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ACCURATE RESULTS
IN THE CLINICAL
LABORATORY
A Guide to Error Detection and Correction

SECOND EDITION
Edited by

AMITAVA DASGUPTA, PHD, DABCC

Professor of Pathology and Laboratory Medicine
University of Texas McGovern Medical School
Houston, TX, United States

JORGE L. SEPULVEDA, MD, PHD

Professor of Pathology and Cell Biology
Columbia University Vagelos College of Physicians and Surgeons
New York, NY, United States
Elsevier
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 List of contributors
Amid Abdullah, MD University of Calgary and Calgary
Laboratory Services, Calgary, AB, Canada
Maria P. Alfaro, PhD Institute for Genomic Medicine,
Nationwide Children’s Hospital, Columbus, OH,
United States
Chris Altomare, BS DRUGSCAN Inc., Horsham, PA,
United States
Leland Baskin, MD University of Calgary and Calgary
Laboratory Services, Calgary, AB, Canada
Lindsay A.L. Bazydlo, PhD Department of Pathology,
University of Virginia, Charlottesville, VA, United States
Jessica M. Boyd, PhD Department of Pathology and
Laboratory Medicine, Cumming School of Medicine,
University of Calgary, Calgary, AB, Canada; Calgary
Laboratory Services, Calgary, AB, Canada
Larry A. Broussard, PhD Department of Clinical Laboratory
Sciences, Louisiana State University Health Sciences Center,
New Orleans, LA, United States
Violeta Chávez, PhD Department of Pathology and
Laboratory Medicine, University of Texas Medical School at
Houston, Houston, TX, United States
Alex Chin, PhD University of Calgary and Calgary
Laboratory Services, Calgary, AB, Canada
Anthony G. Costantino, PhD DRUGSCAN Inc., Horsham,
PA, United States
Amitava Dasgupta, PhD, DABCC Department of Pathology
and Laboratory Medicine, University of Texas McGovern
Medical School, Houston, TX, United States
Pradip Datta, PhD Siemens Healthineers, Newark, DE,
United States
Robert A. DeSimone, MD Department of Pathology and
Laboratory Medicine, Weill Cornell Medicine,
New York-Presbyterian Hospital, New York, NY,
United States
Uttam Garg, PhD Department of Pathology and Laboratory
Medicine, Children’s Mercy Hospitals and Clinics, The
University of Missouri School of Medicine, Kansas City,
MO, United States
Neil S. Harris, MD Department of Pathology, Immunology
and Laboratory Medicine, University of Florida, College of
Medicine, Gainesville, FL, United States
Joshua Hayden, PhD Department of Pathology and
Laboratory Medicine, Weill Cornell Medical Center,
New York, NY, United States
xi
Susan J. Hsiao, MD, PhD Department of Pathology and Cell
Biology, Columbia University Irving Medical Center,
New York, NY, United States
Laura M. Jacobsen, MD Department of Pediatrics, Division
of Endocrinology, University of Florida, College of
Medicine, Gainesville, FL, United States
Kamisha L. Johnson-Davis, PhD Department of Pathology,
University of Utah School of Medicine, ARUP Laboratories,
Salt Lake City, UT, United States
Steven C. Kazmierczak, PhD Department of Pathology,
Oregon Health & Science University, Portland, OR,
United States
Elaine Lyon, PhD Clinical Services Laboratory,
HudsonAlpha Institute for Biotechnology, Huntsville, AL,
United States
Gwendolyn A. McMillin, PhD Department of Pathology,
University of Utah School of Medicine, ARUP Laboratories,
Salt Lake City, UT, United States
Christopher Naugler, MD University of Calgary and
Calgary Laboratory Services, Calgary, AB, Canada
Elena G. Nedelcu, MD Department of Laboratory Medicine,
University of California San Francisco, San Francisco, CA,
United States
Andy Nguyen, MD Department of Pathology and
Laboratory Medicine, University of Texas McGovern
Medical School, Houston, TX, United States
Octavia M. Peck Palmer, PhD Department of Pathology,
University of Pittsburgh School of Medicine, Pittsburgh,
PA, United States; Department of Critical Care Medicine,
University of Pittsburgh School of Medicine, Pittsburgh, PA,
United States; Department of Clinical and Translational
Science, University of Pittsburgh School, Pittsburgh, PA,
United States
Amy L. Pyle-Eilola, PhD Pathology and Laboratory
Medicine, Nationwide Children’s Hospital, Columbus, OH,
United States
S.M. Hossein Sadrzadeh, PhD Department of Pathology
and Laboratory Medicine, Cumming School of Medicine,
University of Calgary, Calgary, AB, Canada; Calgary
Laboratory Services, Calgary, AB, Canada
Jorge L. Sepulveda, MD, PhD Department of Pathology and
Cell Biology, Columbia University Vagelos College of
Physicians and Surgeons, New York, NY, United States
xii LIST OF CONTRIBUTORS
Brian Rudolph Shy, MD, PhD Department of Laboratory
Medicine, University of California San Francisco,
San Francisco, CA, United States
Aaron Stella, PhD University of Massachusetts Lowell,
Lowell, MA, United States
Yvette C. Tanhehco, PhD Department of Pathology and Cell
Biology, Columbia University Irving Medical Center,
New York-Presbyterian Hospital, New York, NY,
United States
Ashok Tholpady, MD Department of Pathology and
Laboratory Medicine, University of Texas MD Anderson
Cancer Center, Houston, TX, United States
Christina Trambas, MD, PhD Chemical Pathologist,
Chemical Pathology Department, Melbourne Pathology,
Collingwood, VIC, Australia
George Vlad, PhD Department of Pathology & Cell Biology,
Columbia University College of Physicians and Surgeons,
New York, NY, United States
Amer Wahed, MD Department of Pathology and
Laboratory Medicine, University of Texas McGovern
Medical School, Houston, TX, United States
William E. Winter, MD Department of Pediatrics, Division
of Endocrinology, University of Florida, College of
Medicine, Gainesville, FL, United States; Department of
Pathology, Immunology and Laboratory Medicine,
University of Florida, College of Medicine, Gainesville, FL,
United States
Alison Woodworth, PhD Pathology and Laboratory
Medicine, University of Kentucky Medical Center,
Lexington, KY, United States
 Foreword (from the first edition)
Clinicians must make decisions from information
presented to them, both by the patient and ancillary
resources available to the physician. Laboratory data
generally provide quantitative information, which
may be more helpful to physicians than the subjective
information from a patient’s history or physical ex-
amination. Indeed, with the prevalent pressure for
physicians to see more patients in a limited timeframe,
laboratory testing has become a more essential compo-
nent of a patient’s diagnostic work-up, partly as a time-
saving measure but also because it does provide
information against which prior or subsequent test re-
sults, and hence patients’ health, may be compared.
Tests should be ordered if they could be expected to
provide additional information beyond that obtained
from a physician’s first encounter with a patient and if
the results could be expected to influence a patient’s
care. Typically, clinicians use clinical laboratory testing
as an adjunct to their history taking and physical
examination to help confirm a preliminary diagnosis,
although some testing may establish a diagnosis, for
example molecular tests for inborn errors of metabolism.
Microbiological cultures of body fluids may not only
establish the identity of an infecting organism, but also
establish the treatment of the associated medical condi-
tion. In outpatient practice clinicians primarily order
tests to assist them in their diagnostic practice, whereas
for hospitalized patients, in whom a diagnosis has
typically been established, laboratory tests are primarily
used to monitor a patient’s status and response to
treatment. Tests of organ function are used to look for
drug toxicity and the measurement of the circulating
concentrations of drugs with narrow therapeutic win-
dows is done to ensure that optimal drug dosing is
achieved and maintained. The importance of laboratory
testing is evident when some physicians rely more on
laboratory data than a patient’s own assessment as to
how he or she feels, opening them to the criticism of
treating the laboratory data rather than the patient.
In the modern, tightly regulated, clinical laboratory
in a developed country few errors are likely to be made,
with the majority labeled as laboratory errors occurring
outside the laboratory itself. One study from 1995
xiii
showed that when errors were made 75% still produced
results that fell within the reference interval (when
perhaps they should not) [1]. Half of the other errors
were associated with results that were so absurd that
they were discounted clinically. Such results clearly
should not have been released to a physician by the
laboratory and could largely be avoided by a simple
review by human or computer before being verified.
However, the remaining 12.5% of errors produced re-
sults that could have impacted patient management.
The prevalence of errors may be less now than previ-
ously, since the quality of analytical testing has
improved, but the ramifications of each error are not
likely to be less. The consequences of an error vary
depending on the analyte or analytes affected and
whether the patient involved is an inpatient or outpa-
tient. If the patient is an inpatient a physician, if
suspicious about the result, will likely have the oppor-
tunity to verify the result by repeating the test or other
tests addressing the same physiological functions,
before taking action. However, if the error occurs with a
specimen from an outpatient causing an abnormal result
to appear normal, that patient may be lost to follow-up
and present later with advanced disease. Despite the
great preponderance of accurate results clinicians should
always be wary of any result that does not seem to fit
with the patient’s clinical picture. It is, of course, equally
important for physicians not to dismiss any result that
they do not like as a “laboratory error”. The unexpected
result should always prompt an appropriate follow-up.
The laboratory has a responsibility to ensure that physi-
cians have confidence in its test results while still
retaining a healthy skepticism about unexpected results.
Normal laboratory data may provide some assur-
ance to worried patients who believe that they might
have a medical problem, an issue seemingly more
prevalent now with the ready accessibility of medical
information available through computer search engines.
Yet both patients and physicians tend to become over-
reliant on laboratory information, either not knowing
or ignoring the weakness of laboratory tests, in general.
A culture has arisen of physicians and patients
believing that the published upper and lower limits of
xiv FOREWORD (FROM THE FIRST EDITION)
the reference range (or interval) of a test define
normality. They do not realize that such a range has
probably been derived from 95% of a group of pre-
sumed healthy individuals, not necessarily selected
with respect to all demographic factors or habits that
were an appropriate comparative reference for a
particular patient. Even if appropriate, 1 in 20 in-
dividuals would be expected to have an abnormal result
for a single test. In the usual situation in which many
tests are ordered together the probability of abnormal
results in a healthy individual increases in proportion to
the number of tests ordered. Studies have hypothesized
that the likelihood of all of 20 tests ordered at the same
time falling within their respective reference intervals is
only 36%. The studies performed to derive the reference
limits are usually conducted under optimized condi-
tions such as the time since the volunteer last ate, his or
her posture during blood collection and, often the time
of day. Such idealized conditions are rarely likely to be
attained in an office or hospital practice.
Factors affecting the usefulness of laboratory data
may arise in any of the preanalytical, analytical or post-
analytical phase of the testing cycle. Failures to consider
these factors do constitute errors. If these errors occur
prior to collection of blood or after results have been
produced, while still likely to be labeled as laboratory
errors because they involve laboratory tests, the labo-
ratory staffs are typically not liable for them. Yet the
staff does have the responsibility to educate those in-
dividuals who may have caused them to ensure that
such errors do not recur. If practicing clinicians were
able to use the knowledge that experienced labo-
ratorians have about the strengths and weaknesses of
tests it is likely that much more clinically useful infor-
mation could be extracted from existing tests. Outside
the laboratory, physicians rarely are knowledgeable
about the intra- and interindividual variation observed
when serial studies are performed on the same in-
dividuals. For some tests a significant change for an
individual may occur when his/her test values shift
from toward one end of the reference interval toward
the other. Thus a test value does not necessarily have to
exceed the reference limits for it to be abnormal for a
given patient. If the preanalytical steps are not stan-
dardized when repeated testing is done on the same
person, it is more likely that trends in laboratory data
may be missed. There is an onus on everyone involved
in test ordering and test performance to standardize the
processes to facilitate the maximal extraction of infor-
mation from the laboratory data. The combined goal
should be of pursuit of information rather than just
data. Laboratory information systems provide the po-
tential to integrate all laboratory data that can then be
integrated with clinical and other diagnostic informa-
tion by hospital information systems.
Laboratory actions to highlight values outside the
reference interval on their comprehensive reports of test
results to physicians with codes such as “H” or “L” for
high and low values exceeding the reference interval
have tended to obscure the actual numerical result and
to cement the concept that the upper and lower reference
limits define normality and that the presence of one of
these symbols necessitates further testing. The use of the
reference limits as published decision limits for national
programs for renal function, lipid or glucose screening
has again placed a greater burden on the values than
they deserve. Every measurement is subject to analytical
error, such that repeated determinations will not always
yield the same result, even under optimal testing con-
ditions. Would it then be more appropriate to make
multiple measurements and use an average to establish
the number to be acted upon by a clinician?
Much of the opportunity to reduce errors (in the
broadest sense) rests with the physicians who use test
results. Over-ordering leads to the possibility of more
errors. Inappropriate ordering, for example repetitive
ordering of tests whose previous results have been
normal, or ordering the wrong test or wrong sequence
of tests to elucidate a problem should be minimized by
careful supervision by attending physicians of their
trainees involved in the direct management of their
patients. Laboratorians need to be more involved in
teaching medical students so that when they become
residents their test ordering practices are not learned
from senior residents who had learned their habits
from the previous generation of residents. Blanket
application of clinical guidelines or test order-sets has
probably led to much misuse of clinical laboratory
tests. Many clinicians and laboratorians have attemp-
ted to reduce inappropriate test ordering, but the
overall conclusion seems to be that education is
the most effective means. Unfortunately, the education
needs to be continuously reinforced to have a lasting
effect. The education needs to address the clinical
sensitivity of diagnostic tests, the context in which
they are ordered and their half-lives. Above all edu-
cation needs to address issues of biological variation
and preanalytical factors that may affect test values,
possibly masking trends or making the abnormal
result appear normal and vice versa.
 FOREWORD (FROM THE FIRST EDITION) xv
This book provides a comprehensive review of the should be of equal value to clinicians, as to labo-
factors leading to errors in all the areas of clinical lab- ratorians, as they seek the optimal outcome from their
oratory testing. As such it will be of great value to all care of their patients.
laboratory directors and trainees in laboratory medicine
and the technical staff who perform the tests in daily Reference
practice. By clearly identifying problem areas, the book [1] Goldschmidt HMJ, Lent RW. Gross errors and workflow analysis
lays out the opportunities for improvement. This book in the clinical laboratory. Klin Biochem Metab 1995;3:131e49.

