The Report is as Good as Specimen:

Impact of Pre analytical Errors in

Critical Care

Dr. Muhammad Zubair MBBS,FCPS,IFCAP

Consultant Chemical Pathologist
INDUS HEALTH NETWROK(MIKD,RTEH)
Learning Objective

• List the pre-analytical variables commonly encountered in laboratory medicine.

• Identify the nature and frequency of pre-analytical factors responsible for

sample rejection.

• How to record errors in laboratory

• What are quality indicators and their utilization in lab processes

• Describe effective strategies to reduce the rate of specimen rejection and

mitigate the risk of patient harm.
What is a Laboratory Error?

• (ISO/TS 22367) Defined laboratory error as “Failure of planned action to

be completed as intended, or use of a wrong plan to achieve an aim,
occurring at any part of the laboratory cycle, from ordering examinations
to reporting results and appropriately interpreting and reacting to them”.
The role of Laboratory in Medical Decision Making

60-70% of clinical decisions based on laboratory tests

Quality in Laboratory Medicine

• It is defined as “The guarantee that each and every step in the total
testing process (TTP) is correctly performed, thus assuring valuable
medical decision making and effective patient care” 
The Total Testing Process
Errors Rate in Total Testing Process
Pre-Analytical Phase

• ISO 15189: 2007 standard for laboratory accreditation defines the pre-
analytical phase as ‘Steps starting in chronological order, from the
clinician’s request and including the examination requisition,
preparation of the patient, collection of the primary sample, and
transportation to and within the laboratory, and ending when the
analytical examination procedure begins’.
Most Common Pre-analytical Error

The most commonly reported types of pre-analytical errors are:

• Hemolysed, clotted, and insufficient samples,
• Missing sample and/or test request,
• Wrong or missing identification,
• Contamination from infusion route,
• Inappropriate containers,
• Inappropriate blood to anticoagulant ratio,
• Inappropriate transport and storage conditions
Pre-Analytical Errors Create Bottlenecks
Pre-Analytical Data of MIKD
Pre-Analytical Data of RTEH
MIKD and RTEH Emergency Department (ED) Recollection Rates
from January to August 2021

Reasons for ED Recollection % of ED Recollections

1. Hemolysis 38.2

2. Clotted specimens 35.4

3. QNS 6.2

4. Test Not Requested 5.2

5.Specimen Contamination 2.3

Hemolysis

• Most common Pre-analytic variable

• “ Rupturing (lysis) of red blood cells (erythrocytes) and the release of

their contents (cytoplasm) into surrounding fluid (e.g. blood plasma).

• Can occur in vivo (inside the body) or in vitro (outside the body)

• May interfere with chemical testing.

How much free hemoglobin is needed to cause an
interference?

Depends on the test

• Analytical or physiologic interference
• Potassium, aspartate aminotransferase (AST), lactate dehydrogenase
(LDH), direct bilirubin, troponin T, among most sensitive.
Depends on lab
• Almost all labs follow test manufacturer guidelines.
• Some labs release results with the comments, some labs recollect
specimens.
Key Features of Automated Serum Indices

• Available on most chemistry analyzers

• Hemolysis, icterus and lipemia (HIL) are the most common specimen
integrity issues

• Objective way to detect interferences compared to visual inspection

• Standardized and reproducible tool

Limitations of HIL on Automated Analyzers
Hemolysis index (H) is assessed by the amount of red
pigmentation associated with free hemoglobin
Categorization of HIL indices with grading
Analytes Affected by Hemolysis

Positive Interference Negative Interference

Elevated intracellular concentration Haptoglobin
• Potassium, magnesium and Positive or Negative Interference
phosphate
Troponins(Depends on
• Lactate dehydrogenase (LDH)
Methodology)
• Aspartate aminotransferase (AST)
How to deal with Hemolyzed Specimens
What causes a Specimen to Hemolyze?

• Drawing from an intravenous (IV) start or central line

• How much higher is the hemolysis rate form an IV start compared to

venipuncture?
• 2-5 times higher in IV start depending on study.
• 5.6% (IV starts) vs. 0.3% (venipuncture)
• 10.2% (IV starts)vs. 5.4%(venipuncture)
Straight Needle Venipuncture superior to IV Start

• Effectiveness of practices to
reduce blood sample hemolysis in
EDs: a laboratory medicine best
practices systematic review and
meta-analysis.
• Nicholas J Heyer et al. Clin
Biochem. 2012 Sep
Other common contributing factors to Hemolysis
• American society of clinical pathology (ASCP)
benchmark
• ≤2% hemolysis
Clotted Specimens

• CBC testing performed in EDTA whole blood

• Coagulation testing performed using citrated plasma

• Ratio of 9 parts blood: 1 Part anticoagulant critical for specimen quality

• Tends to happen on larger blood draws (more tubes to fill)

