Phlebotomy Today

Blood Collection Errors and their Impact on Patients

• You know that you shouldn't leave the tourniquet on longer than one minute, but do you know what can happen to your patient if you do?
• You know you should draw a discard volume when drawing through an IV line, but do you know how it can affect the care your patient receives?
• You know you shouldn't underfill tubes, but do you know what it can do to your patient?

 Most phlebotomists and other healthcare professionals with blood collection responsibilities know the do's and don't's of drawing blood, but not everyone knows why the procedure must be followed exactly as they were taught. As a result, there's a disconnect between cause and effect that leads healthcare professionals to underestimate the importance of every standardized detail when drawing blood samples for clinical testing. Without a thorough understanding of why certain details of a venipuncture or skin puncture must be followed, the missing can't prevent a modification that can profoundly impact not only their patient's care and safety, but their own well-being.

You may know the how, but do you know the why?

Take time to review some of the most common blood collection errors in the chart below and the ultimate consequences they can have on patients. By connecting the dots from a self-styled deviation to the potential impact it can have on the patient, you'll gain a better understanding of why you do what you do, and why you shouldn't do what you shouldn't.

 

Blood Collection Errors that Alter Test Results	Potential Consequences to Patient
Failure to properly identify the patient	Transfusion- or medication-related death. Patient mismanagement due to being treated according to the results of another patient.
Failure to properly cleanse site for blood culture collection; Repalpating a site cleansed for blood culture collection; Failure to allow antiseptic time to take effect prior to blood culture collection.	Unnecessary administration of antibiotic & extended length of hospitalization due to false-positive blood culture.
Prolonged tourniquet application beyond one minute	Seizure, death, & patient mismanagement due to falsely elevated potassium* level. Patient mismanagement due to temporary elevation of albumin, calcium, RBC count, hemoglobin, and hematocrit. Patient mismanagement due to temporary decrease in WBC count and differential. Hypovolemia, anemia, and death if hemoconcentration obscures diagnosis and condition goes untreated.
Patient allowed to pump fist	Seizure, death, patient mismanagement. Fist pumping significantly increases potassium* and ionized calcium levels in blood being drawn.
Underfilling coagulation tube	Stroke due to unwarranted decrease in blood thinner dosage necessitated by falsely prolonged coagulation times.
Underfilling EDTA tube	Patient mismanagement/misdiagnosis from falsely decreased hematocrit and MCV. Unnecessary transfusion.
Underfilling heparin tube	Patient mismanagement/misdiagnosis from altered potassium, sodium, ALT, AST, amylase, and lipase results.
Underfilling blood culture bottles	Death from septicemia due to false-negative result.
Failure to properly mix tubes	Patient mismanagement due to delays when anticoagulated tubes contain clots and must be recollected.
Incorrect order of draw	Seizure and death from potassium carrying over from EDTA into tube to be tested for K+.* Medication errors when additives carry over into coag tubes, falsely lengthening coagulation times and leading to unwarranted and life-threatening medication adjustments. Unnecessary antibiotic administration and prolonged hospitalization due to contaminated blood cultures.
Vigorous mixing samples “Milking” the site of a capillary puncture Improper needle placement Pulling excessively on the plunger of a syringe Line draws Prolonged tourniquet application "Rimming" clot tubes during processing	Seizure, death, medication errors, and patient mismanagement should these practices hemolyze samples causing the contents of red cells to be released into serum/plasma. Hemolysis falsely lengthens prothrombin times and elevates the reported levels of potassium,* LDH, AST, ALT, phosphorous, magnesium, and ammonia. Hemolysis falsely shortens aPTT times and decreases RBC counts, fibrinogen, and hematocrit.
Specimen drawn above IV	Death, medication errors, & patient mismanagement due to contamination by IV fluids of samples tested.
Inadequate discard volume drawn when collecting blood through vascular access device	Stroke/hemorrhage due to modification of blood thinner dosage based on inaccurate coagulation results. Medication errors due to contamination. Patient mismanagement from altered results.
Failure to properly label the specimen	Transfusion- or medication-related death, and patient mismanagement due to being treated or transfused according to the results obtained from another patient's blood.
Failure to label the specimen at the patient’s side	Transfusion- or medication-related death, and patient mismanagement due to being treated or transfused according to the results obtained from another patient's blood.
Pouring contents of one tube into another	Patient mismanagement/misdiagnosis & medication errors based on altered results, especially potassium.* Stroke/hemorrhage due to unwarranted modification to blood thinner dosage.
Drawing timed specimens at the wrong time	Patient mismanagement/misdiagnosis & medication errors.
Delays in drawing blood cultures based on fever spike	Septicemia, death. Since fever spikes  ̴̴ 30 minutes after bacterial shedding into the bloodstream, any delay in fever-based blood culture collections limits the ability of the laboratory to grow and identify the causative organism in a timely manner.
Chilling/refrigerating samples to be tested for potassium prior to centrifugation	Seizure, death, patient mismanagement due to falsely elevated potassium level.*
Tubes not centrifuged properly; Gel tubes centrifuged twice; Centrifuging tubes with stoppers removed.	Seizure, death, patient mismanagement due to falsely elevated potassium levels from platelets and/or red cells remaining in serum or plasma.*
Delay in transporting/testing coagulation specimens	Stroke caused by unwarranted modification to blood thinner dosage based on inaccurate aPTT result.
Transporting sodium citrate tubes on ice	Hemorrhage, death, medication errors. Cold activation of Factor VII causes a falsely shortened prothrombin time, which may mislead the physician into increasing blood thinner dosage.
Delay in centrifuging samples to separate serum from cells	Seizure, death, patient mismanagement. Prolonged serum/cell contact causes a falsely elevated potassium level to be reported.* Other analytes affected include glucose, LD, phosphorous, creatinine, folate, vitamin B-12, ALT, AST, and ionized calcium.
Specimen not protected from light	Newborn suffers irreversible brain damage because bilirubin deterioration leads to falsely lower result, which prevents physician from ordering phototherapy.
*Patients whose reported potassium levels are falsely elevated (pseudohyperkalemia) are at risk whether their reported value is in the normal range or elevated. Actual potassium levels that are below normal (hypokalemic) but falsely elevated into the normal range by collection errors may be inappropriately cleared for surgery due to the "normalizing" of their potassium. Such patients are at risk for seizures and other complications when subjected to anesthesia. Other hypokalemic patients whose potassium levels are falsely elevated into the normal range may require rapid intervention, but go untreated. Such patients are at risk for developing cardiac arrhythmia. Patients whose potassium levels are actually normal but reported as elevated (hyperkalemic) due to collection errors may be treated for a high potassium level unnecessarily.
© Center for Phlebotomy Education. All rights reserved

