how to avoid pre analytical errors

Sometimes there is also doubt whether an error derives from the preanalytical or the analytical phase. Minimizing preanalytical errors in blood gas 1 ed. 3.2 Immediately after drawing, whole blood should remain capped for transport both for safety reasons and to minimize loss of CO2, which causes pH to increase, leading to prolongation of PT and/or aPTT [44]. Thomas L. Haemolysis as influence & interference factor. Saunders company, 1998: 37-38. Thromb Res. Serum tubes: Test that needs to be chilled in a slurry of ice water. 2011 Jul;44(10-11):944-5. doi: 10.1016/j.clinbiochem.2011.05.003. The primary reason for redraw in the ED group was hemolysis (52.2%; EMS=31.6%). If he/she is external to the laboratory, the laboratory must provide all information necessary about good sampling practices [6, 36]. Avoiding Pre-analytical Errors Universit catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NARILIS, Haematology Laboratory, B-5530, Yvoir, Belgium, A. Magnette,M. Chatelain,B. Chatelain&F. Mullier, Maastricht University Medical Centre and Cardiovascular Research Institute (CARIM), Department of Internal Medicine, Maastricht, The Netherlands, You can also search for this author in How do you treat bleeding disorders with desmopressin? Lippi G, Chance JJ, Church S, et al. 3. 2006;64:3157. Phlebotomy. Bognor Regis: Wiley-Blackwell, 2nd Edition. The decision 2022 Radiometer Medical ApS | kandevej 21 | DK-2700 | Brnshj | Denmark | Phone +45 3827 3827 | CVR no. Useful tips to avoid preanalytical errors in blood gas testing Am J Crit Care 1998; 7,6: 439-43. This review is a summary of the most important recommendations regarding the importance of pre-analytical factors for coagulation testing and should be a tool to increase awareness about the importance of pre-analytical factors for coagulation testing. The referring physician should also have done a proper physical examination in order to detect signs of coagulopathy. Temperature control is recommended in rooms where samples are kept for analysis [2]. HHS Vulnerability Disclosure, Help J Thromb Haemost. tentative algorithms for detection of an incorrect type of sample. It should also be mentioned that hemolysis has several lowering effects on plasma cCa2+: 3.8 Ideally, samples for coagulation assays should be performed in the laboratory that performs the assays. Thromb Res. 2011;155:3044. Sample tubes for haemostasis analyses generally contain an anticoagulant. Vol. Cornes M, van Dongen-Lases E, Grankvist K, Ibarz M, Kristensen G, Lippi G, Nybo M, Simundic AM, Working Group for Preanalytical Phase EFoCC, Laboratory M. Order of blood draw: Opinion Paper by the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE). Consequently, pH will decrease.. Clin Chem 2002; 48,5. Chen YW, Chen JK, Wang JS. One way to avoid preanalytical errors is to implement standardized procedures and educate all staff involved in all phases of the sampling process: from patient preparation to analysis of the sample. Poorly handled frozen material may also causes shortening of aPTT or PT [5]. Data combined from [14] and unpublished data by Radiometer Medical A/S. Bethesda, MD 20894, Web Policies This step, based on a variety of manual activities, is the most vulnerable part of the total testing process and is a major component of the reliability and validity of results in haemostasis and constitutes the most important source of erroneous or un-interpretable results. Ann Biol Clin (Paris). Rull G, Mohd-Zain ZN, Shiel J, Lundberg MH, Collier DJ, Johnston A, Warner TD, Corder R. Effects of high flavanol dark chocolate on cardiovascular function and platelet aggregation. WebIn a Radiometer-sponsored webinar on avoiding preanalytical errors in blood gas testing, 48% of participants mentioned issues related to mixing as the most prevalent errors in the preanalytical phase of blood gas testing. 2009;20:45865. With an increasing amount of testing occurring at the point of care, it is even more important to ensure the continuous competence of staff. 2012;38:57685. Moreover, it is very important that the clinician and the laboratory exchange all relevant information as much as possible [25]. The ISTH/SSC Joint Working Group agreed to establish a single BAT to standardize the reporting of bleeding symptoms which would be useful for both paediatric and adult populations. They should be kept away from light [36]. Furthermore, sample quality can be compromised by exposure to extremes of temperature and physical forces during transportation. Describe the type and rates of errors in the three stages of the laboratory testing process. Bonini P, Plebani M, Ceriotti F et al. Lock, R. The whole-blood sampling handbook. 