Donald S. Young MD, Ph.D

Professor of Pathology and Laboratory Medicine
University of Pennsylvania Perelman College of
Medicine, Philadelphia, PA
 Preface
Clinical laboratory tests have significant impact on
patient safety and patient management because more
than 70% of all medical diagnosis are based on laboratory
test results. Physicians rely on hospital laboratories for
obtaining accurate results and a falsely elevated or
falsely lower value due to interference or pre-analytical
errors may have significant influence on diagnosis and
management of patients. Usually, a clinician questions
the validity of a test result if the result does not match
with clinical evaluation of the patient and calls labora-
tory professionals for interpretation. However, clini-
cally significant inaccuracies in laboratory results may
go unnoticed and mislead the clinicians into inappro-
priate diagnostic and therapeutic approaches, some-
times with very adverse outcomes. The first edition of
“Accurate Results in the Clinical Laboratory: A Guide
to Error Detection and Correction” was published by
Elsevier in 2013 and was intended as a guide to increase
awareness of both clinicians and laboratory pro-
fessionals about the various sources of errors in clinical
laboratory tests and what can be done to minimize or
eliminate such errors. The first edition of the book had
22 chapters and was well received by readers. Due to
success of the first edition, Elsevier requested a second
edition of the book. In this edition, we not only updated
all chapters of the first edition, but also added 9 new
chapters so that the second book could be a concise
but comprehensive guide for both clinicians and
laboratory professionals to detect errors and sources
of misinterpretation in the clinical laboratory and to
prevent or correct such results.
Recently, biotin interferences in immunoassays that
utilize biotinylated antibodies have been described
which may lead to wrong diagnosis of Grave’s disease
due to falsely low TSH (sandwich assay that shows
negative interference due to biotin) but falsely elevated
T3, T4 and FT4 (competitive immunoassays showing
positive biotin interferences). The Food and Drug
Administration reported a fatal outcome due to a falsely
low troponin value as a result of negative interference
xvii
of biotin in the troponin assay. Because people take
megadoses of biotin, this is a serious public health
concern. Therefore, we added a new chapter (Chapter 8).
Another new chapter (Chapter 16) is also added to
discuss issues of false negative results in toxicology due
to the difficulty in detecting certain drugs such as syn-
thetic cathinone (bath salts) and synthetic cannabinoids
(spices). Chapter 27 is also added to discuss sources of
errors in flow cytometry. Moreover, Chapters 29e31 are
also newly added chapters in the second edition.
The objective of this second edition book is to provide
a comprehensive guide for laboratory professionals and
clinicians regarding sources of errors and misinterpreta-
tion in the clinical laboratory and how to resolve such
errors and identify discordant specimens. Accurate lab-
oratory result interpretation is essential for patient safety.
This book is intended as a practical guide to laboratory
professionals and clinicians who deal with erroneous
results on a regular basis. We hope this book will help
them to be aware of such sources of errors and empower
them to eliminate such errors when feasible or to account
for known sources of variability when interpreting
changes in laboratory results.
We would like to thank all contributors for taking time
from their busy professional demands to write chapters.
Without their dedicated contributions this project would
never materialize. We also thank our families for putting
up with us for the last year when we spent many hours
during weekends and evenings writing chapters and
editing this book. Finally our readers will be the judges of
the success of this project. If our readers find this book
useful, all the hard work of contributors and editors will
be rewarded.
Respectfully Submitted
Amitava Dasgupta
Houston, TX
Jorge L. Sepulveda
New York, NY
 C H A P T E R

1
Variation, errors, and quality in the
clinical laboratory
Jorge L. Sepulveda
Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons,
New York, NY, United States

INTRODUCTION 5. The analytical assay measured the concentration of

Recent studies demonstrated that in vitro diagnostic
tests are performed in up to 96% of patients and that
up to 80% of clinical decisions involve consideration of
laboratory results [1]. In addition, approximately
40e94% of all objective health record data are laboratory
results [2e4]. Diagnostic errors accounted for 26e78% of
identified medical errors [5] and nearly 60% of malprac-
tice claims [6], and were involved in 17% of adverse
effects due to medical errors in one large study [7].
Undoubtedly, appropriate ordering and interpretation
of accurate test results are essential for major clinical de-
cisions involving disease identification, classification,
treatment, and monitoring. Factors that constitute an
accurate laboratory result involve more than analytical
accuracy and can be summarized as follows:
1. The right test, with the right costs and right method,
was ordered for the right patient, at the right time, for
the right reason [8]: the importance of appropriate test
selection cannot be minimized as studies have shown
that at least 20% of all test orders are inappropriate [9],
up to 68% of tests ordered do not contribute to improve
patient management [10] and conversely tests were not
ordered when needed in nearly 50% of patients [9].
2. The right sample was collected on the right patient, at
the correct time, with appropriate patient
preparation.
3. The right technique was used collecting the sample to
avoid contamination with intravenous fluids, tissue
damage, prolonged venous stasis, or hemolysis.
4. The sample was properly transported to the
laboratory, stored at the right temperature, processed
for analysis, and analyzed in a manner that avoids
artifactual changes in the measured analyte levels.
the analyte corresponding to its “true” level
(compared to a “gold standard” measurement) within
a clinically acceptable margin of error (the total
acceptable analytical error (TAAE)).
6. The report reaching the clinician contained the right
result, together with interpretative information, such
as a reference range and other comments, aiding
clinicians in the decision-making process.
Failure at any of these steps can result in an erroneous
or misleading laboratory result, sometimes with adverse
outcomes. For example, interferences with point-of-care
glucose testing due to treatment with maltose containing
fluids have led to failure to recognize significant hypo-
glycemia and to mortality or severe morbidity [11].
ERRORS IN CLINICAL LABORATORY
Errors can occur in all the steps in the laboratory
testing process, and such errors can be classified as
follows (see Table 1.1):
1. Pre-analytical steps, encompassing the decision to
test, transmission of the order to the laboratory for
analysis, patient preparation and identification,
sample collection, and specimen processing.
2. Analytical assay, which produces a laboratory result.
3. Post-analytical steps, involving the transmission of
the laboratory data to the clinical provider, who uses
the information for decision making.
Although minimization of analytical errors has been
the main focus of developments in laboratory medicine,
the other steps are more frequent sources of erroneous

Accurate Results in the Clinical Laboratory, Second Edition

https://doi.org/10.1016/B978-0-12-813776-5.00001-7 3 Copyright © 2019 Elsevier Inc. All rights reserved.
4 1. VARIATION, ERRORS, AND QUALITY IN THE CLINICAL LABORATORY

TABLE 1.1 Types of error in the clinical laboratory. TABLE 1.1 Types of error in the clinical laboratory.dcont’d

PRE-ANALYTICAL ANALYTICAL

Test ordering • High analytical turnaround • Test perform by

• Duplicate Order
• Ordering provider not
identified
• Ordered test not performed
(include add-ons)
Sample collection
• Unsuccessful phlebotomy
• Traumatic phlebotomy
• Patient complaint about
phlebotomy
Specimen transport
• Inappropriate sample
transport conditions
• Specimen leaked in transit
• Order misinterpreted (test
ordered <> intended test)
• Inappropriate/outmoded test
ordered
• Order not pulled by specimen
collector
• Check-in not performed (in
the LIS)
• Wrong patient preparation
(e.g., non-fasting)
• Therapeutic drug monitoring
test timing error
• Specimen damaged during
transport
• Specimen damaged during
centrifugation/analysis
time
• Instrument caused random
error
• Instrument malfunction
• QC failure
• QC not completed
POST-ANALYTICAL
• Report not completed
• Delay in reporting results
• Critical results not called
• Delay in calling critical
results
• Results reported incorrectly
• Results reported incorrectly
from outside laboratory
• Results reported to wrong
provider
OTHER
unauthorized personnel
• Results discrepant with other
clinical or laboratory data
• Testing not completed
• Wrong test performed
(different from test ordered)
• Reported questionable
results, detected by
laboratory
• Reported questionable
results, detected by clinician
• Failure to append proper
comment
• Read back not done
• Results misinterpreted
• Failure to act on results of
tests

Specimen identification • Proficiency test failure • Employee injury

• Specimen unlabeled
• Specimen mislabeled: No
Name or ID on tube
• Specimen mislabeled: No
Name on tube
• Specimen mislabeled:
Incomplete ID on tube
• Wrong specimen label
• Wrong name on tube
• Wrong ID on tube
• Wrong blood type
High pre-analytical turnaround time
• Delay in receiving specimen
in lab
• Delay in performing test
Specimen quality
• Specimen contaminated with
infusion fluid
• Specimen contaminated with
microbes
• Specimen too old for analysis
Specimen containers
• No specimens received/
Missing tube
• Specimen lost in laboratory
• Wrong specimen type
• Inappropriate container/tube
type
• Wrong tube collection
instructions
• Date/time missing
• Collector’s initials missing
• Label illegible
• Two contradictory labels
• Overlapping labels
• Mismatch requisition/label
• Specimen information
misread by automated reader
• STAT not processed urgently
• Hemolyzed
• Clotted or platelet clumps
• Wrong preservative/
anticoagulant
• Insufficient specimen
quantity for analysis
• Tube filling error (too much
anticoagulant)
• Tube filing error (too little
anticoagulant)
• Empty tube
• Product wastage • Safety failure
• Product not delivered timely • Environmental failure
• Product recall • Damage to equipment
results. An analysis indicated that pre-analytical errors
accounted for 62% of all errors, with post-analytical rep-
resenting 23% and analytical 15% of all laboratory errors
[12]. The most common pre-analytical errors included
incorrect order transmission (at a frequency of approxi-
mately 3% of all orders) and hemolysis (approximately
0.3% of all samples) [13]. Other frequent causes of pre-
analytical errors include the following:
• Patient identification error
• Tube filling error, empty tubes, missing tubes, or
wrong sample container
• Sample contamination or collected from infusion
route
• Inadequate sample temperature
Particular attention should be paid to patient identifi-
cation because errors in this critical step can have severe
consequences, including fatal outcomes, for example,
due to transfusion reactions or misguided therapeutic
decisions. To minimize identification errors, health
care systems are using point-of-care identification sys-
tems, which typically involve the following:
1. Handheld devices connected to the laboratory
information systems (LIS) that can objectively
identify the patient by scanning a patient-attached
bar code, typically a wrist band.