 

[Editor's note: The Center for Phlebotomy Education has developed Blood Collection Errors and Their Impact on Patients, a 20" x 28" laminated poster containing this and much more information for managers to display in their facilities to facilitate their staff's understanding of the impact preanalytical errors have on patient care.]

 

Product Spotlight: Stocking stuffers for phlebotomists

Do those who draw blood samples in your facility need a special gift this Christmas? Do you need special pricing to be their Holiday Hero? If you answered "yes" and "yes," we've got the goods.

Celebrate those who collect laboratory samples at your facility with phlebotomy-related gifts that keep them at the top of their game. Act before December 20, 2019, and you'll get 15 % off some of our best selling items. Whether you manage a specimen collection team or teach those concepts every phlebotomist must know, stuff their stockings this year with unique gifts that reinforce sound phlebotomy practices. 

 

1. Put an Order of Draw Pen in every pocket so the correct order in which tubes must be filled is also right at their fingertips.
2. The Phlebotomy Tips card is a pocket reminder of key concepts in phlebotomy including the order of draw, and tips on specimen collection. The reverse shows the anatomy of the antecubital area featuring veins, arteries, and nerves.
3. Our Order of Draw Badge Tags attach to your staff's or students' ID clip or lanyard so the order of draw is always in front of them.
4. The Lab Draw Answer Book is the gift that keeps on giving ANSWERS. Almost 400 to be exact. Put this in the hands of your top performers and mentors. If you have an entire staff of top performers, quantity discounts are available.

