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Rooting out ‘invisible’ blood collection errors

Multilayered ID at Mass General

Minimum content of a specimen collection training program (PDF, 166 Kb)

December 2003
Karen Lusky

Whoever coined the saying “what you don’t know can’t hurt you” surely wasn’t thinking about collecting blood specimens for clinical lab testing. Phlebotomists can make any number of errors that compromise specimen integrity in ways that clinical laboratories cannot detect during the testing phase. And these "invisible" errors can cause false results.

For example, faulty specimen collection techniques can bump up potassium readings by 1-2 mEq/L. And the errors can seem like little things, such as leaving the tourniquet on too long, filling the blood collection tubes in the wrong order, or allowing the patient to pump his or her fist during the venipuncture. Potassium levels also creep up in specimens that sit around too long before centrifugation.

"If a patient were really hypokalemic, the extra potassium added from these errors-for example, due to cross-contamination from a blood tube with a preservative, EDTA-can drive up the potassium into the normal range," says Dennis Ernst, MT(ASCP), director of the Center for Phlebotomy Education, Ramsey, Ind. And that can be tragic for the patient whose potassium is really too low for surgery, even though the lab result shows a normal level. "That patient can die during surgery," Ernst says.

Forty-six to 56 percent of all errors that can affect a specimen are made during the collecting, processing, and transportation phase-not during testing, Ernst says. "Therefore, most errors are buried in the collector’s technique," he says. "And the negative outcomes usually leave physicians scratching their heads."

That’s why phlebotomy best practices are a growing focus for clinical laboratories, including commercial labs and hospital systems. "It’s a new name for an old concept that’s getting fresh attention due to an awareness of what can happen when people underestimate blood specimen collection procedures as a cause of false lab results and patient injury," says Ernst.

Comprehensive training programs provide the underpinning to phlebotomy best practices. "That training program should encompass all of the errors in the procedure that can have a significant impact on patients’ lab results," Ernst says.

Patient ID and specimen integrity

What is the most important thing a phlebotomist can do to ensure accurate lab results? "Correctly identify the patient and correctly label the specimen," says Sterling Bennett, MD, director of clinical pathology for LDS Hospital, Salt Lake City, which is owned by Intermountain Health Care.

LDS Hospital is working toward "zero tolerance" for patient misidentification, says Doyle Harcrow, CPT, ASPT, phlebotomy education supervisor and instructor for Intermountain Health Care laboratory services. "We teach that positive patient identification is the No. 1 step in the entire phlebotomy practice," he says. The hospital has a standardized operating procedure in which the phlebotomist has to talk to the patient to identify the person. "We don’t just go by the identification bracelet and room number," Harcrow says. "If the patient is comatose or cannot communicate, the phlebotomist must get a second person in the patient’s room to verify the patient’s identity." Phlebotomists are also taught to complete the specimen labeling process in the patient’s presence.

LabOne in Lenexa, Kan., has implemented a patient identification and labeling protocol that detects mismatched specimens. "The patient’s name is on each label for each tube in addition to a bar code," explains Deborah Bjerkan, LabOne’s vice president and chief compliance officer for regulatory affairs and quality improvement. When the patient’s specimen is received in LabOne’s specimen processing department, the system scans the requisition, which has an assigned bar code. "The tubes also have that bar code, and if for some reason they don’t all match, an error code is reported which prompts an investigation by our specimen integrity department," Bjerkan says.

Best practices also encompass policies and procedures to ensure specimen integrity. For example, the tourniquet creates a "fishnet" effect when left on the arm too long, and it can drive up the specimen’s concentrations of potassium, glucose, cholesterol, albumin-even blood cells, Ernst says.

Lactate levels are also sensitive to tourniquet time, says LDS Hospital’s Dr. Bennett. "Our laboratory has had questions on a fairly regular basis about lactate levels that appear higher than expected based on the clinical situation," he says. In such cases, "repeat testing on either venous specimens collected with very short tourniquet times or arterial specimens has produced lower lactate results."

LDS Hospital adheres to the national standard of one minute for the length of time the tourniquet can be left on the patient’s arm during the lab draw. "We are a large transplant facility, and with some of the pre-liver transplants, the draw can include up to 33 tubes at one sitting," Harcrow says. Phlebotomists are told, too, that they don’t necessarily have to use a tourniquet if the patient has prominent veins.

Laboratory Support Services at Massachusetts General Hospital in Boston limits tourniquet time to one to two minutes. "If the phlebotomist approaches two minutes before he or she gets the needle in the patient’s arm, the phlebotomist is instructed to remove the tourniquet and allow for at least a five-minute rest time before reapplying it, or explore options in the other arm if appropriate," explains George Souza, BS, CPT, CPI, supervisor for clinical support services for the MGH clinical laboratory.

