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Sources of preanalytical error in primary health care: implications for patient safety
Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Venous blood tests constitute an important part in the diagnosis and treatment of patients. However, test results are often viewed as objective values rather than the end result of a complex process. This has clinical importance since most errors arise before the sample reaches the laboratory. Such preanalytical errors affect patient safety and are often due to human mistakes in the collection and handling of the sample. The preanalytical performance of venous blood testing in primary health care, where the majority of the patients contact with care occurs, has not previously been reported.

Aims To investigate venous blood sampling practices and the prevalence of haemolysed blood samples in primary health care.

Methods A questionnaire investigated the collection and handling of venous blood samples in primary health care centres in two county councils and in two hospital clinical laboratories. Haemolysis index was used to evaluate the prevalence of haemolysed blood samples sent from primary health care centres, nursing homes and a hospital emergency department.

Results and discussion The results indicate that recommended preanalytical procedures were not always followed in the surveyed primary health care centres. For example, only 54% reported to always use name and Swedish identification number, and 5% to use photo-ID, the two recommended means for patient identification. Only 12% reported to always label the test tubes prior to blood collection. This increases the possibility of sample mix-up. As few as 6% reported to always allow the patient to rest at least 15 minutes before blood collection, desirable for a correct test result. Only 31% reported to have filed an incident report regarding venous blood sampling, indicating underreporting of incidents in the preanalytical phase.

Major differences in the prevalence of haemolysed blood samples were found. For example, samples collected in the primary health care centre with the highest prevalence of haemolysed samples were six times (95% CI 4.0 to 9.2) more often haemolysed compared to the centre with the lowest prevalence. The significant variation in haemolysed samples is likely to reflect varying preanalytical conditions.

Conclusions This thesis indicates that the preanalytical procedure in primary health care is associated with an increased risk of errors with consequences for patient safety and care. Monitoring of haemolysis index could be a valuable tool for estimating preanalytical sample quality. Further studies and interventions aimed at the preanalytical phase in primary health care are clearly needed.

Place, publisher, year, edition, pages
Umeå: Institutionen för medicinsk biovetenskap , 2009. , 72 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1250
Keyword [en]
blood specimen collection, haemolysis, medical errors, phlebotomy, preanalytical, primary health care, quality indicators, quality of health care, questionnaires, specimen handling
National Category
Other Clinical Medicine
Research subject
Medicine
Identifiers
URN: urn:nbn:se:umu:diva-21256ISBN: 978-91-7264-741-1 (print)OAI: oai:DiVA.org:umu-21256DiVA: diva2:211202
Public defence
2009-05-08, Sal 135, Byggnad 9A, Bv, Norrlands Universitetssjukhus, 901 85 Umeå, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2009-04-20 Created: 2009-04-09 Last updated: 2012-11-02Bibliographically approved
List of papers
1. Is the test result correct? A questionnaire study of blood collection practices in primary health care
Open this publication in new window or tab >>Is the test result correct? A questionnaire study of blood collection practices in primary health care
2010 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 16, no 4, 707-711 p.Article in journal (Refereed) Published
Abstract [en]

Rationale, aims and objectives  Venous blood tests are important for clinical decision making. Most errors in blood testing are due to human errors before the blood samples reach the laboratory. The present study was designed to investigate venous blood sampling (VBS) practices in primary health care centres (PHCs) compared with clinical laboratory staff.

Method  A cross-sectional survey of 70 PHCs and two clinical laboratories is conducted. All staff responsible for VBS (317 respondents, response rate 94%) completed a questionnaire on VBS practices.

Results  Instructions for VBS were not followed in the surveyed PHCs. For example, only 54% reported that they always identified the patient by using name/Swedish identification number and only 5% reported that they always used photo-ID, the two preferred means for patient identification. Only 12% reported that they always released venous stasis as soon as possible. Fewer PHC staff than clinical laboratory staff reported correct VBS practices. For example, 54% of the PHC staff reported that they always identified the patient by name and Swedish identification number, as compared with 95% of the clinical laboratory staff (P < 0.001). Documented VBS routines and re-education in VBS were not clearly associated with reported correct VBS practices.

Conclusions  In the surveyed PHCs, there are clinically important risks for misidentification of patients and erroneous test results, with consequences for the diagnosis and treatment of patients. Quality interventions, aimed at improving VBS practices, are needed to ensure patient safety.

Place, publisher, year, edition, pages
Blackwell Publishing, 2010
Keyword
blood specimen collection, medical errors, phlebotomy, primary health care, questionnaires, specimen handling
National Category
Other Clinical Medicine
Research subject
Clinical Chemistry
Identifiers
urn:nbn:se:umu:diva-40744 (URN)10.1111/j.1365-2753.2009.01179.x (DOI)000279901700007 ()20557417 (PubMedID)
Available from: 2011-03-08 Created: 2011-03-08 Last updated: 2017-12-11Bibliographically approved
2. Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling
Open this publication in new window or tab >>Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling
2009 (English)In: Clinical Chemistry and Laboratory Medicine, ISSN 1434-6621, E-ISSN 1437-4331, Vol. 47, no 2, 195-201 p.Article in journal (Refereed) Published
Abstract [en]

Background: Most errors in laboratory medicine occur in the preanalytical phase and are the result of human mistakes. This study investigated information search procedures, test request management and test tube labelling in primary healthcare compared to the same procedures amongst clinical laboratory staff.

