentification of patients. Quality improvement of blood sample collection is clearly needed, particularly in hospital wards.

Keyword
adverse events; clinical guidelines; error research; nursing practice; patient safety; questionnaire; quality and safety; venous blood sampling
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-39342 (URN)10.1111/j.1471-6712.2009.00753.x (DOI)000281000800020 ()21050248 (PubMedID)
Available from: 2011-01-24 Created: 2011-01-24 Last updated: 2017-12-11Bibliographically approved
4. A questionnaire survey of error reporting practices regarding venous blood sampling in hospitals
Open this publication in new window or tab >>A questionnaire survey of error reporting practices regarding venous blood sampling in hospitals
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(English)Manuscript (Other academic)
National Category
Clinical Laboratory Medicine
Identifiers
urn:nbn:se:umu:diva-3262 (URN)
Available from: 2008-05-21 Created: 2008-05-21 Last updated: 2012-02-03Bibliographically approved
5. Preanalytical effects of pneumatic tube transport on routine haematology, coagulation parameters, platelet function and global coagulation
Open this publication in new window or tab >>Preanalytical effects of pneumatic tube transport on routine haematology, coagulation parameters, platelet function and global coagulation
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2009 (English)In: Clinical Chemistry and Laboratory Medicine, ISSN 1434-6621, E-ISSN 1437-4331, Vol. 46, no 10, 1443-1449 p.Article in journal (Refereed) Published
Abstract [en]

Background: Pneumatic tube transport of blood samples reduces turnaround times and labour. However, the preanalytical effects on new clinical chemistry parameters and instruments are not fully known. The aim of this study was to evaluate the effect of pneumatic tube transport on haematology and coagulation parameters, including platelet function with PFA-100®, and global coagulation with a thromboelastograph.

Methods: Paired venous blood samples from healthy volunteers were obtained before and after 1 week of treatment with acetylsalicylic acid. One sample was transported by pneumatic tube transport, while the other remained in the laboratory.

Results: No preanalytical effect of pneumatic tube transport could be seen for most haematology and coagulation parameters, as well as analysis with PFA-100®. For the thromboelastographic analysis, time to clot formation was shorter (–16%, p=0.037) in the transported samples. Treatment with acetylsalicylic acid had no effect on the majority of the test results.

Conclusions: Pneumatic tube transport does not introduce preanalytical errors when transporting samples for analysis of routine haematology, coagulation parameters and platelet function with the PFA-100®. We recommend manual transport of samples for analysis with thromboelastographic techniques.

Keyword
platelet function anlysis, pneumatic tube transport, preanaltical, thromboelastograph, venous blood specimen
Identifiers
urn:nbn:se:umu:diva-3263 (URN)10.1515/CCLM.2008.288 (DOI)18844500 (PubMedID)
Available from: 2008-05-21 Created: 2008-05-21 Last updated: 2017-12-14Bibliographically approved

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