To take advantage of this 15%-off sale, call us or place your order online on or before 12/27/2019 using the coupon code JOLLY at checkout.

We've been helping you educate for over 20 years. Now let us help you celebrate.

 

What Should We Do?:

Dear Center for Phlebotomy Education:

We're struggling with how we use tourniquets at our facility. We have on hand some extra wide and extra long (18") orange tourniquets for bariatric and obese patients that works very well for many patients, not just bariatrics. But using them on every patient is not cost effective, so some phlebotomists are cutting them into shorter pieces and getting three wide, but shorter tourniquets out of one so they can use them on non-obese patients instead of the conventional blue tourniquets. Because they are wider, the modified orange tourniquets work well for geriatric patients with crepe-paper skin and other difficult situations. 

Now our quality control people are telling us to stop altering the product. They cite concerns over modifying a medical device, claim the wider band constricts too much, and infection control issues. We like the wider bands, but using them without modification for every patient would be cost-prohibitive. Some of us have taken to doubling up on a standard tourniquet, using two instead of one, but that's also being thwarted as being potentially too tight for patients. Blood pressure cuffs and other alternatives have not generally been available. What should we do?

Our response:

This is a very interesting question. We're not a big fan of cutting tourniquets to make them shorter. If wider bands were acceptable and equally functional, manufacturers would already be making them that way, but they don't. That tells us they're either not effective or not marketable. We would discourage the practice as well. We would also discourage the practice of doubling tourniquets. There's no evidence supporting that as being an effective means of providing constriction. It's what I call a "homemade modification" to an established practice.

The bigger issue is that your fellow phlebotomists are taking it upon themselves to change things without authorization (or so it seems). If they are making these quirky changes because they think they have a better way, there's no telling what other aspects of the procedure they are modifying, some with potentially detrimental consequences and impacts. We strongly advocate sticking to the procedure your facility has established, and if anyone wants to change things it should be brought to the manager's attention for consideration.

For the elderly crowd with crepe skin, one way to make it more comfortable is to make sure to wrap the tourniquet on top of the sleeve. The skin is less likely to pinch and cause discomfort.

To reduce costs, you might have your facility implement a practice where every patient is given a tourniquet upon admission that stays with them and is used only on them. That way they won't be transmitting pathogens from one patient to the next.

 

The Guru Maker

From the Editor's Desk

One hundred and six years ago last month, a storm moved into the Great Lakes so fierce that over 250 mariners perished and 12 freighters sunk. The "White Hurricane" as it became known, punished Lakes Huron, Michigan, Superior and Erie with 60 m.p.h. winds gusting up to 90 m.p.h., producing 35-foot waves for 16 hours straight. Ships over 500-feet long were tossed about like bathtub toys, then hurled to their watery graves with their doomed crews trapped within. There has never been a storm so great nor a day so deadly on these massive inland lakes.

Now that I live on shore of one of them, Lake Huron, where most of the ships were lost in the Great Storm of 1913, I often stare over the expanse wondering what it must have been like to stand here 106 years ago. The lake, the 4th largest in the world, is ocean-like, massive and usually calm. It's estimated that water entering the lake stays for 22 years before flowing out the other side. Tourism agencies tout Lake Huron and the Great Lakes in general as being "Shark Free and Unsalted." Yet to be caught on any of them at the wrong time is to be caught without mercy or hope of survival. Huron is among the most unforgiving, second only to Lake Superior to the north, which gobbled up the famed Edumnd Fitzgerald in 1976 and her crew of 29.