The order of the draw is also paramount in preventing false lab results-most notably, elevated potassium and coagulation levels, says Terry Jo Gile, MT(ASCP), MA Ed., a St. Louis, Mo.-based lab safety consultant who retired this past fall as the administrative coordinator of the clinical laboratory for Barnes-Jewish Hospital in St. Louis. NCCLS has established the order as sterile tubes first, plain non-additive tubes second, blue-stopper coag tubes third, gel separator tubes fourth, green-stopper heparin tubes fifth, lavender-stopper EDTA tubes sixth, and gray-stopper oxalate/fluoride tubes last. Says Ernst: "But NCCLS is now considering revising the order of draw to reflect the prevalence of plastic tubes in use today. Some facilities are modifying the order based on internal studies, so phlebotomists should follow the order their facilities establish."

Some labs and hospitals also provide memory aids to help staff remember the order of the draw. Gile reports that when she was at Barnes-Jewish, the hospital provided its phlebotomists, nursing service, and new physicians with a pocket-sized plastic card outlining the order in which to fill blood collection tubes.

Another collection problem occurs when phlebotomists don’t ask patients the right questions to obtain the information needed to interpret certain tests-for example, fasting blood glucose and triglycerides and peak and trough drug levels. LDS Hospital thus trains its phlebotomists to carefully query patients about when they last ate or took their last dose of medication, if applicable.

Phlebotomists must also know how to handle more complex, esoteric tests that require special collection or processing. For example, the LDS Hospital laboratory computer system includes specimen collection and handling information. "Yet occasionally, phlebotomists still collect incorrect specimen types or handle specimens improperly, which usually happens when a phlebotomist thinks he or she knows the specimen type but is wrong," Dr. Bennett says. "So we teach and encourage phlebotomists to access specimen information online when drawing a specimen for an unfamiliar or uncommon test, even if they think they know the specimen requirements."

Flagging problem specimens

Of course, phlebotomy best practices can’t work in a vacuum. The clinical laboratory has to act as a safety net by performing a number of visual, mechanical, and computerized safety checks to ferret out detectable problem specimens. "Some laboratory information systems can, for example, flag potassium readings that are significantly different from previous results," Ernst says. "Testing personnel can then confirm the result before reporting it."

Phlebotomists at Compunet Clinical Laboratories in western Ohio flag questionable specimens by stamping them "Attention, Processing" and listing the potential problem on the test requisition, such as a difficult draw, which could produce some level of hemolysis. "Or they might note that the patient may have been under stress or not feeling well, which will affect glucose levels," says Sharon Kopczynski, team leader for the Compunet patient service centers. (Compunet Clinical Laboratories is a joint venture formed by Quest Diagnostics, Miami Valley Hospital Enterprises, and Valley Pathologists.) Compunet also directs the phlebotomist to turn the lab test requisition inside out to further alert the person processing the specimen to pay special attention to it.

To avoid erroneous lab results, laboratories must also pay attention to how old specimens are. At Massachusetts General, for example, the phlebotomist is required to put the date and time of the blood collection on the requisition. "If the lab sees a specimen that’s beyond the acceptable time limit, it refuses that specimen," Souza says.

LDS Hospital medical technologists check each specimen visually for hemolysis and coagulation. "For hematology tests, the technologists rely on analyzer flags, discrepant test results, and blood smear examinations to identify problem specimens," Dr. Bennett reports. "Specimens known to have a high frequency of clots, such as Microtainer specimens from neonates, are routinely checked for clots using a wooden stick prior to testing."

Elevated potassium levels always raise a concern that the specimen has undetectable hemolysis. "Sometimes we find corroborating evidence of hemolysis when the LDH and AST concentrations are elevated in addition to the potassium levels," Dr. Bennett says. "Yet potassium is frequently ordered without LDH or AST."

LabOne assesses specimens tested on its chemistry analyzers for hemolysis and examines the effectiveness of the centrifugation and specimen preparation. "If there are still red cells in contact with the serum, we capture that information on the front end," says Rich Sokol, senior vice president of lab operations for LabOne. "Say we find, for example, a potassium of 8 with no visible hemolysis in the specimen. If the processors indicate that red cells were still in contact with the serum, that information prompts the appropriate qualifying response when reporting the result to the physician."