I. SOURCES OF ERRORS IN CLINICAL LABORATORIES: AN OVERVIEW

 ERRORS IN CLINICAL LABORATORY
2. Current laboratory orders can be retrieved from
the LIS.
3. Ideally, collection information, such as correct tube
types, is displayed in the device.
4. Bar-coded labels are printed at the patient’s side,
minimizing the possibility of misplacing the labels on
the wrong patient samples.
5. After attaching to containers with the patient
samples, bar-coded labels should be scanned to
confirm that they were applied to the right patient,
especially if any significant delay has occurred
between label printing and sample collection. In this
case, rescanning of patient-attached identifiers should
be done in close temporal proximity to sample
scanning.
Analytical errors are mostly due to interference or
other unrecognized causes of inaccuracy, whereas
instrument random errors accounted for only 2% of all
laboratory errors in one study [12]. According to that
study, most common post-analytical errors were due to
communication breakdown between the laboratory
and the clinicians, whereas only 1% were due to
miscommunication within the laboratory, and 1% of
the results had excessive turnaround time for reporting
[12]. Post-analytical errors due to incorrect transcription
of laboratory data have been greatly reduced because of
the availability of automated analyzers and bidirectional
interfaces with the LIS [12]. However, transcription
errors and calculation errors remain a major area of
concern in those testing areas without automated
interfaces between the instrument and the LIS. Further
developments to reduce reporting errors and minimize
the testing turnaround time include auto-validation of
test results falling within pre-established rule-based
parameters and systems for automatic paging of critical
results to providers.
When classifying sources of error, it is important to
distinguish between cognitive errors, or mistakes, which
are due to poor knowledge or judgment, and noncogni-
tive errors, commonly known as slips and lapses, due
to interruptions in a process that is routine or relatively
automatic. Whereas the first type can be prevented by
increased training, competency evaluation, and process
aids such as checklists or “cheat sheets” summarizing
important steps in a procedure, noncognitive errors are
best addressed by process improvement and environ-
ment re-engineering to minimize distractions and
fatigue. Furthermore, it is useful to classify adverse
occurrences as activedthat is, the immediate result of
an action by the person performing a taskdor as latent
or system errors, which are system deficiencies due to
poor design or implementation that enable or amplify
active errors. In one study, only approximately 11% of
the errors were cognitive, all in the pre-analytical phase,
I. SOURCES OF ERRORS IN CLINICAL LABORATORIES: AN OVERVIEW
5
and approximately 33% of the errors were latent [12].
Therefore, the vast majority of errors are noncognitive
slips and lapses performed by the personnel directly
involved in the process. Importantly, 92% of the pre-
analytical, 88% of analytical, and 14% of post-analytical
errors were preventable. Undoubtedly, human factors,
engineering, and ergonomicsdoptimization of systems
and process redesigning to include increased automation
and user-friendly, simple, and rule-based functions,
alerts, barriers, and visual feedbackdare more effective
than education and personnel-specific solutions to
consistently increase laboratory quality and minimize
errors.
Immediate reporting of errors to a database accessible
to all the personnel in the health care system, followed
by automatic alerts to quality management personnel,
is important for accurate tracking and timely correction
of latent errors. In our experience, reporting is improved
by using an online form that includes checkboxes for the
most common types of errors together with free-text for
additional information (Fig. 1.1). Reviewers can subse-
quently classify errors as cognitive/noncognitive,
latent/active, and internal to laboratory/internal to
institution/external to institution; determine and
classify root causes as involving human factors (e.g.,
communication and training or judgment), software, or
physical factors (environment, instrument, hardware,
etc.); and perform outcome analysis. Outcomes of errors
can be classified as follows:
1. Target of error (patient, staff, visitors, or equipment).
2. Actual outcome on a severity scale (from unnoticed
to fatal).
3. Worst outcome likelihood if error was not intercepted
on the same severity scale, since many errors are
corrected before they cause injury.
Errors with significant outcomes or likelihoods of
adverse outcomes should be discussed by quality man-
agement staff and laboratory directors to determine
appropriate corrective actions and process improvement
initiatives.
Clearly, efforts to improve accuracy of laboratory
results should encompass all of the steps of the testing
cycle, a concept expressed as “total testing process”
or “brain-to-brain testing loop” [14]. Approaches to
achieve error minimization derived from industrial pro-
cesses include total quality management (TQM) [15];
lean dynamics and Toyota production systems [16];
root cause analysis (RCA) [17]; health care failure modes
and effects analysis (HFMEA) [18,19]; failure review
analysis and corrective action system (FRACAS) [20];
and Six Sigma [21,22], which aims at minimizing the
variability of products such that the statistical frequency
of errors is below 3.4 per million. A detailed description
6 1. VARIATION, ERRORS, AND QUALITY IN THE CLINICAL LABORATORY

FIG. 1.1 Example of an error reporting form for the clinical laboratory.

of these approaches is beyond the scope of this book, but
laboratorians and quality management specialists
should be familiar with these principles for error pre-
vention, error detection, and error management to
achieve efficient, high-quality laboratory operation and
patient care [15].
QUALITY IMPROVEMENT IN CLINICAL
LABORATORY
Quality is defined as all the features of a product that
meet the requirements of the customers and the health
care system. Many approaches are used to improve
and ensure the quality of laboratory operations. The
concept of TQM involves a philosophy of excellence
concerned with all aspects of laboratory operations
that impact on the quality of the results. Specifically,
TQM approaches apply a system of statistical process
control tools to monitor quality and productivity (quality
assurance) and encourage efforts to continuously
improve the quality of the products, a concept known
as continuous quality improvement. A major component
of a quality assurance program is quality control (QC),
which involves the use of periodic measurements of
product quality, thresholds for acceptable performance,
and rejection of products that do not meet acceptability
criteria. Most notably, QC is applied to all clinical
laboratory testing processes and equipment, including
testing reagents, analytical instruments, centrifuges,
and refrigerators. Typically, for each clinical test,
external QC materials with known performance, also
known as controls, are run two or three times daily in
parallel with patient specimens. Controls usually have
preassigned analyte concentrations covering important
medical decision levels, often at low, medium, and

I. SOURCES OF ERRORS IN CLINICAL LABORATORIES: AN OVERVIEW

 QUALITY IMPROVEMENT IN CLINICAL LABORATORY
high concentrations. Good laboratory QC practice
involves establishment of a laboratory- and instrument-
specific mean and standard deviation for each lot of
each control and also a set of rules intended to maximize
error detection while minimizing false rejections, such as
Westgard rules [23]. Another important component of
quality assurance for clinical laboratories is participation
in proficiency testing (or external quality assessment pro-
grams such as proficiency surveys sent by the College of
American Pathologists), which involves the sharing of
samples with a large number of other laboratories and
comparison of the results from each laboratory with its
peers, usually with reporting of the mean and standard
deviation (SD) of all the laboratories running the same
analyzer/reagent combination. Criteria for QC rules
and proficiency testing acceptability should take into
consideration the concept of total acceptable analytical
error because deviations smaller than the total analytical
errors are unlikely to be clinically significant and there-
fore do not need to be detected.
Total analytical error (TAE) is usually considered to
combine the following (Fig. 1.2): (1) systematic error
(SE), or bias, as defined by deviation between the
average values obtained from a large series of test results
and an accepted reference or gold standard value, and
(2) random error (RE), or imprecision, represented by
the coefficient of variation of multiple independent test
results obtained under stipulated conditions (CVa).
Assuming a normal distribution of repeated test results,
at the 95% confidence level, the RE is equal to 1.65 times
the CVa for the method; consequently.
FIG. 1.2 Total analytical error (TE) components: random error (RE),
or imprecision and systematic error (SE), or bias, which cause the
difference between the true value and the measured value. Random
error can increase or decrease the difference from the true value.
Because in a normal distribution, 95% of the observations are contained
within the mean  1.65 standard deviations (SDs), the total error will
not exceed bias þ 1.65  SD in 95% of the observations.
I. SOURCES OF ERRORS IN CLINICAL LABORATORIES: AN OVERVIEW
7
TAE ¼ 1:65  CVa þ bias
Clinical laboratories frequently evaluate imprecision
by performing repeated measurements on control mate-
rials, preferably using runs performed on different days
(between-day precision), whereas bias (or trueness) is
assessed by comparison with standard reference mate-
rials with assigned values and also by peer comparison,
where either the peer mean or median are considered
the reference values.
One important concept that some clinicians disregard
is that no laboratory measurement is exempt of error;
that is, it is impossible to produce a laboratory result
with 0% bias and 0% imprecision. The role of techno-
logic developments, good manufacturing practices,
proficiency testing, and QC is to identify and minimize
the magnitude of the TAE. A practical approach is to
consider the clinically acceptable total analytical error
or TAAE for each test. Clinical acceptability has been
defined by legislation (e.g., the Clinical Laboratory
Improvement Act (CLIA)), by clinical expert opinion,
and by scientific and statistical principles that take
into consideration expected sources of variation. For
example, Callum Fraser proposed that clinically accept-
able imprecision, or random error, should be less than
half of the intraindividual biologic variation for the ana-
lyte and less than 25% of the total analytical error [24].
The systematic error, or bias, should be less than 25%
of the combined intraindividual (CVw) and interindi-
vidual biological (CVg) variation:
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
TAAE95% < 1:65  0:5  CVw þ 0:25  CV2w þ CV2g
Tables of intra- and interindividual biological varia-
tion, with corresponding allowable errors, are available
and frequently updated [25]. See Table 1.2 for examples.
Importantly, the allowable errors may be different at
specific medical decision levels because analytical
imprecision tends to vary with the analyte concentra-
tion, with higher imprecision at lower levels. Also,
biological variation may be different in the various
clinical conditions, and available databases are starting
to incorporate studies of biologic variation in different
diseases [25].
A related concept is the reference change value (RCV),
also called significant change value (SCV)dthat is, the
variability around a measurement that is a consequence
of analytical imprecision, within-subject biologic vari-
ability, and the number of repeated tests performed
[24,26,27]. Assuming a normal distribution, at the 95%
confidence level, RCV can be calculated as follows:
pffiffiffi qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
RCV95% ¼ 1:96  2  CV2a þ CV2w
Because multiple repeats decrease imprecision errors,
if the change is determined from the mean of repeated
8 1. VARIATION, ERRORS, AND QUALITY IN THE CLINICAL LABORATORY

tests, the formula can be modified to take into consider-
ation the number of repeats in each measurement
(n1 and n2) [27]:
sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
2 pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
RCV95% ¼ 1:96   CVa2 þ CVw2
n 1  n2
For example, for a serum creatinine measurement
with an analytical imprecision (CVa) of 7.6% and
within-subject biologic variation of 5.95%, the RCV at
95% confidence is 26.8% with one measurement for
each sample. With two measurements for each sample,
the RCV is 18.9%. Therefore, a change between two re-
sults that does not exceed the RCV has a greater than
95% probability that it is due to the combined analytical
and intraindividual biological variation; in other words,
the difference between the two creatinine results
(measured without repeats) should exceed 26.8% to be
95% confident that the change is due to a pathological
condition. Conversely, for any change in laboratory
values, the RCV formula can be used to calculate the
probability that it is due to analytical and biological
variation [24,26,27]. See Table 1.2 for examples of RCV
at the 95% confidence limit, using published intraindi-
vidual variation and typical laboratory imprecision for
each test. Ideally, future LIS should integrate available
knowledge and patient-specific information and auto-
matically provide estimates of expected variation based

TABLE 1.2 Allowable errors and reference change values for selected tests.