5. Measurement of potassium in whole blood. Regarding the surgical and obstetrical history, it is important to note the number of interventions that resulted in bleeding complications (new intervention due to complication, transfusion, admission to intensive care, etc. J Thromb Haemost. Pre-, Post- & Analytical Errors - Westgard How to Avoid Pre-analytical Errors in Arterial Blood Collection for Am J Clin Pathol. Here are some case examples of preanalytical errors that occurred over a period of one week at a local hospital. 9 % of the reference value for cK+ (3.5-5.0 mmol/L)., Hemolysis causes the release of intracellular components from destroyed erythrocytes (red blood cells) into the extracellular fluid. Thromb Haemost. Venous catheters are used for IV infusions and transfusions.. Haemostasis. 3min at 1000g) used before performing dilute thrombin time and ecarin clotting time, was not validated [78]. Impact of Educational Activities in Reducing Pre-Analytical Laboratory Errors: A quality initiative. 2013;132:e1527. 2004;114:40914. 1. A quantitative analysis of bleeding symptoms in type 1 von willebrand disease: results from a multicenter European study (MCMDM-1 VWD). Haemolysed samples may lead to early flow obstruction in the PFA, presumably due to platelet activation, fragmentation of platelet and red blood cells and the presence of micro-thrombi [4]. Influence of temperature and time before centrifugation of specimens for routine coagulation testing. Centers for Disease Control and Prevention: http://www.cdc.gov. PubMed In case of a factor defect observed on a frozen sample, it is suggested to repeat the analysis on a fresh sample. Pregnancy is associated with increase in fibrinogen, factors VII, VIII, X, VWF, D-dimer concentration and with increase in levels of prothrombin fragments 1+2 and thrombin-antithrombin III complexes. Blood venous sample collection: Recommendations overview and a checklist to improve quality. An example: Pre-analytical issues in the haemostasis laboratory: guidance for the clinical laboratories. This applies also to fibrinolysis parameters [35, 47, 52, 81, 83]. Providing patients with the appropriate instructions before blood sampling and proper training of those persons involved in sampling procedures can reduce or prevent negative influences on laboratory results and their misinterpretation [4, 35]. Thromb Res. Useful tips to avoid preanalytical errors in blood gas testing: electrolytes. Pre-analytical errors can occur at the time of patient assessment, test order entry, request completion, patient identification, specimen collection, specimen transport, In haemostasis, even more than in other disciplines of biology, quality is determined by a pre-analytical step that encompasses all procedures, starting with the formulation of the medical question, and includes patient preparation, sample collection, handling, transportation, processing, and storage until time of analysis. Another common way to obtain blood samples from critically ill patients for analysis of the electrolyte status is to use a venous catheter. The major effect of exposure to air is alteration of p ao 2, with less pronounced changes in pH, p CO 2 and ionized calcium (iCa). 2015. http://site.geht.org/site/Pratiques-Professionnelles/Documents-GEHT/Variables-Preanalytiques/Recommandations-Variables-preanalytiques_69_722.html. the patient identification before drawing a sample. Preventing pre-analytical errors to Blood Coagul Fibrinolysis. NSAIDs) should be stopped at least 3days before sampling, and treatment with drugs known to irreversibly inhibit platelet function (e.g. In addition, the following issues should be considered: When heparin is added to whole blood it forms a complex with antithrombin III, and the blood's ability to coagulate is inhibited. 9. Contraception. In order to eliminate platelet debris and microparticles from plasma, which may contribute to the variability in thrombin generation results, a second centrifugation step at 10,000g is recommended [2]. Results: Lillo R, Salinas M, Lopez-Garrigos M, Naranjo-Santana Y, Gutirrez M, Marn MD, Miralles M, Uris J. Al-Ghaithi H, Pathare A, Al-Mamari S, Villacrucis R, Fawaz N, Alkindi S. Sultan Qaboos Univ Med J. Transporting blood tubes in a vertical rather than a horizontal position limits the extent of in vitro microparticles (MP) generation [62, 63]. This may cause haemolysis when cells under pressure from the plunger collide with the tube wall [4]. 5.1 Correspondence to Blood Gases and Preanalytic Error Prevention The accurate standardization of the pre-analytical phase is of pivotal importance to achieve reliable results of coagulation tests. Right or wrong sample received for coagulation testing? According to the CLSI, a first discard tube (or a non-additive tube) is unnecessary for routine coagulation assays [47]. This article (1) illustrates several different types of analytical errors and situations within laboratories that may result in increased variability in data, (2) provides Holbek CC et al. Quality standards for sample collection in coagulation testing. Lacroix R, Judicone C, Mooberry M, Boucekine M, Key NS, Dignat-George F, The ISSCW. It is recommended to use a centrifuge that has a rotor with swing-out buckets to facilitate the separation of plasma from the cellular components and to minimize re-mixing of plasma and red cells [5, 36, 44]. Google Scholar. 