• Education on order of draw and tube inversion, use vacutainer when you
can.
QNS(Quantity Not Sufficient)

• Volume of specimen insufficient for testing

• Not enough to test or specimen does not contain the correct ratio of blood and anticoagulant

• Most commonly encountered in the NICU due to

• Elevated hematocrit (reduced plasma) as high as 70% in newborn
• Blood conservation efforts
• Due to high rate of hospital acquired anemia ~41%

• Recommendations:
• <3% total body volume patient <2 months(~9 mL/day 7 lb infant)
• <10% total body volume patients >2 months (~150 mL/day healthy adult)
Instrument sample volume requirements for testing

• Most analyzers do not require a significant volume of plasma/serum for the actual test/reaction

• Depends on
• Sum of individual test volumes
• CMP: <50 µL specimen
• Dead volume: volume of specimen that remains after samples for testing
• Indices for specimen integrity (hemolysis/lipemia/icterus)
• 10 µL specimen

• To reduce QNS among NICU patients, we can provide a list of commonly ordered tests and the
minimum volume required so that testing can be prioritized
Line draws and Suspected Specimen Contamination

• Issue with line draw (central venous catheter, PICC, arterial line)
• Hemolysis
• Dilution
• Heparin contamination (coagulation tests) analyte/drug contamination
• Drug given via iv line
• Heparin
• Glucose, lipids, potassium, magnesium, phosphorus, calcium, others
Line draws and suspected specimen contamination

• Why draw blood specimens from indwelling lines?

• Patient comfort and convenience
• Reduce burden on dedicated phlebotomy staff
• More timely blood draws
• Difficult venous access

• Type of blood specimen contamination resulting from IV fluids varies by the type of
fluid being infused
Common Abnormal results from line draws

• Hemolyzed specimen • Falsely Decreased

Falsely elevated • Creatinine
• Glucose • Hemoglobin/cell count
• Magnesium • Sodium(e.g., Dextrose infusion
• Phosphorus where sodium <50% serum)
• Calcium • potassium
• Potassium
• Sodium(saline)
• Chloride
Total Parental Nutrition (TPN) Contamination

• In ICU TPN nutritional support very common

• TPN compounded for each individual patient.
• 15000 mg/dl glucose
• 41 mmol/L sodium
• 16 mmol/L potassium
• 30 mg/dL calcium
• Vitamins, minerals, amino acids
• Glucose, potassium, calcium often affected by TPN contamination
• If lipid emulsion is also infused, specimen may appear turbid (lipemic)
and result in specimen rejection
Contamination Through Order of Draw

• European federation for clinical chemistry Pre-analytical phases

working group—Opinion paper: order of blood draw(2017)
• Problems with incorrect order of draw
• Hypernatremia due to Na citrate or Na EDTA
• Hyperkalemia due to K EDTA contamination
• Hypocalcaemia, low magnesium, zinc, iron, or alkaline phosphatase
due to K EDTA
• Poor coagulation due to transfer of anticoagulants
• Clot activator transfer interfering with coagulation test
• Dilution effects from pouring one sample into another
European Federation for clinical chemistry Pre-analytical
phases working group
• opinion paper: order of blood draw(2017)
• Three potential mechanisms of anticoagulant contamination
• Direct transfer (pour off) : not related to order of draw, bad practice
• Backflow during closed loop (vacutainer) collection: Data do not
support that this occurs
• Contamination by syringe needle transfer: Amount required to impact
results varies by study, most likely mechanism
• Conclusion: Order of draw not important during routine closed system
venipuncture
• Contamination may occur during syringe transfer
Contamination during Routine Venipuncture

• Cornes et al., 2012

• 11 healthy volunteers, drawn by experienced phlebotomist
• Serum tube, EDTA tube, serum tube (BD)
• Measure EDTA, K, calcium, Mg, zinc, alkaline phosphatase, creatinine in
first and third serum tube
• EDTA undetectable (<0.2 mmol/L) in all serum samples
• No difference in mean K, calcium, Mg, zinc, alkaline phosphatase, or
creatinine between first and third serum tubes
Contamination during Routine Venipuncture

• Indevuyst et al., 2014

• 100 patients attending outpatient anticoagulation clinic
• Multiple experienced phlebotomists
• Phase 1: Citrate, citrate, Li heparin, Citrate
• Phase 2: Serum clot activator, citrate, citrate, K EDTA, citrate
• Not statistically significant different in PT regardless of collected first
tube, second tube, after clot activator, or after EDTA
• Very small(< 1 second) differences in aPTT
• Order of draw made no clinically significant difference
Order of Draw Conclusion

• Evidence suggest that K EDTA contamination does not occur during

closed draws with plastic tubes (lyophilized K EDTA)
• No backflow contamination

• In 5 UK hospitals, K EDTA contamination is seen in 2-15% of samples with

abnormal K, Ca, Mg, or Zinc

• Assumption, contamination happen with syringe draws.