Test CVa CVw CVg CLIA TAAE Bio TAAE Allowable imprecision Allowable bias RCV95

Amylase 5.3 8.7 28.3 30 14.6 4.4 7.4 28.2

Alanine aminotransferase 2.8 19.4 41.6 20 27.48 9.7 11.48 54.3
Albumin 2.6 3.2 4.75 10 4.07 1.6 1.43 11.4
Alkaline phosphatase 4.2 6.45 26.1 30 12.04 3.23 6.72 21.3
Aspartate aminotransferase 2.2 12.3 23.1 20 16.69 6.15 6.54 34.6

Bilirubin total 10.0 21.8 28.4 20 26.94 10.9 8.95 66.5

Chloride 2.4 1.2 1.5 5 1.5 0.6 0.5 7.4
Cholesterol 2.7 5.95 15.3 10 9.01 2.98 4.1 18.1
Cortisol 5.3 21.7 46.2 25 30.66 10.85 12.76 61.9
Creatine kinase 3.6 22.8 40 30 30.3 11.4 11.5 64.0
Creatinine 7.6 5.95 14.7 15 8.87 2.98 3.96 26.8

Glucose 3.4 4.5 5.8 10 5.5 2.3 1.8 15.6

HDL cholesterol 3.3 7.3 21.2 30 11.63 3.65 5.61 22.2
Iron 2.5 26.5 23.2 20 30.7 13.3 8.8 73.8
Lactate dehydrogenase (LDH) 2.5 8.6 14.7 20 11.4 4.3 4.3 24.8
Magnesium 2.8 5.6 11.3 25 7.8 2.8 3.2 17.4
pCO2 1.5 4.8 5.3 8 5.7 2.4 1.8 13.9

Protein, total 2.6 2.75 4.7 10 3.63 1.38 1.36 10.5

Thyroxine (T4) 4.8 4.9 10.9 20 7 2.5 3 19.0
Triglyceride 3.9 19.9 32.7 25 25.99 9.95 9.57 56.2
Urate 2.9 8.6 17.5 17 11.97 4.3 4.87 25.2
Urea nitrogen 6.2 12.1 18.7 9 15.55 6.05 5.57 37.7

All values are percentages. Bio TAAE, total allowable analytical error based on interindividual and intraindividual variation; CLIATAAE, total allowable analytical error
based on Clinical Laboratory Improvement Act (CLIA); CVa, analytical variability in a typical clinical laboratory; CVg, interindividual variability; CVw, intraindividual
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
variability. Allowable imprecision ¼ 50% of CVw. Allowable bias ¼ 0:25  CV2w  CV2g . RCV95, reference change value at 95% confidence based on CVw and CVa.
Based on Westgard J. Desirable specifications for total error, imprecision, and bias, derived from intra- and inter-individual biologic variation. 2014. Available from: http://www.
westgard.com/biodatabase1.htm.

I. SOURCES OF ERRORS IN CLINICAL LABORATORIES: AN OVERVIEW

 REFERENCES
on the previous formulas to facilitate interpretation of
changes in laboratory values and guide laboratory staff
regarding the meaning of deviations from expected
results. In summary, the use of TAAE and RCV brings
objectivity to error evaluation, QC and proficiency
testing practices, and clinical decision making based
on changes in laboratory values.
CONCLUSIONS
As in other areas of medicine, errors are unavoidable
in the whole diagnostic process involving laboratory
testing. A good understanding of the sources of error,
frequently involving pre-analytical factors, together
with a quantitative evaluation of the clinical significance
of the magnitude of analytical errors, aided by the estab-
lishment of limits of acceptability based on statistical
principles of analytical and intraindividual biological
variation, are critical to design a quality program to
minimize the clinical impact of errors in the clinical
laboratory.
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[3] Forsman RW. Why is the laboratory an afterthought for managed
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[7] Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR,
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[8] Lippi G, Bovo C, Ciaccio M. Inappropriateness in laboratory
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[10] Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors
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[11] Gaines AR, Pierce LR, Bernhardt PA. Fatal iatrogenic hypoglyce-
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5099.htm.
[12] Carraro P, Plebani M. Errors in a stat laboratory: types and
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[13] Carraro P, Zago T, Plebani M. Exploring the initial steps of the
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Clin Chem 2012;58(3):638e42.
[14] Plebani M, Lippi G. Closing the brain-to-brain loop in laboratory
testing. Clin Chem Lab Med 2011;49(7):1131e3.
[15] Valenstein P, editor. Quality management in clinical laboratories.
Northfield (IL): College of American Pathologists; 2005.
[16] Rutledge J, Xu M, Simpson J. Application of the Toyota produc-
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[17] Dunn EJ, Moga PJ. Patient misidentification in laboratory medi-
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 C H A P T E R
2
Errors in patient preparation, specimen
collection, anticoagulant and preservative use:
how to avoid such pre-analytical errors
Leland Baskin, Alex Chin, Amid Abdullah, Christopher Naugler
University of Calgary and Calgary Laboratory Services, Calgary, AB, Canada
INTRODUCTION
Patient preparation and the specimen type are impor-
tant pre-analytical factors to consider for laboratory
assessment. Although the clinical laboratory has limited
capabilities in controlling for the physiological state of
the patient, such as biological rhythms and nutritional
status, these variables as well as the effect of patient
posture, tourniquets, and serum/plasma indices (hemo-
lysis, icterus, lipemia) on measurement of analytes must
be understood by both the clinical team and laboratory
personnel. The most accessible specimen types include
blood, urine, and oral fluid. The numerous functions
associated with blood make it an ideal specimen to
measure biomarkers corresponding to various physio-
logical and pathophysiological processes. Blood can be
collected by skin puncture (capillary), which is preferred
when blood conservation and minimal invasiveness is
stressed, such as in the pediatric population. Other
modes of collection include venipuncture and arterial
puncture, where issues to consider include the physical
state of the site of collection and patient safety. Blood can
also be taken from catheters and other intravascular
lines, but care must be taken to eliminate contamination
and dilution effects associated with heparin and other
drugs. Clinical laboratory specimens derived from
blood include whole blood, plasma, and serum. Howev-
er, noticeable differences between these specimen types
need to be considered when choosing the optimal
specimen type for laboratory analysis. Such important
factors include the presence of anticoagulants in plasma
and in whole blood, hematocrit variability, and the dif-
ferences in serum characteristics associated with blood
Accurate Results in the Clinical Laboratory, Second Edition
https://doi.org/10.1016/B978-0-12-813776-5.00002-9
coagulation. Anticoagulants for plasma and/or whole
blood collection include ethylenediaminetetraacetic
acid (EDTA), heparin, hirudin, oxalate, and citrate,
which are available in solid or liquid form. Optimal
anticoagulant-to-blood ratios are crucial to prevent clot
formation while avoiding interference with analyte mea-
surement, including dilution effects associated with
liquid anticoagulants. Given the availability of multiple
anticoagulants and additives, blood collection tubes
should be filled according to a specified order to mini-
mize contamination and carryover. Other factors to
consider regarding blood collection tubes include differ-
ences between plastic and glass surfaces, surfactants,
tube stopper lubricants, and gel separators, which all
affect analyte measurement.
The second most popular clinical specimen is urine,
which is essentially an ultrafiltrate of blood before
elimination from the body and is the preferred spec-
imen to detect metabolic activity as well as urinary
tract infections. Proper timing must be ensured for
urine collections depending on the need for routine
tests, patient convenience, clinical sensitivity, or quan-
titation. Furthermore, proper technique is required for
clean catch samples for subsequent microbiological
examination. Certain urine specimens require addi-
tives to preserve cellular integrity for cytological
analysis and to prevent bacterial overgrowth. It is
important to recognize the pre-analytical variables
that affect analyte measurement in patient specimens
so that properly informed decisions can be made
regarding assay selection and development as well
as troubleshooting unexpected outcomes from labora-
tory analysis.
11 Copyright © 2019 Elsevier Inc. All rights reserved.
12 2. PATIENT PREPARATION AND OTHER ISSUES AFFECTING LAB TESTS
BIOLOGICAL RHYTHMS AND
LABORATORY TEST RESULTS
Predictable patterns in the temporal variation of
certain analytes, reflecting patterns in human needs,
constitute biological rhythms. Different analytes have
different rhythms, ranging from a few hours to monthly
changes. Awareness of such changes can be relevant
to proper interpretation of laboratory results. These
changes can be divided into circadian, ultradian, and
infradian rhythms according to the time interval of their
completion.
During a 24-h period of human metabolic activity,
programming of metabolic needs may cause certain
laboratory tests to fluctuate between a maximum and a
minimum value. The amplitude of change of these circa-
dian rhythms is defined as one-half of the difference
between the maximum and the minimum values.
Although, in general, these variations occur consistently,
alteration in these natural circadian rhythms may be
induced by artificial changes in sleep/wake cycles
such as those induced by different work shifts. There-
fore, in someone working an overnight (“graveyard”)
shift, an elevated blood iron level taken at midnight
would be normal for that individual; however, the
norm is for high iron levels to be seen only in early
morning.
Patterns of biological variation occurring on cycles
less than 24 h are known as ultradian rhythms. Analytes
that are secreted in a pulsatile manner throughout the
day show this pattern. Testosterone, which usually
peaks between 10:00 a.m. and 5 p.m., is an example of
an analyte showing this pattern.
The final pattern of biological variation is infradian.
This involves cycles greater than 24 h. The example
most commonly cited is the monthly menstrual cycle,
which takes approximately 28e32 days to complete.
Constituents such as pituitary gonadotropin, ovarian
hormones, and prostaglandins are significantly affected
by this cycle.
PATIENT PREPARATION
There are certain important issues regarding patient
preparation for obtaining meaningful clinical laboratory
test results. For example, glucose testing must be done
after the patient has fasted overnight. These issues are
discussed in this section.
Fasting
The effects of meals on blood test results have been
known for some time. Increases in serum glucose, tri-
glycerides, bilirubin, and aspartate aminotransferase
I. SOURCES OF ERRORS IN CLINICAL LABORATORIES: AN OVERVIEW
are commonly observed after meal consumption. On
the other hand, fasting will increase fat metabolism
and increase the formation of acetone, b-hydroxybutyric
acid, and acetoacetate both in serum and in urine.
Longer periods of fasting (more than 48 h) may result
in up to a 30-fold increase in these ketone bodies.
Glucose is primarily affected by fasting because insulin
keeps the serum concentration in a tight range
(70e110 mg/dL). Diabetes mellitus, which results from
either a deficiency of insulin or an increase in tissue
resistance to its effects, manifests as an increase in blood
glucose levels. In normal individuals, after an average of
2 h of fasting, the blood glucose level should be below
7.0 mmol/L (126 mg/dL). However, in diabetic individ-
uals, fasting serum levels are elevated and thus consti-
tute one criterion for making the diagnosis of diabetes.
Other well-known examples of analytes showing varia-
tion with fasting interval include serum bilirubin, lipids,
and serum iron.
Body position
Physiologically, blood distribution differs signifi-
cantly in relation to body posture. Gravity pulls the
blood into various parts of the body when recumbent,
and the blood moves back into the circulation, away
from tissues, when standing or ambulatory. These shifts
directly affect certain analytes due to dilution effects.
This process is differential, meaning that only constitu-
ents of the blood that are non-diffusible will rise because
there is a reduction in plasma volume upon standing
from a supine position. This includes, but is not limited
to, cells, proteins, enzymes, and protein-bound analytes
(e.g., thyroid-stimulating hormone, cholesterol, T4, and
medications such as warfarin). The reverse will take
place when shifting from erect to supine because there
will be a hemodilution effect involving the same previ-
ously mentioned analytes. Postural changes affect
some groups of analytes in a much more profound
waydat times up to a twofold increase or decrease
depending on whether the sample was obtained from
a supine or an erect patient. Most affected are factors
directly influencing homeostasis, including renin, aldo-
sterone, and catecholamines. It is vital for laboratory
requisitions to specify the need for supine samples
when these analytes are requested.
WHOLE BLOOD, PLASMA, AND SERUM
SPECIMENS FOR CLINICAL
LABORATORY ANALYSIS
Approximately 8% of total human body weight is
represented by blood, with an average volume in fe-
males and males of 5 and 5.5 L, respectively [1]. Whole
 WHOLE BLOOD, PLASMA, AND SERUM SPECIMENS FOR CLINICAL LABORATORY ANALYSIS 13
blood consists of a cellular fraction (w45%) composed of laboratory analysis, plasma can be obtained from whole
erythrocytes (red blood cells), leukocytes (white blood blood through the use of anticoagulants followed by
cells), and thrombocytes (platelets), and a liquid fraction centrifugation. Consequently, plasma specimens for
(plasma) (w55%) that transports these elements the clinical laboratory contain anticoagulants such as
throughout the body. Blood vessels interconnect all the heparin, citrate, EDTA, oxalate, and fluoride. The rela-
organ systems in the body and play a vital role in tive roles of these anticoagulants in affecting analyte
communication and transportation between tissue com- measurements are discussed later in this chapter. In
partments. Blood serves numerous functions, including contrast to anticoagulated plasma specimens, serum is
delivery of nutrients to tissues; gas exchange; transport the clear liquid that separates from blood when it is
of waste products such as metabolic by-products for allowed to clot. Further separation of the clear serum
disposal; communication to target tissues through from the clotted blood can be achieved through centrifu-
hormones, proteins and other mediators; and cellular gation. Given that fibrinogen is converted to fibrin in clot
protection against invading organisms and foreign formation during the coagulation cascade, serum con-
material. Given these myriad roles, blood is an ideal tains no fibrinogen and no anticoagulants. In the clinical
specimen for measuring biomarkers associated with laboratory, suitable blood specimens include whole
various physiological conditions, whether it is direct blood, plasma, and serum. Key differences in these
measurement of cellular material and surface markers sample matrices influence their suitability for certain
or measurement of soluble factors associated with laboratory tests Table 2.2.
certain physiological conditions.
Plasma consists of approximately 93% water, with the
remaining 7% composed of electrolytes, small organic
molecules, and proteins. Various constituents of plasma
Whole blood
are summarized in Table 2.1. These analytes are in In addition to the obvious advantage of whole blood
transit between cells in the body and are present in vary- for the analysis of cellular elements, these specimens are
ing concentrations depending on the physiological state also preferred for analytes that are concentrated within
of the various organs. Therefore, accurate analysis of the the cellular compartment. Erythrocytes can be consid-
plasma is crucial for obtaining information regarding ered to be a readily accessible tissue with minimal inva-
diagnosis and treatment of diseases. In clinical sive procedures and may more accurately reflect tissue
distribution of certain analytes. Examples of such analy-
tes, including vitamins, trace elements, and certain
TABLE 2.1 Principal components of plasma. drugs, are listed in Table 2.3. Erythrocytes are the most
abundant cell type in the blood. In adults, 1 mL of blood
Component Reference range Units
contains approximately 4e6 million erythrocytes,
Sodium 136e145 mmol/L 4000e11,000 leukocytes and 150,000e450,000 platelets
Potassium 3.5e5.1 mmol/L [2]. (The ratio of erythrocytes: platelets: leukocytes is
on the order of 900:60:1.) The hematocrit is the volu-
Bicarbonate 17e25 mmol/L
metric fraction of erythrocytes expressed as a percentage
Chloride 98e107 mmol/L of packed erythrocytes in a blood sample after centrifu-
Hydrogen ions 40 mmol/L gation. The normal range for adult males is 41e51%, and
that for adult females is 36e45% [2]. Clearly, alterations
Calcium 8.6e10.2 mg/dL
in hematocrit will directly alter the available plasma wa-
Magnesium 1.6e2.6 mg/dL ter concentration, which in turn affects the measurement
Inorganic phosphate 2.5e4.5 mg/dL of water-soluble factors in whole blood.
A major use for whole blood specimens is for point-
Glucose 70e99 mg/dL
of-care analysis. Although point-of-care meters can be
Cholesterol <200 (Desirable) mg/dL located in the clinical laboratory, the primary advantage
Fatty acids 3.0 g/L of this technology is near-patient testing offering rapid
and convenient analysis and using small sample vol-
Total protein 6.4e8.3 g/dL
Albumin 3.2e4.6 g/dL
umes while the clinician is examining the patient. The
a-Globulins 0.1e0.3 g/dL most common point-of-care specimens are taken by
b-Globulins 0.7e1.2 g/dL skin puncture. Commonly called capillary blood, these
g-Globulins 0.7e1.6 g/dL samples are composed of a mixture of blood from the
Fibrinogen 145e348 mg/dL arterioles, venules and capillaries with interstitial and
Prothrombin 1 g/L
Transferrin 200e360 mg/dL
intracellular fluids. Furthermore, the extent of dilution
with interstitial and intracellular fluid is also affected