Out my back window, the view of Huron is mesmerizing. The usually calm waters of what early French explorers referred to as "the freshwater sea" float a steady stream of freighters carrying cargo to and from Chicago and Duluth to New York City and ports between. My Boat Watch app tells me the names of each one passing by, their home port, their destinations, their size and other specs. Industrial commerce up and down the Great Lakes provides a fairly busy commute through my back yard, most freighters passing two miles from shore at about 15 miles per hour. That's about a 5-minute trip across my field of view. 

 Our view is to the north with thick woods to our left and right, which means sunrises and sunsets are to be had only by descending to the narrow beach and looking far to the east and west respectively. It's a descent worth taking. Even from indoors, the rising and setting suns cast their colors across the northern sky giving us a hue-filled hint of what is transpiring at the east or west horizon. A 25-foot bluff keeps my land well above the lapping waves as they rinse the sand in continuous sweeps. Mild or violent, there are always waves. Even though the walls of our home are 6-inches thick and well insulated, the waves' rhythmic cadence is often loud enough to be the lullaby by which we fall asleep at day's end and to which we awake each morning.     

Just how angry "the Big H" must have been that grim day in 1913 is inconceivable. I'd have been killed just standing at my bluff, and my home some 30 yards back would have been destroyed. At the time, though, there was no home here, nor the road upon which we live but that doesn't keep me from imagining a time when the power of nature could raise the water 35 feet from its surface and 10 feet over my head for 16 hours straight. At that time, the land upon which I stand and the trees surrounding me endured a punishment no less than epic, biblical in magnitude, dwarfed only by the grief and mourning of the widows made that day. At that time, what I would have seen from my bluff were walls of water pushed by hurricane-force winds filled with snow rendering visibility to near-zero and the icy pelting of my face to nearly intolerable. The crashing of the mountainous, driven waves day and night would have been deafening before me, impossible to see coming, and horrifying to be amidst. It is the very definition of terror, and exactly what over 235 seamen experienced on ships in the waters before me the day they died. 

That day and this day are like night and day. Instead of being caught in an epic storm that will send me and my ship to the bottom of Lake Huron, I'm tapping on my app to see what freighter passes by next. It feels odd and not at all comfortable. One hundred and six years was a long time ago, but when you're standing in the same place, time is all that separates you from something catastrophic. I suppose one would feel the same way standing on the battlefields of Gettysburg, but then Gettysburg is not my home and will never be repeated. One can never be so sure about The Great Storm. 

Such is the human dilemma.

Rather than dwell upon the slippery slope our mortal existence truly is---for me, the nature of nature on this lake of lakes---I can dwell upon something as equally epic but opposite. Namely, what nature puts on display for me every day and every season. It's the far superior choice, and one that brings what was in short supply here on November 9-10, 1913: peace and hope. 
     So as this year winds down, that's precisely what I want for you. As you weather your storms, either at work or in your personal lives, know that there's a safe harbor for you just ahead. As devastating as they may be, storms are always temporary. What lies ahead is your new normal. One that is quite likely to be vastly superior to the one that this storm is rearranging. That's your harbor, and its just beyond the next gust. Focus on the harbor. There are sunrises and sunset waiting for you.

     You may not be in enduring a storm right now, and for that I am very grateful. As your editor for the last 21 years, my readers have become like family to me. Of course I want you to know and practice phlebotomy procedures according to the standards every time. Articulating those standards have been my goal ever since I left the bench on December 13, 1998. My work is far from done and education is far from all I want to deliver to you. Respect for what you do, hope that you can tackle your biggest problems where you work, and peace in knowing you are working in one of the most noble vocations on the planet: caring for the sick and injured.

Trust me, I've had my share of storms. Just exactly how and why I got washed upon your shore remains a mystery to me, but I'm awfully glad for it. Being your source of reliable information is truly an honor, and one I hope to continue earning. It's my safe harbor, and one into which you are always welcome. 

Merry Christmas and Happy New Year, my good friend. 