2014;25:2925. Another common way to obtain blood samples from critically ill patients Air entrapment is probably one of the most common and most easily remedied sources of error in blood gas analysis. WebDiagnostic Errors / prevention & control* Humans Quality Assurance, Health Care / methods* the time required to enter the sample into the intra-analytical phase. Then preventive and corrective procedures will take place to ensure and prevent reoccurrence of errors during laboratory tests. Levine AB, Teppa J, McGough B, Cowchock FS. The diameter of the needle should preferably be comprised between 19 and 22 gauge [34, 49]. The recommendations are to start with the citrate tube for coagulation, followed by plain serum tube, followed by heparin, EDTA tube and fluoride/oxalate tube. It is in the interest of everybody involved in laboratory medicine and the safety of the patients to keep the preanalytical factors under control.. errors Ernst DJ, Ernst C. Phlebotomy tools of the trade: part 4: proper handling and storage of blood specimens. It may be necessary to remove part of the citrate solution from the sampling tube prior to drawing blood [35, 36, 44] (Table2). indirect vs. direct measurement of the electrolyte parameters [25]. The pre-analytical phase is the most vulnerable part of the total testing process and is considered to be among the greatest challenges to laboratory professionals. 2010;151:24551. Haemophilia. Adjusted ionized calcium (at pH 7.4) and actual calcium (at actual pH) in capillary blood compared for clinical evaluation of patients with disorders. This fact indicates that the laboratory is a major aid to the clinicians who have requested the tests. Article Provided by the Springer Nature SharedIt content-sharing initiative. Flush solutions consist of saline (0.9 % NaCl) with or without heparin added and are present in all catheters to avoid clotting., When sampling from a catheter, it is important to remove an adequate amount of fluid (also called the discard volume, consisting of flush solution and blood) before sampling to avoid interference and dilution from/by the flush solution on the electrolyte, pH, and blood gas parameters.. Freezing has an inconstant and unpredictable effect on the results and may cause significant elevations of aPTT, but also PT [4, 8486]. 2016;55:2731. This phase is part of the total laboratory procedure consisting of several stages and beginning with the physician requesting the performance of a laboratory investigation on a patient. Steps labs can take: minimizing pre-analytical errors. WebGuest Essay Pre-, Post- & Analytical Errors Written by David Plaut, Sten Westgard, and James O. Westgard. Wayne, Pa.: NCCLS, 1999; 19, 8. when updating procedures or when conducting refresher training. However, the focus of the article is not restricted to this application only, as electrolyte values can also be measured on venous blood, capillary blood, plasma, and serum. 2015;13:31422. doi: 10.18295/squmj.2017.17.03.008. analytical errors 2013;110:142. Gresele P. Subcommittee on platelet physiology of the international society on T, Hemostasis Diagnosis of inherited platelet function disorders: guidance from the SSC of the ISTH. Pre Cookies policy. Clipboard, Search History, and several other advanced features are temporarily unavailable. A quality laboratory manager should verify the length of tourniquet application and forearm clenching in order to eliminate this source of laboratory error and safeguard quality throughout the total testing process [48]. F. Mullier. Effect of pneumatic tube transport on rotational thromboelastometry. 2014;12:15629. If not, specimens should be shipped from peripheral collection facilities to the core laboratory utilizing current CLSI guidelines (non-refrigerated at ambient temperature in as short a time as possible, preferably within the first hour after collection) [5, 57]. An example: This article provides useful tips for avoiding preanalytical errors on electrolyte parameters; tips which you can incorporate in your standardized procedures and training of your staff. Tosetto A, Castaman G, Rodeghiero F. Bleeders, bleeding rates, and bleeding score. Consumption of caffeine should be discouraged within the 2h prior to sampling [4, 15]. Which improvements should be made first? 2016;116:100310. Some factors can alter the result of a sample constituent after collection during transportation, preparation and storage. 10. PubMed 27509185, Explore selected articles curated by biochemist and journalist Chris Higgins, Presented by Ana-Maria Simundic, PhD, Prof. of Medical Biochemistry, Zagreb University, Zagreb, Croatia. An example: Crit Care Med 2003; 31,6: 1654-58. Discard tubes are not necessary when drawing samples for specialized coagulation testing. 