I. SOURCES OF ERRORS IN CLINICAL LABORATORIES: AN OVERVIEW

Another random document with
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los caballos enjaezados. Fijó las riendas en el extremo delantero de
carro, y aseguró sus pies en los borceguíes adheridos a él.[139] Primero
suplicó a los dioses de esta manera, levantando al cielo las manos
«Si soy criminal, ¡oh Zeus!, que no viva más, y que mi padre conozca
que ha sido injusto conmigo, ya después de mi muerte, ya mientras
vea la luz». Y mientras tanto, cogió el látigo y aguijó los caballos
nosotros, sus servidores, seguíamos cerca del carro a nuestro dueño
que se encaminó en derechura a Argos y Epidauro. Poco después que
entramos en lugares desiertos, más allá de esta tierra,[140] y llegamos a
la orilla del mar Sarónico, se oyó cierto ruido horrible, como si fuera e
de un trueno subterráneo de Zeus, que nos hizo temblar a todos; los
caballos levantaron la cabeza y enderezaron las orejas; nosotros
teníamos gran miedo, no sabiendo cuál fuese la causa que lo
producía; pero habiendo mirado a la orilla del alborotado mar, vimos
una espantosa ola que amenazaba al cielo, hasta el punto de
ocultarnos la ribera Sarónica, y el istmo y el promontorio de Esculapio
Hinchándose más después, y derramando en torno mucha espuma, y
bramando horriblemente, se estrelló en la orilla, en donde estaba la
cuadriga, y del seno de la tempestad y de las agitadas olas salió un
toro, monstruo fiero, con cuyos mugidos resonaba pavorosamente la
tierra; a todos los que presenciamos este espectáculo parecía
espantoso, y no podíamos mirarlo sin estremecernos. El miedo se
apoderó de los caballos, y mi señor, muy diestro en manejarlos, cogió
en sus manos las riendas y tiró hacia atrás, como el marinero hace
con el remo, y con ellas ciñó su cuerpo; pero los caballos, tascando e
bocado endurecido al fuego, arrancaron con ímpetu, sin cuidarse de la
mano que los regía, ni e las riendas, ni de los carros bien labrados
siempre que en tierra llana, y sin soltar las riendas, cambiaba su
carrera, aparecía el toro delante, como para acometer al carro, e
infundía en los caballos invencible miedo; si con furia lo llevaban
contra los peñascos, seguía acercándose en silencio, hasta que le
embistió y volcó, rompiendo las ruedas contra una peña. Todo fue
entonces confusión; los rayos de las ruedas y los clavos de los ejes
saltaron en todas direcciones. El desventurado, sujeto por las riendas
se estrelló la cabeza contra los peñascos y se magulló el cuerpo
exclamando con la mayor amargura: «Deteneos, caballos alimentados
en mis pesebres; no me matéis. ¡Oh, cruel maldición de mi padre
¿Quién quiere socorrerme y salvar a un hombre bueno si los hay?»
Muchos que lo deseábamos, con tardo paso le seguíamos de lejos. A
fin, desenredándose de las riendas, cayó no sé de qué modo, y le
quedan pocos instantes de vida, y los caballos y el malhadado y
milagroso toro se escondieron no sé en qué lugar montañoso. Yo soy
en verdad, un siervo de tu palacio, ¡oh rey!, pero jamás podré cree
que tu hijo ha delinquido, aunque se ahorquen todas las mujeres y
escriban tantas tablillas cuantas pueden hacerse de las selvas de
Ida,[141] seguro como estoy de su inocencia.
EL CORO
¡Ay, ay de mí! Consumáronse nuevos desastres, e inevitable es e
destino.
TESEO
Gozo me infundieron tus palabras por el odio que tengo a la víctima
de estos males; venerando ahora a los dioses, y recordando que es m
hijo, ni sus desdichas me placen ni me afligen.
EL MENSAJERO
¿Qué hacemos, pues? ¿Lo traemos aquí? ¿Cuáles son tus órdenes
acerca de ese desventurado? ¿Cómo te agradaremos? Piénsalo bien
y si quieres seguir mi consejo, no seas cruel con tu infortunado hijo.
TESEO
Traedme para que vean mis ojos al que negó haber profanado m
lecho, y lo convenzan mis palabras, y la desgracia que le agobia, obra
de los dioses.
EL CORO[142]
Tú, Afrodita, doblegas el ánimo inflexible de los hombres y de los
dioses con ayuda de tu hijo, revestido de variado plumaje, que los
cobija bajo sus alas velocísimas. Vuela por toda la tierra y por e
salado mar, que profundamente resuena. Cupido ablanda los
corazones y los asalta con su antorcha, resplandeciente como el oro
que inspira el furor, y a las fieras que viven en los montes, y a los
peces del mar, y a cuanto alimenta la tierra, que el sol purifica con sus
rayos: todos los hombres están sujetos a su imperio, y Afrodita sola
manda en todos a un tiempo como reina.
 ARTEMISA (en un carro de nubes doradas).[143]
Óyeme, que tal es mi voluntad, noble hijo de Egeo; yo soy Artemisa
hija de Leto, ¡oh Teseo! ¿Por qué, mísero mortal, te deleitan estos
males, y has dado injusta muerte a tu hijo, creyendo lo que no es
cierto, seducido por las falsas palabras de tu esposa? Manifiesta es la
desdicha que te pierde. ¿Cómo no te precipitas con rubor en los
abismos de la tierra, o evitas este daño volando? Ya no podrán
contarte entre los justos. Entérate, Teseo, de sus desdichas, que esto
aunque de nada te sirva, te llenará al menos de dolor. No tiene otro
objeto mi venida que probar la piedad de tu hijo, y su gloria al morir, y
el furor de tu esposa, y hasta cierto punto su nobleza. Estimulada po
la diosa más aborrecida de los que rendimos grato culto a la
virginidad, se enamoró de Hipólito, intentó vencer su pasión, y murió
inesperadamente por la imprudencia de su nodriza, que la descubrió a
tu hijo mediante juramento. Él, como era honrado, no accedió a sus
deseos ni fue impío, a pesar de tu enojo, violando después su
juramento. Pero Fedra, temiendo que supieras su delito, escribió una
carta falsa y te persuadió lo que quiso, y perdió con engaño a tu hijo.
TESEO
¡Ay, ay de mí!
ARTEMISA
¿Te afligen mis palabras? Tranquilízate, oye lo restante y llorarás
más. ¿No sabías que tu padre[144] había de cumplir tres votos tuyos?
Contra tu hijo, ¡oh tú, el más malvado de los hombres!, fulminaste uno
de ellos, como si hubiese sido tu mayor enemigo. Tu marino padre
que bien te quiere, te concedió lo que debía, puesto que lo había
prometido; pero tú has sido criminal con él y conmigo, y no esperaste
que las pruebas te convencieran, ni oíste a los adivinos, ni nada
averiguaste, ni aguardaste a que el tiempo descubriese la verdad, sino
que más pronto de lo que convenía maldijiste a tu hijo y ocasionaste
su muerte.
TESEO
Que yo muera, ¡oh diosa!
ARTEMISA
 Cometiste atrocidades, pero aún puedes obtener el perdón. Afrodita
ha sido causa de todo por saciar su ira: es ley entre los dioses que
ninguno se oponga a los deseos del otro, y que todos cedan cuando
es menester. Ten por cierto que, de otra manera, y a no temer a Zeus
no me deshonraría hasta el punto de consentir en la muerte del morta
que más amo. Tu ignorancia demuestra que has faltado sin malicia, y
además tu esposa al morir destruyó las pruebas orales que te
hubiesen convencido. Sobre ti principalmente descargan ahora estos
males, aunque yo también los sienta. No agrada a los dioses la muerte
de los piadosos, sino la ruina de los malvados, con sus hijos y su
familia. (Hácese invisible).
EL CORO
Ya llega el infeliz, desgarrados horriblemente sus miembros
juveniles y desaliñada su blonda cabellera. ¡Oh palacio infortunado
¡Que doble calamidad[145] te agobia por mandato del cielo!
HIPÓLITO (que llega en una camilla).
¡Ay de mí! ¡Ay de mi! ¡Ay de mí! ¡Cuánta es mi desventura!
despedazado injustamente a causa de las imprecaciones[146] de un
padre, también injusto. No tiene remedio mi desdicha; ¡ay de mí
mísero! ¡Ay, ay! Dolores intolerables atormentan mi cabeza, e
incesantes espasmos acometen mi cerebro. Dejadme descansar
dejad que reciba algún consuelo mi fatigado cuerpo. (Ponen en tierra
la camilla). ¡Ay, ay de mí! ¡Oh caballos odiosos que alimentó mi mano
me habéis perdido, me habéis dado la muerte! (Mientras lo sientan sus
servidores). ¡Ay, ay, por los dioses! ¡Oh esclavos, tocad con cuidado
mis doloridos miembros! ¿Quién está a mi derecha? Levantadme con
amor, con suave movimiento, que mi desdicha es grande y mi padre
me maldijo equivocado. Zeus, Zeus, ¿ves esto? Yo soy aquel varón
casto que daba a los dioses culto, el que en la práctica de esta virtud
superó a todos, y ahora pierdo la vida y me aguarda la muerte debajo
de la tierra; en vano fui piadoso entre los hombres y sufrí grandes
molestias, ¡ay, ay, ay, ay de mí!, y ahora el dolor, sí, el dolor me aflige
de nuevo. Dejadme abandonado a mi desventura; no prolongad m
martirio, y que la muerte cure mis males. Matadme, matadme, que soy
un desdichado; ojalá que me hiera una espada de dos filos y acabe de
una vez conmigo. ¡Oh malhadada imprecación de mi padre! ¡Oh
parientes manchados de sangre![147] Mi desdicha corona ahora sin
vacilar las de mis viejos progenitores, y viene contra mí, que nada
tengo que ver con ellas. ¡Ay de mí, ay de mí! ¿Qué diré? ¿Cómo me
libertaré de este dolor cruel? Que la negra y nocturna Necesidad, que
habita en el palacio de Hades, aletargue mis sentidos.
ARTEMISA (invisible).
¡Oh infeliz! ¡Qué calamidad te atormenta! La grandeza de tu alma
ha sido causa de tu ruina.
HIPÓLITO
¡Ay de mí! ¡Oh divino y embriagador perfume![148] Aun en medio de
mis males te he percibido, y mi cuerpo siente consuelo. Aquí está la
diosa Artemisa.
ARTEMISA
¡Oh mísero! A tu lado está la diosa que más te ama.
HIPÓLITO
¿Vesme, señora, en la desventura en que me hallo?
ARTEMISA
Te veo; pero no me es lícito derramar lágrimas de mis ojos.
HIPÓLITO
Ya no sobrevivirá a su desdicha tu cazador y sacerdote.
ARTEMISA
No, seguramente; pero mueres amado de mí.
HIPÓLITO
Ni el que guiaba tus caballos y guardaba tus estatuas.
ARTEMISA
Obra es de la engañosa Afrodita.
HIPÓLITO
¡Ay de mí! Ya reconozco la deidad causa de mis males.
ARTEMISA
Enojada porque no la adorabas, se vengó de tu castidad.
 HIPÓLITO
Ella sola, según veo, nos ha perdido a los tres.
ARTEMISA
A tu padre, a ti, y en tercer lugar a su esposa.
HIPÓLITO
También deploro los infortunios de mi padre.
ARTEMISA
Ha sido engañado por las sugestiones de la diosa.
HIPÓLITO
¡Oh padre infeliz! ¡Grande es tu desventura!
TESEO
Perecí, ¡oh hijo!; no me deleita ya la vida.
HIPÓLITO
Deploro tu suerte más que la mía, a causa de tu yerro.
TESEO
¡Ojalá, ¡oh hijo!, que yo hubiese muerto en tu lugar!
HIPÓLITO
¡Oh dones crueles de tu padre Poseidón!
TESEO
Quisiera no haberlo evocado nunca.
HIPÓLITO
¿Y por qué? Segura era siempre mi muerte, siendo tanta tu ira.
TESEO
Los dioses habían perturbado mi juicio.
HIPÓLITO
¡Ay de mí! ¡Ojalá que los mortales pudiesen maldecir a los
dioses![149]
ARTEMISA (invisible).
 Déjame, que ni aun cuando vayas a las tinieblas que hay debajo de
la tierra se ensañarán en ti impunemente las iras de Afrodita, acordes
con su deseo, pues de ellas te libraron tu piedad y buenos
pensamientos. Yo, con mi misma mano, y con mis inevitables saetas
te vengaré, dando muerte a uno de sus favoritos, al mortal que más
ame.[150] Te concederé, ¡oh desventurado!, por tus graves desdichas
los más grandes honores en la ciudad de Trecén; las doncellas, antes
de casarse, cortarán en tu honor sus cabellos, y gozarás largo tiempo
de sus lágrimas copiosas.[151] Siempre te honrará música de vírgenes
y se hará público el amor que inspiraste a Fedra. Y tú, hijo del viejo
Egeo, toma en tus brazos a tu hijo, y oprímelo contra tu pecho
Involuntariamente lo has perdido, pero errar es natural en los hombres
consintiéndolo los dioses. Ruégote, ¡oh Hipólito!, que no odies a tu
padre, que el destino ha sido causa de tu muerte. Adiós, que no me es
lícito mirar los muertos ni empañar mis ojos con el aliento de
moribundo, y veo que se aproxima ya tu última hora.
HIPÓLITO
Adiós, tú también, virgen bienaventurada; olvida sin pena mi trato
cotidiano. Perdono a mi padre, accediendo a tus ruegos, como antes
te obedecí siempre en todo. (Retírase Artemisa). ¡Ay, ay de mí! ¡Que
las tinieblas envuelven ya mis ojos! Abrázame, padre, y levanta m
cuerpo.
TESEO
¡Ay de mí, hijo mío! ¿Cómo me abandonas así, sumido en la mayo
desventura?
HIPÓLITO
Yo muero; ya veo las puertas de los infiernos.
TESEO
¿Y me dejas el alma mancillada?
HIPÓLITO
De ningún modo, puesto que no te imputo este desastre.
TESEO
¿Qué dices? ¿Me absuelves de haber derramado tu sangre?
 HIPÓLITO
Por testigo pongo a Artemisa, la de las irresistibles saetas.
TESEO
¡Oh hijo el más amado! ¡Cuánta es tu generosidad para con tu
padre!
HIPÓLITO
Adiós, tú también, ¡oh padre!; adiós muchas veces.
TESEO
¡Ay, cuán piadoso y bueno eres!
HIPÓLITO
Pide que así sean tus hijos legítimos.
TESEO
No me abandones, ¡oh hijo!; recobra tus fuerzas.
HIPÓLITO
Mis fuerzas se acaban; yo muero, ¡oh padre!; cubrid cuanto antes
mi rostro con el peplo.[152]
TESEO
¡Oh maldita región de Atenas y de Palas! ¡Qué hombre has perdido
¡Oh desventurado de mí! ¡Cuántas veces, ¡oh Afrodita!, recordaré los
males que me causas!
EL CORO
A todos nos sorprende esta desgracia; ríos correrán de lágrimas
porque la memoria de los grandes hombres debe llorarse mucho
tiempo.
 LAS FENICIAS