Inappropriate Laboratory Test Requisition

• The estimations of inappropriate laboratory tests vary from 11% to 70%

for general biochemistry and hematology tests, 5% to 95% for urine
screens and microbiology, and 17.4% to 55% for cardiac enzymes and
thyroid tests.
Reasons for Ordering inappropriate tests

• Order inappropriate tests for a variety of reasons, including confusion

over tests with similar names (such as 25-hydroxyvitamin D versus 1,25-
dihydroxyvitamin D), unnecessary duplicate orders, transcription errors
during order entry, and misinterpreted verbal orders, which occur when
physicians do not place test orders themselves.
Strategies for detection of Pre Analytical errors

• Erroneous result flags

• Critical result flags

• Rules

• Delta checks

• Serum indices
Quality Indicators in Laboratory

• ISO 15189- 4.12.4, “Establish QIs to monitor and evaluate performance

throughout critical aspects of pre-examination, examination and post

examination processes’.
Quality Management System in Laboratory

• Quality management system, include the identification and control of

non-conformances, continual improvement, internal audit and quality
indicators (QIs).
Mandatory Quality Indicators of Pre analytical Phase
Recording of Laboratory Errors

• A robust continuous mechanism of error collection must be established.

• The processes are easy to use and understood by staff in the laboratory
tasked with recording errors.

• Standardization of processes is important to ensure the accuracy of the

recording mechanisms and enable effective staff training.
Recording of Laboratory Errors

1. Audits
2. Manual recording processes
3. Incident reporting
4. Laboratory information management systems
Audit

• ISO 15189: 2012 states that this should incorporate audits of pre-
analytical areas to collect information on the relative rates of errors.
Examples of such audits might be:
• an audit of request forms to identify the percentage which do not have
complete information regarding the requester;
• an audit of specimens to identify the percentage which do not have
complete (or accurate) patient information
• an audit of ‘booking-in’ processes to identify the percentage of booking
in errors.
Limitations of Audits

• It is retrospective.

• Audit does not provide a real-time assessment of rates of error

incidence, but a survey of error rates at a particular point in time.

• Audit does not immediately alert users to the quality issues with their
requests
Manual recording processes

• ‘Quality Query Reports’ (QQRs) QQRs: usage of report forms at

workstations to records errors

• The process is labour intensive compared with automated systems of

error identification in terms of both error recording and especially in
reviewing data, and as such risks lower levels of compliance and
underreporting of errors
Incident Reporting

• Incident reporting, often using risk management software such as Datix

(Datix Limited, London, UK), should be part of any healthcare provider’s
clinical governance processes.
Laboratory Information Management Systems

• It is used to record receipt of specimens and report results, have the

potential to be used to record quality errors, report them to users, act as
repositories of error data and also gather data on error rates.
Advantage of using LIMS-based systems for the recording of
errors

• LIMS usage is both prospective in alerting users to quality failures and

retrospective, when regular data extractions are performed for trend
analysis.

• Past data review in a simple and effective way.

Report Attributes

• Sub clause 5.8.2 of the ISO 15189: 2012 Standard deal with report
attributes

• It states that the report should contain ‘comments on sample quality

that might compromise examination results’ and ‘comments regarding
sample suitability with respect to acceptance/rejection criteria’.
Usage of LIMS for Report Attributes

• Usage of ‘Report Comment’ fields to record quality failures and highlight

them in the report.

• Standardization of error codes (which improves information gathering

and review) and the flexibility to record errors of a variety of sources.

• Use of coded comments, in place of results for samples that cannot be

analyzed, e.g. HAEM for samples that cannot be analyzed due to
hemolysis.
Data Review

There are a number of quality management tools which can be utilized in

the investigation of laboratory quality errors, including the following.

1. Benchmarking

2. Statistical process control. in the same way that the laboratory reviews
quality control data for outliers, error rates can be compared against a
target mean and standard deviations to identify statistically significant
changes
3.Failure mode and effect analysis (FMEA) – FMEA requires a knowledge of
the steps involved in the testing process, target areas of high risk and
looks at methods of adapting processes to reduce failures

4.Pareto analysis – Pareto diagrams organize elements in order of

frequency of occurrence, enabling the laboratory to target areas of high
risk. Errors can be grouped by error type or location.
Conclusion

• Hemolysis, the number one variable to consider for hospital inpatient practices
• Clotting, QNS, test not requested, sample contamination next most important pre-
analytical variables
• Clotting has yet to be easily solved other than training and education
• Sample testing utilizes a very small volume of specimen, but large volume need
to accommodate instrument dead volume
• Contamination with IV fluids can be prevented with proper technique if certain
patient populations avoided (TPN, heparin or drug administration)
• Insufficient sample volume, incorrect order of draw( K EDTA contamination) is a
unique and sporadic cause of contamination for syringe draws.