2014;36:28995. The sampling equipment must be sterile and non-pyrogenic. Thromb Haemost. Lima-Oliveira G, Lippi G, Salvagno GL, Montagnana M, Picheth G, Guidi GC. Tubes should be stored at ambient temperature until centrifugation [4, 5, 36]. Clinical decisions regarding platelet function and aspirin responsiveness should not be based on blood specimens transported by a PTS [6568] (Table3). Preanalytical error occurrence rate in clinical chemistry laboratory of a public hospital in India, Clin Lab. Studies have reported an increase in blood coagulability but impaired fibrinolysis in habitual smokers when compared with nonsmokers [42]. Antecedents of anemia, iron supplementation, hospitalization or blood transfusion can also guide the clinician [11, 12]. Google Scholar. The recommendation to avoid using a rotor brake is based on expert opinion and should be demonstrated in appropriate studies. Google Scholar. To reduce pre-analytical error rates, all procedures should be standardized and automated whenever possible. contraceptives containing levonorgestrel) [22, 23]. Because the presence of lipid particles can still bias the measurement for biologic interference, the CLSI currently recommends the removal of excess triglycerides by ultracentrifugation [61]. Intravascular hemolyzation may occur during blood transfusion, depending on the age of the transfused blood [8]. Tosetto A, Rodeghiero F, Castaman G, Goodeve A, Federici AB, Batlle J, Meyer D, Fressinaud E, Mazurier C, Goudemand J, Eikenboom J, Schneppenheim R, Budde U, Ingerslev J, Vorlova Z, Habart D, Holmberg L, Lethagen S, Pasi J, Hill F, Peake I. Blood samples should be collected after the subject has rested for a short period (at least 5min) [15]. I believe, if we have relevant data for it, we can have better graphics or charts then better will be our understanding of errors. WebThe quality of blood sample with completely filled requisition forms and prompt transportation of sample to the lab are essential components to avoid pre-analytical errors. Under-filling increases the dilution of the sample due to the volume of liquid anticoagulant, and may increase the clotting time due to the excess calcium-binding citrate present [4, 5, 47]. The maximum errors happen in the pre 2007;5:14. 2010 Jan;36(1):16-20, Favaloro EJ. Reducing preanalytical laboratory sample errors through educational and technological interventions. However there may also be higher citrate concentration (i.e., 3.8% or 129mmol/L) leading to greater calcium binding and longer clotting times. These tubes allow for more reliable measurement of unfractionated heparin (UFH) and are useful for the study of membrane glycoproteins platelet by flow cytometry. 3 shows the effect of different degrees of hemolysis on cNa+, cK+ and cCa2+. 2006;17:5139. Air Entrapment. 1 Flowchart of the pre-analytical phase from bedside to bench in biomedical metabolomics and lipidomics projects. V n5 du 20/10/10. Preanalytical considerations in blood gas analysis - PMC 5.2 Transfus Med. Correct patient identification and test tube labeling before phlebotomy are of extreme importance for patient safety. This can be improved by educating healthcare professionals who are involved in drawing blood for testing. It is the most vulnerable part of the total testing process, where most laboratory errors occur [2, 3]. McCraw A, Hillarp A, Echenagucia M. Considerations in the laboratory assessment of haemostasis. Your US state privacy rights, Residual platelets in plasma have been known to affect phospholipid-dependent coagulation tests through the exposure from platelet membranes of anionic phospholipids that quench LA activity. The temperature during transport is of special relevance. errors 2010;32:1328. It is also advisable not to eat dark chocolate [39]. FIG. WebMETHODS: A retrospective study was conducted to identify the rates and the types and frequencies of pre-analytical errors in the laboratory and analyze them according to the departments of patients, the sections of the laboratory, and the wards of the hospital. 2014;24:2530. This increased risk depends on the estrogen dose as well as the progestogen type of oral contraceptives [22]. That means handling stress, getting good women's health care, and nurturing yourself. Recently the French Society of Anaesthesia and Intensive Care issued recommendations for the prescription of routine preoperative testing before a surgical or non-surgical procedure, requiring any type of anaesthesia [9]. Our aim was to compare the routine training (RT) method with the intensive training (IT) method, described for the first time by our group, for preventing pre-analytical errors in induced hemolysis. The less dense components of the sample, such as the plasma phase, will be thrown out of the vial. The passage of blood through