ARGUMENTO
Si damos fe al escoliasta de Aristófanes (Las Ranas, v. 53) y a lo
que nos dice J. A. Hartung (Euripides restitutus, tomo II, pág. 415 y
siguientes), la tragedia titulada Las Fenicias es la tercera de una
trilogía, cuya primera y segunda fueron, por su orden, Antíope e
Hipsípile. El argumento de la Antíope era la fundación de Tebas, y e
de Hipsípile el asedio de esta ciudad por los siete capitanes mandados
por Adrasto, antes de ocurrir la muerte de los hijos de Edipo.
La fábula de Las Fenicias (con algunas variantes si se compara con
algunas tragedias griegas y tradiciones épicas pertenecientes como
ella al ciclo tebano) cuenta la muerte de Eteocles y Polinices, nietos de
Layo. El poeta supone que Polinices, desterrado de Tebas por su
hermano Eteocles, no obstante el pacto celebrado entre ambos de
reinar un año cada uno, se refugia en la corte de Adrasto, rey de
Argos, con cuya hija se desposa, y con cuyo auxilio y el de otros
famosos guerreros pone sitio a Tebas para obligar a su hermano a
cederle parte del reino. Yocasta, madre y mujer de Edipo, y madre de
ambos, obtiene de Eteocles que permita a Polinices la entrada en
Tebas con el maternal objeto de reconciliarlos; pero no pudiendo
conseguirlo a pesar de sus ruegos y exhortaciones, se da el asalto po
los sitiadores, que son rechazados de las murallas y vencidos por los
tebanos, después que Meneceo, hijo de Creonte, se sacrifica por su
patria, obedeciendo al oráculo que revela el adivino Tiresias. Eteocles
entonces, para evitar la efusión de sangre inútil, propone a ambos
ejércitos la decisión de la fratricida contienda por medio de un combate
singular entre él y Polinices, que se verifica, en efecto, sucumbiendo
uno y otro. Al saberlo, su madre Yocasta se dirige al campamento con
su hija Antígona, ansiosa de evitarlo, pero llega tarde; se precipita
inconsolable sobre la espada de uno de los muertos, y perece también
abrazada a ellos. Eteocles, antes de pelear con su hermano, encarga a
Creonte, su tío, que no dé sepultura a Polinices si muere, y aque
intenta cumplir sus órdenes, no obstante la resistencia de la piadosa
Antígona, que al fin acompaña a su padre, ciego, al destierro a que lo
condena Creonte.
La acción de esta tragedia, como se deduce fácilmente de las líneas
anteriores, es eminentemente trágica, no solo en el sentido que esta
palabra tiene entre nosotros, sino también en el griego. El destino con
su horrible influjo se muestra en toda ella, y recuerda a los mortales
sus inflexibles decretos. Sin embargo, ni la escena en que el pedagogo
enseña a Antígona los capitanes del ejército sitiador, ni la entrada de
Polinices en Tebas, forman parte esencial de ella, a pesar de su
belleza incomparable. Los dos caracteres de Eteocles y Polinices, que
aparecen en primer término, están bien dibujados y sostenidos, y
ambos se distinguen por su ambición y por su odio fratricida y por sus
opuestos sentimientos.
En nuestro juicio, y no obstante los lunares mencionados, algunas
máximas nada morales que contiene y las extrañas críticas literarias de
Eurípides intercaladas en la tragedia, es una de las mejores que de é
nos quedan. Tiene escenas inimitables, trozos felicísimos, y su
versificación es en general muy superior a otras obras suyas. En una
palabra: leyéndola despacio, y no una vez sola, se puede aprende
mucho.
Séneca la ha imitado en su Tebaida, de la cual solo existen
fragmentos, y Estacio en su poema heroico que lleva el mismo
nombre; entre los franceses, Rotrou en su Antígona, y Racine en sus
Hermanos enemigos, una de sus más débiles producciones.
En cuanto a la fecha de su representación, parece lo más probable
atendiendo al escolio citado al principio, que fuera en la olimpiada 93, 2
(407 antes de Jesucristo). En efecto, además de este dato de
escoliasta, que no deja de tener fuerza, y que en todo caso es el único
que poseemos, confírmalo también la observación que hace Hermann
(in Præfat. Phœn., pág. XV) cuando dice: Quum illa (Yocasta) deinde
cum Polinice coierit sermonem, ejus prior pars, qua singulatim exquiri
cur grave sit patria carere, non est ita inserta, ut apareat qui hoc in
mentem venerit Yocastæ. Quo fit ut ista aliena abs re videri debeant
Chocan en verdad las preguntas que Yocasta hace a su hijo Polinices
acerca de los males del destierro, y es de presumir que aluda el poeta
a la vuelta de Alcibíades a su patria a principios de junio del año 407
en el arcontado de Euctemón, cuya fecha concuerda exactamente con
la señalada por el escoliasta.

PERSONAJES
Yocasta, esposa de Edipo, antes de Layo.
El pedagogo.
Antígona, hija de Edipo y de Yocasta.
Coro de vírgenes fenicias.
Polinices
y hijos de Edipo y de Yocasta.
Eteocles
Creonte, hermano de Yocasta.
Meneceo, hijo de Creonte.
Tiresias, adivino.
Un mensajero.
Otro mensajero.
Edipo, hijo de Layo y esposo de Yocasta.

La acción es en Tebas.
 La escena representa la plaza de Tebas, frente al Palacio Real.