Methods: A questionnaire was completed by 317 venous blood sampling staff in 70 primary healthcare centres and in two clinical laboratories (response rate = 94%).

Results: Correct procedures were not always followed. Only 60% of the primary healthcare staff reported that they always sought information in the updated, online laboratory manual. Only 12% reported that they always labelled the test tubes prior to drawing blood samples. No major differences between primary healthcare centres and clinical laboratories were found, except for test tube labelling, whereby the laboratory staff reported better practices. Re-education and access to documented routines were not clearly associated with better practices.

Conclusions: The preanalytical procedure in the surveyed primary healthcare centres was associated with a risk of errors which could affect patient safety. To improve patient safety in laboratory testing, all healthcare providers should survey their preanalytical procedures and improve the total testing process with a systems perspective.

Place, publisher, year, edition, pages
Walter de Gruyter, 2009
Keyword
blood specimen collection, medical errors, preanalytical, primary health care, questionnaire
National Category
Other Clinical Medicine
Research subject
Medicine
Identifiers
urn:nbn:se:umu:diva-21253 (URN)10.1515/CCLM.2009.048 (DOI)
Available from: 2009-04-09 Created: 2009-04-09 Last updated: 2017-12-13Bibliographically approved
3. Incident reporting practices in the preanalytical phase: low reported frequencies in the primary health care setting
Open this publication in new window or tab >>Incident reporting practices in the preanalytical phase: low reported frequencies in the primary health care setting
2009 (English)In: Scandinavian Journal of Clinical and Laboratory Investigation, ISSN 0036-5513, E-ISSN 1502-7686, Vol. 69, no 7, 731-735 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Incident reporting is commonly used to improve patient safety. The preanalytical phase of laboratory testing contains several manual error-prone tasks where mistakes can affect patient outcomes. However, the practical use of incident reports in this area has not been previously investigated in the primary health care setting, where the majority of the patients come in contact with health care.

MATERIAL AND METHODS: All staff responsible for venous blood sampling in 70 primary health care centres and in two hospital clinical laboratories (317 respondents, response rate 94%) completed a questionnaire.

RESULTS: Of the primary health care staff, 69% reported that they had never filed an incident report regarding venous blood sampling. Barriers for not filing incident reports often/always included lack of time (44%) and a complicated reporting procedure (27%). A higher proportion of staff with re-education (43%) had filed at least one incident report as compared to those without re-education (20%, p < 0.001). No differences in incident reporting practices were found between primary health care and hospital clinical laboratory staff.

CONCLUSIONS: The investigated incident reporting system is likely to underreport incidents in the preanalytical phase. Therefore, the ability to discover preventable system vulnerabilities needs refinement.

Place, publisher, year, edition, pages
Taylor & Francis, 2009
National Category
Other Clinical Medicine
Research subject
Medicine
Identifiers
urn:nbn:se:umu:diva-21254 (URN)10.3109/00365510903007018 (DOI)19929714 (PubMedID)
Projects
blood specimen collection, medical errors, phlebotomy, quality of health care, questionnaires
Available from: 2009-04-09 Created: 2009-04-09 Last updated: 2017-12-13Bibliographically approved
4. Haemolysis index: an estimate of preanalytical quality in primary health care!
Open this publication in new window or tab >>Haemolysis index: an estimate of preanalytical quality in primary health care!
Show others...
2009 (English)In: Clinical Chemistry and Laboratory Medicine, ISSN 1434-6621, E-ISSN 1437-4331, Vol. 47, no 8, 940-944 p.Article in journal (Refereed) Published
Abstract [en]

Background: Haemolysis is usually caused by inadequate specimen collection or preanalytical handling, and is suggested to be a suitable indicator of preanalytical quality. We investigated the prevalence of detectable haemolysis in all routine venous blood samples to identify differences in preanalytical quality. Methods: Haemolysis index (HI) values were obtained from a Vitros 5,1 in the routine clinical chemistry laboratory for samples collected in primary health care centres (PHCs), nursing homes, and a hospital emergency department (ED). Haemolysis was defined as a HI ≥ 15 (detection limit). Results: Samples from the PHC with the highest prevalence of haemolysis were 6.1 times (95% confidence interval (CI) 4.0-9.2) more often haemolysed compared to the centre with the lowest prevalence. Of the samples collected in primary health care, 10.4% were haemolysed compared to 31.1% in the ED (p< 0.001). A notable difference in haemolysed samples was found between the ED section staffed by emergency medicine physicians and the section staffed by primary health care physicians (34.8% vs. 11.3%, p<0.001). Conclusions: The significant variation in haemolysis indices among the investigated units is likely to reflect varying preanalytical conditions. The HI is a valuable tool for estimation and follow-up of preanalytical quality in primary health care.

Keyword
blood specimen collection, haemolysis, medical errors, phlebotomy, primary health care, Quslity indicators
Identifiers
urn:nbn:se:umu:diva-21255 (URN)
Available from: 2009-04-09 Created: 2009-04-09 Last updated: 2017-12-13Bibliographically approved

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