butterfly tubing and IV catheters might cause increased haemostatic alterations in comparison to blood collection using a conventional straight needle, directly into the tube [2]. pre A New Method for the Prevention of Pre-Analytical Errors Background: Our aim was to compare the routine training (RT) method with the intensive training (IT) Both results were statistically significant. Catheters are used for multiple sampling to measure pH, blood gases, and electrolytes. Lacroix R, Judicone C, Poncelet P, Robert S, Arnaud L, Sampol J, Dignat-George F. Impact of pre-analytical parameters on the measurement of circulating microparticles: towards standardization of protocol. For samples coming from external laboratories, it is important to check prior to analysis whether the aliquot external samples (fresh or frozen) really consist of citrated plasma. Evaluation of the prethrombotic state in pregnancy and in women using oral contraceptives. WebClinical labs have several tools at their disposal to detect pre-analytical errors. These procedures are intended to prevent these problems and to protect against complications and patient mismanagement that could otherwise arise when specimens are not collected properly in order to achieve accurate and reliable coagulation measurements. Unfortunately, we seem to be arguing that some errors are more important (i.e. Bach J, Haubelt H, Hellstern P. Sources of variation in factor VIII, von Willebrand factor and fibrinogen measurements: implications for detecting deficiencies and increased plasma levels. Semin Thromb Hemost. J Thromb Haemost. 5.1 van Dongen-Lases EC, Cornes MP, Grankvist K, Ibarz M, Kristensen GB, Lippi G, Nybo M, Simundic AM. potassium (K+), are up to 30 times as concentrated in the intracellular compartment as in the plasma phase. Samples for aPTT testing should be stored at room temperature and be performed using fresh plasma within 4h. The limited stability is largely due to time-dependent generation or loss of labile factors, particulary factor VIII and possibly factor V [83]. Buckley M, Rawson M, Russell J. Plasma is generally prepared by centrifugation of a whole blood sample. Implementing procedures to Guder WG, Narayanan S, Wisser H et al. The combination of the standardized bleeding questionnaire and an interpretation grid has been referred to as a Bleeding Assessment Tool (BAT) [7]. PRE-ANALYTICAL ERRORS IN THE CLINICAL LABORATORY These changes tend to me more pronounced in women taking third generation combined oral contraceptives than on second generation [21]. Stress should be avoided under all circumstances (e.g. Our experience shows it is important to check the absence of vibration (during acceleration/deceleration processes) due to lack of centrifuge maintenance. Additionally, they studied samples from the EMS (n = 200) and the ED (n = 200). 2012;130:e14750. Blood Coagul Fibrinolysis. CLSI H21-A5: Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays and Molecular Hemostasis Assays; Approved GuidelineFifth Edition. Samples should be transported non-refrigerated at ambient temperature (1525C) in as short a time as possible [8, 49, 57]. Pre-analytical errors. Specimens must be labeled: Immediately and in front of the patient. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Before blood sampling, the disturbing influences of food and drink should be excluded. Salvagno GL, Lippi G, Montagnana M, Franchini M, Poli G, Guidi GC. 5 % hemolysis (~ 0.8 g/dL free hemoglobin). Accessed 17 Nov 2016. Sandset PM. CAS These account for the vast majority of what we shall term laboratory errors. ODonnell J, Laffan MA. J Thromb Haemost. Rapid preparation of plasma for Stat coagulation testing. The concentration of free calcium ions in the blood plasma "ionized calcium". Preventing Pre-analytical Errors Saunders Company, 2002. Vol. errors The lists can be used as checklists when a specific problem is encountered, or as a tool to supplement or expand the knowledge of the staff involved in laboratory medicine, e.g. Freeze-thawing may produce phospholipid rich membrane microvesicles from platelet damage which may then mask the presence of a lupus anti-coagulant [89]. Extremes of temperature (e.g., both refrigerated or high) should be avoided. Geneva; 2010. http://www.euro.who.int/__data/assets/pdf_file/0005/268790/WHO-guidelines-on-drawing-blood-best-practices-in-phlebotomy-Eng.pdf?ua=1. Thode J, Holmegaard SN, Transbl I, Fogh-Andersen N, Siggaard-Andersen O. Published studies have demonstrated that for routine coagulation testing, the use of a discard tube is not necessary because there was no significant difference in the aPTT and PT results between the first and second tubes drawn [2, 4, 5, 36, 44, 54]. Appropriateness of physician order - Whether the request was placed without indication or placed with The column "due to" refers to the sections in this article.
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