YOCASTA
¡Oh sol, que en tu curso cortas los astros del cielo, sentado en carro
de oro, y haces girar la llama con tus ligeros caballos! ¡Qué día tan
infausto fue para Tebas[153] el que alumbraron tus rayos, cuando
Cadmo[154] vino a esta tierra, dejando las riberas fenicias! Casose con
Harmonía,[155] hija de Afrodita, y tuvo de ella a Polidoro, padre, según
dicen, de Lábdaco,[156] y este de Layo. A mí me llaman la hija de
Meneceo, y Creonte es mi hermano, e hijo de mi madre.[157] Yocasta es
el nombre que me puso mi padre, y Layo fue mi esposo. Como no
tuviese hijos después de muchos años de matrimonio, fue a consulta
a Apolo y le pidió que le diese herederos varones. Respondiole así
«¡Oh tú, que imperas en los caballeros tebanos!, no siembres el sulco
en donde nacerán tus hijos, que te son contrarios los dioses; te matará
el que tengas, y tu palacio se llenará de sangre». Pero él, amigo de
deleite, y excitado por el vino, engendró en mí un hijo, y confesando su
yerro al recordar el oráculo del dios, lo entregó al nacer a los pastores
para que lo expusiesen en el prado de Hera y en la cima de
Citerón,[158] atravesados sus talones por férreas agujas, por lo cual lo
llama Edipo[159] la Grecia. Pero los yegüerizos de Pólibo lo recogieron
y lo llevaron a su casa, y lo entregaron a su dueña. Ella amamantó con
sus pechos al fruto de mis entrañas, e hizo creer a su marido que era
suyo. Ya hombre, cuando la barba sombreaba su rostro, o por sus
propias sospechas, o por consejo ajeno, quiso conocer a sus padres, y
se encaminó al templo de Apolo al mismo tiempo que Layo, que
deseaba averiguar si vivía o no su hijo expósito. Y los dos se juntaron
en una encrucijada de la Fócide, y así dijo a Edipo el cochero de Layo
«Deja libre el paso a los tiranos, ¡oh peregrino!». Él iba callado
aunque lleno de arrogancia. Los caballos lo atropellaron y lo
mancharon de sangre, y por esta causa (¿pero a qué referir antiguas
desdichas?) el hijo mató al padre, y dio su carro a Pólibo, el que lo
había criado. Después de la muerte de mi esposo, y cuando la
Esfinge[160] devastaba a la ciudad con sus rapiñas, Creonte anunció
por sus heraldos que daría mi mano al que adivinase los artificiosos
enigmas de la virgen. Y mi hijo Edipo los explicó, y recibió el cetro en
premio. El desdichado, sin saberlo, se casó conmigo, ignorando que
su madre, que también lo ignoraba, había de ser la compañera de su
tálamo. Tengo de él dos hijos varones, Eteocles y el esforzado
Polinices, y dos hijas. Su padre llamó a la una Ismene; yo puse a la
mayor el nombre de Antígona. Y cuando Edipo averiguó que su
esposa era también su madre, él, que tantos males había sufrido, se
cegó con rabia, hiriendo sus pupilas con los dorados broches.[161
Cuando la barba cubrió las mejillas de mis dos hijos, ocultaron a su
padre en los aposentos interiores del palacio para que se olvidase este
suceso, lo cual, en verdad, no era fácil empresa. Vivo está, pues, en e
palacio, pero lleno de ira y quejoso de su suerte, y ha pronunciado
contra ellos las más impías maldiciones, y ha pedido a los dioses que
desgarren el seno de esta familia con el aguzado hierro. Temiendo
ambos que se realizasen las imprecaciones paternales si vivían juntos
convinieron en que Polinices, que es el más joven, se desterrase de
Tebas voluntariamente, y que Eteocles se quedase en ella, reinando
un año cada uno. Pero después que se sentó Eteocles en el trono, no
ha querido bajar de él, sino que ha expulsado de este reino a
Polinices. Encaminose, pues, a Argos, en donde se casó con la hija de
Adrasto, y ha reunido numeroso ejército de argivos, que acaudilla, y ha
atacado las siete puertas de esta muralla, reclamando el cetro paterno
y parte del territorio. Yo, para acabar la contienda, persuadí a mi hijo
que le diese un salvoconducto para venir aquí antes de empuñar la
lanza. El mensajero que se ha enviado dice que vendrá. Líbranos
pues, de estos males, ¡oh Zeus!, que habitas los esplendentes senos
del cielo, y reconcilia a mis dos hijos; que si eres sabio, conviene que
no hagas a los mortales perpetuamente desdichados. (Entra en e
palacio).
EL PEDAGOGO[162] (que aparece en el terrado
y habla dirigiéndose hacia dentro).
¡Oh noble Antígona, hija de ilustre padre! Ya que tu madre te ha
dado licencia para dejar la compañía de las vírgenes y subir a
terrado[163] del palacio, accediendo a tu deseo de ver el ejército argivo
detente para que yo explore las avenidas, por si aparece algún
ciudadano y me reprenden y me avergüenzan como a siervo y a t
como reina; todo lo he examinado, y te diré cuanto he visto y oído de
los argivos cuando fui a entregar a tu hermano el salvoconducto
primero de aquí para allá, y luego a mi vuelta. Pero ningún ciudadano
se acerca al palacio; sube por estas viejas escaleras de cedro, y mira
los campos y la corriente del Ismeno,[164] y la fuente Dircea,[165] y e
numeroso ejército enemigo.
ANTÍGONA (oculta todavía).
Dame, dame tu arrugada mano desde los peldaños en que te
hallas, para que pueda subir allá.
EL PEDAGOGO
Tómala, pues, ¡oh virgen! A tiempo has subido, que el ejército
pelásgico se mueve y sus cohortes se separan unas de otras.
ANTÍGONA (que aparece sobre el terrado).
¡Oh Hécate, hija veneranda de Leto! Todo el campo broncíneo[166
resplandece.
EL PEDAGOGO
Seguramente no viene Polinices desprevenido, que le acompañan
con estrépito muchos caballos e innumerables hoplitas.
ANTÍGONA
¿Están seguras las puertas del palacio y las barras de bronce que
defienden los muros de piedra construidos por Anfión?[167]
EL PEDAGOGO
No tengas miedo; por dentro está la ciudad bien fortificada. Pero
mira primero, si quieres saber lo que sucede.
ANTÍGONA
¿Quién es aquel del blanco penacho que va al frente del ejército
llevando en su brazo sin trabajo el pesado escudo de bronce?[168] ¡Es
uno de los jefes! ¿Quién es? ¿En dónde ha nacido? Di, anciano
¿cómo se llama?
EL PEDAGOGO
 Dicen que ha nacido en Micenas, pero que ahora habita junto a la
laguna de Lerna,[169] y se llama el rey Hipomedonte.[170]
ANTÍGONA
¡Ay, ay! ¡Qué soberbio! ¡Qué temible es su aspecto, como el de un
gigante, hijo de la Tierra, con sus estrellas pintadas! No se asemeja a
los demás hombres.
EL PEDAGOGO
¿Ves a aquel jefe que atraviesa las aguas de Dirce?
ANTÍGONA
Distintas, distintas son sus armas; pero ¿quién es?
EL PEDAGOGO
Es Tideo,[171] el hijo de Eneo, que lleva en su pecho el Ares etolio.
ANTÍGONA
¿Este es, ¡oh anciano!, el marido de la hermana de la mujer de
Polinices? ¡Qué peregrino es el color de sus armas! ¡Es semibárbaro!
EL PEDAGOGO
Todos los etolios[172] llevan clípeos, y manejan bien la lanza.[173]
ANTÍGONA
¿Y cómo sabes esto, ¡oh anciano!?
EL PEDAGOGO
Observé las divisas de sus escudos cuando los vi al llevar a tu
hermano el salvoconducto; y como me acuerdo bien de ellos, los
conozco cuando los veo.
ANTÍGONA
¿Quién es ese que pasa ahora junto al monumento de Zeto,[174] de
cabellos rizados, feroz mirada y juvenil aspecto? Parece un jefe
porque le rodea y sigue armada muchedumbre.
EL PEDAGOGO
Ese es Partenopeo,[175] el hijo de Atalanta.[176]
ANTÍGONA
 ¡Que Artemisa, que veloz corre las selvas con Atalanta, su madre
lo mate con sus dardos por haber venido a devastar mi ciudad!
EL PEDAGOGO
¡Ojalá que así suceda, oh hija! Con razón vinieron aquí, sin
embargo, y temo que se la den los dioses.
ANTÍGONA
¿En dónde está el que nació de mi misma madre con destino
funesto? Dime, anciano muy querido, ¿en dónde está Polinices?
EL PEDAGOGO
Cerca de Adrasto,[177] junto al sepulcro de las siete vírgenes, hijas
de Níobe.[178] ¿Lo ves?
ANTÍGONA
No claramente; pero me parece que columbro su figura y como la
traza de su pecho. Ojalá que, cual ligera nube, pudiese atravesar e
aire con mis pies y llegar hasta mi hermano; con mis brazos, después
de tanto tiempo, rodearía el muy amado cuello de este mísero
desterrado. ¡Cómo se distingue de los demás por sus armas doradas
¡oh anciano!, brillando como los matutinos rayos del sol!
EL PEDAGOGO
Vendrá a este palacio a llenarte de gozo, que ya ha recibido
permiso para hacerlo.
ANTÍGONA
¿Quién es, ¡oh anciano!, ese que, sentado, rige un reluciente carro?
EL PEDAGOGO
Ese, ¡oh señora!, es el adivino Anfiarao,[179] y con él van víctimas
que serán ofrecidas a la tierra, ávida de sangre.
ANTÍGONA