Technologists can also perform a number of checks to detect specimen problems that can affect coagulation test results. Lab professionals at LDS Hospital check to see, for example, if the blood collection tubes are filled to the correct levels. "The tubes have to be filled to the proper level or the plasma won’t have the correct citrate-to-blood ratio," Dr. Bennett says. "For example, under-filled tubes tend to elevate the INR." A related problem occurs in polycythemia. "The low plasma volume yields an excessive citrate-to-blood ratio. Thus, during the visual inspection of specimens, technologists also check for high hematocrits and request redraws with reduced citrate volumes if indicated," Dr. Bennett says.

Labs can sometimes detect specimens contaminated by IV solutions when they obtain nonphysiologic test results. "The contamination may result when venipuncture is performed downstream from a running IV or from inadequately flushed IV line draws," says Dr. Bennett. "Such contamination occurs more commonly in specimens collected by nurses than by phlebotomists." Thus, he adds, the nursing procedures should spell out how much discard volume should be withdrawn from an IV line before the specimen is collected, based on the volume of the particular IV catheter.

Monitoring performance and preventing injury

Many laboratories and hospital systems have monitoring systems that can detect patterns of faulty specimen collection and phlebotomy performance. For example, LabOne tracks accounts that have samples with abnormal potassiums or clotting. "That way, we can recognize physician offices that either have problems with venipuncture technique or with preparing the samples correctly," Sokol says. "We then target our education to those clients."

LabOne monitors its phlebotomists’ success rate in terms of obtaining a specimen without having to re-stick the patient. "Our standard is 80 percent success with a single draw," says Deanna Loeffler, lab service center manager. "If the phlebotomist falls below that standard, he or she is counseled and placed in a four-week retraining program. If the person’s skill level does not improve immediately, he or she is not allowed to continue as a phlebotomist."

The standard for successful draws varies by setting, however. "Patients at MGH challenge phlebotomy staff in terms of vascular access," says Souza. "The hospital has a large population of anticoagulation patients, transplant patients, dialysis patients, burn patients, and other situations in which the patient’s veins have been damaged."

LDS Hospital uses a problem-and-deviation log to monitor its phlebotomists’ workload and performance, including the quality of the phlebotomists’ specimens and care. Each phlebotomist is assigned a tech code, which identifies him or her as the person responsible for collecting a specimen, which can then be tracked for problems or errors. Phlebotomists who make an error receive counseling and, if warranted, retraining.

"If there is something that the phlebotomist just isn’t getting . . . then, in addition to the counseling and retraining, we do a write-up that goes in the employee’s file," Harcrow says. After three write-ups for the same discrepancy, the phlebotomist gets a pink slip. "We don’t want to sound like a mean group to work with," Harcrow says, "but we can’t jeopardize patient care. After all, in the health care industry, patients are the ones signing our paychecks."

Most patients who enter a lab draw station never dream they might walk away with a permanent nerve injury-most commonly, to the antebrachial cutaneous nerve.

Such injuries usually occur when the person doing the venipuncture "fishes" for the basilic vein. To prevent such injuries, Harcrow teaches phlebotomy students the anatomy of the arm. "They learn that the vein of first choice for lab draws is the median cubital, followed by the cephalic, with the basilic being the third choice," he says. "We also teach them never to prod a patient’s arm or hand with a needle, or to stick a needle in someone just to say they tried" if they don’t see or feel a vein.

Communication is also key to preventing injuries and, in that regard, patients often know best. "The phlebotomist should ask patients what they think the best site is for venipuncture based on their previous experience with having the procedure done," Harcrow says. And if the patient complains of shooting pain during the phlebotomy procedure, the phlebotomist must know to discontinue the procedure immediately, which might prevent nerve injury.

"Patients with potential nerve injury from venipuncture should be referred to a physician or sent to the hospital emergency department for evaluation," Ernst advises. "In many cases, the laboratory pathologist can evaluate the patient and make recommendations" for followup.

As a part of its internal protocol, LabOne would refer patients complaining of shooting pain during phlebotomy to a physician for evaluation. Then, with the phlebotomist who performed the procedure, it would investigate the incident thoroughly. "We would review any extenuating circumstances as well. For example, the patient may have jerked his or her arm during the procedure," Loeffler says.

Keeping phlebotomists safe

Phlebotomy best practices also encompass employee safety and OSHA compliance. Compunet’s definition of the role of the phlebotomist is, in fact, "to collect a quality specimen by the safest means possible for both the patient and phlebotomist."

The biggest safety danger to phlebotomists, of course, is potential exposure to bloodborne pathogens. Some of the common safety shortcuts and errors Ernst and Gile see even experienced phlebotomists make in this regard include:

  • Failing to use a safety needle in the manner intended. Ernst finds that people tend to resist change and inconvenience. "So when they are provided a device with a safety feature that requires an additional step, they might try to use it like a conventional needle and either fail to activate it, or they disable or remove the safety feature prior to use," he says.