¡Oh luna!, hija del sol, que ciñes cinturón espléndido, bella luz en
cerco de oro; ¡con cuánta modestia y serenidad aguija a los caballos
de su carro! ¿En dónde está el que ha proferido contra esta ciudad tan
atroces amenazas?
 EL PEDAGOGO
Capaneo[180] examina ahora la entrada de las torres, y mide
escrupulosamente los muros.
ANTÍGONA
¡Oh Némesis,[181] y tú, Zeus, de horrísonos truenos, y de rayos que
disipan las tinieblas! Refrena su soberbia y castiga sus insolentes
palabras. ¿Entregará las cautivas tebanas a los guerreros de Micenas
y al tridente lerneo,[182] e impondrá el yugo de la esclavitud en las
aguas de Amimone, consagradas a Poseidón? Nunca, nunca, ¡oh
Artemisa veneranda!, hija de Zeus, de cabellos de oro, sufriré yo ta
servidumbre.
EL PEDAGOGO
Entra en el palacio, ¡oh hija!, y no salgas de tu gineceo, ya que has
tenido el gusto de ver lo que tanto deseabas. Una turba de mujeres se
encamina al palacio de los reyes, alborotada la ciudad. Maligno es po
naturaleza el sexo femenino, y por el más leve pretexto habla hasta la
saciedad; cierto placer sienten las mujeres en murmurar unas de otras
EL CORO (que llega de la ciudad).[183]
Estrofa 1.ª — He venido desde la isla Fenicia, dejando el mar Tirio
ofrenda escogida de Febo, para servir en su templo en las gargantas
del Parnaso, cubierto de nieves, atravesando en las naves el ma
Jónico, mientras el céfiro agitaba el aire en los estériles campos que
rodean a Sicilia, y resonaba armoniosamente.
Antístrofa 1.ª — Don grato a Apolo, he venido desde mi ciudad
predilecta a la tierra cadmea de los ínclitos Agenóridas,[184] y he
llegado a las murallas de Layo, fundadas por mis ascendientes. Como
a estatua dorada me han hecho sierva de Febo. Pero también es
verdad que me esperan las aguas de la fuente Castalia para lavar en
ellas mi cabellera, y gozar de estos virginales deleites al servicio de
Apolo.
Epodo. — ¡Oh peñasco brillante!, que despides dos llamas en las
báquicas cumbres consagradas a Dioniso, y tú, vid, que cada día
haces germinar pesados racimos de lozanas uvas; gruta divina de
dragón, rústicas cavernas de los dioses y sagrado monte, cubierto de
nieve.[185] ¡Ojalá que danzando en los coros de los dioses inmortales
pierda el miedo en los valles de Febo, en donde está el centro de la
tierra, lejos de la fuente Dircea!
Estrofa 2.ª — El fiero Ares me sale al encuentro delante de estas
murallas, y promueve contra esta ciudad (ojalá que no sucedan
bélicas matanzas. Comunes son los dolores de los amigos, y si algo
padece este país, fortificado con siete torres, también sufrirá la región
fenicia. ¡Ay, ay! La sangre es la misma, hijos son también de la
cornígera Ío,[186] y yo compartiré sus trabajos.
Antístrofa 2.ª — Densa nube de escudos fulgura en torno de la
ciudad, anunciando la sangrienta batalla que Ares dará a los hijos de
Edipo, y la destrucción con que amenazan las Furias. ¡Oh pelásgico
Argos! Tengo miedo al poder y a la venganza divina: el que armado
pide su palacio, no ataca sin justicia.
POLINICES (con la espada desenvainada,
y mirando receloso a todas partes).
Con facilidad me abrieron paso los guardas de las puertas y me
dejaron entrar en la ciudad, y por lo mismo temo algún lazo, y que no
pueda escaparme sin derramar mi sangre. Miraré, pues, a todas
partes, no sea que me armen asechanzas. En la diestra traigo m
espada, y mi osadía me salvará. ¡Hola! ¿Quién es aquel? ¿Me asusta
acaso el ruido? Todos son peligros para los que se atreven a pisa
tierra enemiga. Confío ciertamente en mi madre, y desconfío de ella a
mismo tiempo, por haberme persuadido que viniese aquí, fiado en su
palabra. A mano está el socorro, que hay cerca altares, y un palacio
no abandonado. Vamos, guardaré mi espada en la oscura vaina, y
preguntaré a las que veo junto a la regia morada. Mujeres extranjeras
decidme: ¿de dónde habéis venido a este país griego?
EL CORO
La Fenicia es la patria que me crió. Los nietos de Agénor, como
presente escogido del botín de su victoria, me enviaron al servicio de
Febo, y cuando el ínclito hijo de Edipo deseaba que fuese a venerar e
oráculo y a las aras de Apolo, atacaron a la ciudad los argivos. Dime tú
ahora quién eres, y a qué vienes a las torres de las siete puertas de
Tebas.
POLINICES
 Mi padre es Edipo, el hijo de Layo; mi madre Yocasta, hija de
Meneceo, y el pueblo tebano me llama Polinices.
EL CORO
¡Oh tú!, de la misma sangre que los hijos de Agénor, mis señores
que me han traído aquí. De rodillas te adoro, ¡oh rey!, según se
acostumbra en mi patria. Largo tiempo has tardado en venir al lugar de
tu nacimiento. Dueña veneranda, ven corriendo, abre las puertas. ¿Me
oyes, madre que diste a luz a este? ¿Por qué tardas en salir de los
altos atrios y abrazar a tu hijo?
YOCASTA
Al oír, ¡oh vírgenes!, estas voces fenicias[187] dentro del palacio
vengo arrastrando mis trémulos pasos. ¡Oh hijo!, al fin veo tu rostro
después de largo tiempo, después de muchos días; que mis brazos
maternales opriman tu pecho; déjame besar tus mejillas, y que tus
rubios y rizados cabellos den sombra a mi cuello. Bendigamos
bendigamos a los dioses, que te traen a mis brazos contra toda
esperanza. ¿Qué te diré? ¿Cómo, palpándote todo con mis manos y
hablándote al mismo tiempo, podré en múltiple deleite recordar mis
antiguas alegrías? ¡Oh hijo, hijo mío, que dejaste desierto el hoga
paterno, y sin razón fuiste desterrado por tu hermano! ¡Cuánto te
echan de menos tus amigos! ¡Cuánto la ciudad de Tebas! Desde
entonces corto sollozando mis blancos cabellos en señal de duelo, y
no me he puesto blancos vestidos, ¡oh hijo!, sino estos negros y
tenebrosos paños. Pero el anciano ciego, víctima de su profunda
pena, no viendo unidos a sus dos hijos como a dos novillos de una
misma yunta, hoy separados, se precipita sobre su espada para darse
la muerte, y prepara lazos en el techo, arrepentido de las maldiciones
que ha fulminado contra vosotros, y siempre se oculta en las tinieblas
dando gritos y sollozos. Ya sé, ¡oh hijo!, que te has casado y disfrutas
de los placeres conyugales, teniendo en palacio extranjero parientes
también extranjeros, motivo de tristeza y de disgusto para mí y para e
linaje del viejo Layo. Ni yo encendí en tus bodas las nupciales
antorchas, con arreglo a nuestras leyes, y como lo hubiese hecho una
madre más afortunada, ni te lavaron las ondas del Ismeno, ni se
celebró en Tebas con cantos la entrada de tu esposa. ¡Oh! Que todo
esto se acabe, o por el hierro, o por la discordia, o por tu padre
también interesado en ello, o por el destino, que fijó su eterno asiento
en el palacio de Edipo, que yo soy víctima de los tormentos que estos
males producen.[188]
EL CORO
Doloroso es el parto de las mujeres, y sin embargo, todas aman a
sus hijos.
POLINICES
Prudente he sido, e imprudente, ¡oh madre!, en venir adonde
estaban mis enemigos; pero una fuerza irresistible nos obliga a todos
a amar a nuestra patria; quien otra cosa dice habla por hablar, pero no
lo siente. Miedo y temor tengo a un tiempo de que mi hermano me
mate a traición, y por esto he atravesado la ciudad mirando a todas
partes, y llevando en mi diestra la espada. Tranquilízanme, sin
embargo, la tregua y tu palabra, que me facilitaron la entrada en las
murallas paternas. Mucho he llorado al venir, viendo al cabo de tanto
tiempo los templos y las aras de los dioses, y los gimnasios en que me
eduqué, y la fuente Dircea, de todo lo cual fui despojado sin derecho
habitando desde entonces en una ciudad extranjera, convertidos mis
ojos en fuentes de lágrimas. Ya te contemplo, ¡oh madre!, víctima de
incesantes dolores, con la cabeza rapada y llevando negros vestidos
¡Ay de mí y de mis males! ¿Qué desgracia es comparable al odio entre
los que habitan bajo un mismo techo? Y ¿qué más difícil que su
reconciliación, cuando llegan a aborrecerse? Y mi viejo padre, ¿qué
hace en el palacio solo en las tinieblas? ¿Y mis dos hermanas?
¿Lloran mi mísero destierro?
YOCASTA
Algún numen maléfico se ensaña en el linaje de Edipo desde que
yo tuve hijos contra la voluntad divina, y tu padre se casó, y tú naciste
Pero ¿de qué sirven estos recuerdos? Suframos nuestro destino
Temo y deseo a un tiempo preguntarte por no afligir tu ánimo.
POLINICES
Pregunta sin cuidado cuanto quieras; tu voluntad, ¡oh madre!, es
también la mía.
YOCASTA