  • Drawing blood without gloves or using gloves with fingers cut out. "Oftentimes phlebotomists cut the fingers out of gloves because the gloves don’t fit well enough for them to palpate veins and perform venipuncture effectively," Gile notes. Thus, supplying gloves that are snug but don’t impede circulation will help circumvent this practice.

  • Failing to wear proper lab coats. Gile points to a recent study showing that blood sprays resulting from venipuncture or fingersticks tend to occur from the tips of the fingers to the elbows, and from the collarbone to the waist. "Staff performing venipuncture should wear lab coats with knitted cuffs and pull the gloves over the cuffs to cover exposed skin," she advises.

  • Using winged blood collection sets without a tube holder.

  • Filling tubes from a syringe without a safety transfer device and delaying the activation and disposal of a contaminated sharp. Massachusetts General has designed the phlebotomy procedure areas so phlebotomists don’t have to reach for a sharps container. The hospital also has a needle safety committee that evaluates new products for safety.

Developing a culture to support best practices

Phlebotomy best practices work best when integrated into the hospital system with a goal of ensuring patient and employee safety and satisfaction. For example, an investment in training phlebotomists helps not only prevent errors and patient injuries but also creates a culture where these frontline staff feel valued and understand their role in promoting optimal patient outcomes. That perception on phlebotomists’ part appears to dramatically lower attrition rates, which means a more experienced staff that knows how to ensure patient safety.

For example, when Intermountain Health Care started its phlebotomy training school in 1997, it had a 78 percent turnover among phlebotomists in its urban central regional system, which includes three hospitals and the physician-division clinics. Harcrow credits the training program (three weeks of classes and a three-week externship) for pushing that rate to four percent in two of its hospitals-and five percent in the largest hospital. Most impressively, the turnover has dropped to nearly zero in the outreach clinics.

"We offer the training right up front and then put the phlebotomists on a step rate where we pay them 25 cents more each quarter if they meet all the requirements that are set for that quarter," Harcrow says.

Communication and rapport between the laboratory, nursing, and other departments where lab draws are done are important to help ensure everyone is on the same page with phlebotomy best practices. For example, "while phlebotomy is decentralized at MGH, the lab still provides policies and procedures for specimen collection so that everyone in the hospital is using information put forth by the hospital lab," Souza says. "Nursing has its own training and does competency checks, but I meet with nursing education representatives so we can keep each other current and communicate constantly on phlebotomy competency."

Winchester (Mass.) Hospital has made a concerted effort to promote more collaboration and understanding between the lab, including its phlebotomists, and nursing services. "It’s important for these two groups to work together in order to obtain laboratory specimens in a way that will produce the most accurate test results and interact with patients" in the most positive ways, says Donna Cefalo, CMA, CPI, clinical associate coordinator for the hospital.

The hospital’s effort in this area is part of a cultural awareness campaign to help all staff be more sensitive to and respectful of each department’s subculture and the cultural diversity of patients. To help accomplish this goal, Cefalo has added cultural awareness to the phlebotomy training program.

Ensuring patient satisfaction with phlebotomy services is a goal of best practices, an effort that also affects patient outcomes. "The quality of the patient service center can affect the patient’s willingness to get their lab work done," says Compunet’s Kopczynski.

Massachusetts General includes customer service as an integral part of its phlebotomy best practices program, Souza says. "We stress that it is important to reduce patient anxiety as much as possible" to prevent altered blood chemistry and customer dissatisfaction, he says. "So we do a lot of training to emphasize how personal interactions and reduced wait time can help patients feel comfortable and at ease. In fact, customer service is considered a skill and is one of the annual competency checks made on our staff."

MGH also gives its phlebotomists flexibility to act in certain situations to help patients, which increases patient satisfaction and the phlebotomists’ sense of professional autonomy. To do this, the hospital set up a series of "red and blue rules." Red rules are the ones that phlebotomists always have to follow, such as obtaining two identifiers for the patient and HIPAA privacy requirements. But the blue rules give phlebotomists room to decide to do little things out of the ordinary to help or please a patient. For example, the phlebotomist can decide to transport a wheelchair-bound patient to where he or she needs to go, if time permits.

The phlebotomist also gives patients a tri-fold business card with information about the best time to come for shorter wait times. The card includes a place where the phlebotomist can write his or her name. That way, patients can ask for the same phlebotomist if they come back for another lab test. And that is, after all, the ultimate goal of any business: repeat customers.

Karen Lusky is a writer in Brentwood, Tenn.