 

Take care, 

Dennis J. Ernst, editor
phlebotomy@phlebotomy.com 

 

Addressing Staffing Shortages in Phlebotomy

A study published recently in the Archives of Pathology and Laboratory Medicine focused on the magnitude and causes of staffing shortages in healthcare facilities with phlebotomy personnel. Two human resource practices were found to reduce staff turnover.

To determine the average 3-year turnover rate for clinical laboratory staff---including phlebotomists and other laboratorians---researchers collected data from 21 institutions in the U.S. and Canada. They also assessed the potential associations between turnover rates and human resource practices. They found the median of the 3-year average turnover rate for all laboratory staff was 16.2%, i.e., over three years, 16% of the staff left their positions; half of the facilities had a higher rate; half had a lower rate.

The researchers also calculated the turnover rates within various categories of laboratory personnel. It comes as no surprise that phlebotomy services experienced the highest rate of turnover with a median of nearly 25% in 3 years. Those in the 90th percentile saw nearly half of their phlebotomists leaving within three years.

The laboratory's "ancillary staff" had the lowest median rate (11.1%). Among laboratory departments, microbiology came in with the lowest median rate (7.8%) while anatomic pathology had the highest median (14.3%).

Finally, the authors of the study reported that laboratories with well-developed and clear, effectively communicated career paths for their staff had significantly lower turnover rates than those that didn't. Additionally, those that paid for their staff's continuing education activities had significantly lower 3-year average turnover rates than laboratories that did not.

Read the full study.

 

What's Wrong Here?

What's wrong with this picture? We guarantee something isn't as it should be. The answer will be in next month's issue. (Click image at left to enlarge.)

Last month's image (right) depicted a patient sitting upright on an exam table getting her blood drawn. According to the venipuncture standard published by the Clinical and Laboratory Standards Institute, seated patients must be in a chair with at least two arm rests. Patients who cannot be comfortably seated on such chairs must be lying down.

The risk of improper positioning is when patients lose consciousness during or immediately after the procedure. When in a chair without side arm rests, injuries are more likely. Since studies show 2.5 percent of patients pass out during phlebotomy procedures, proper seating and positioning is critical. Positioning patients upright on exam tables or on hospital beds violate the standards and threaten the patient.

The inpatient's bedside tray provides no protection from falling forward and is not a substitute for a chair with arm rests. Instead, have inpatients who are sitting upright in bed lie in a recumbent  position. Have outpatients sitting on an exam table recline on the table or move to a chair with arm rests.

 

Test Talk: Parathyroid hormone

Behind the thyroid gland in the neck are four small parathyroid glands that secrete parathyroid hormone (PTH), also known as parathormone PTH), into the bloodstream. The hormone is important in helping the body maintain the proper level of circulating calcium. Without PTH, a calcium imbalance can affect heart function, muscle contraction, nerve signaling, and blood clotting. 

Physicians use PTH to diagnose parathyroid problems including hyperparathyroidism and hypoparathyroidism. The former leads to abnormally low calcium levels while the latter causes dangerously high calcium levels. Physicians often order calcium and vitamin D levels at the same time as PTH. Vitamin D helps the body absorb dietary calcium. If vitamin D is not ordered, the physician may not be able to tell if the patient's abnormal calcium level in the blood is caused by a dysfunctional parathyroid gland or a problem absorbing calcium in the diet.

PTH is sometimes, but not always, ordered as a fasting test. Although it can be tested on serum or plasma from an EDTA tube, serum sample are unstable and must be immediately placed in an ice slurry before leaving the patient, then centrifuged at refrigerated temperatures. If it cannot be tested immediately, serum should be frozen. If collected into an EDTA tube, however, it remains stable in whole blood for at least 24 hours at room temperature (two days, according to some studies).

 

Bibliography

• LabTestsOnline. American Association for Clinical Chemistry. AACC. Accessed 5/3/2017.
• CLSI. Procedures for the Handling and Processing of Blood Specimens for Common Laboratory Tests; Approved Guideline—Fourth Edition. H18-A4. Clinical and Laboratory Standards Institute. Document H18-A4 Wayne, Pennsylvania 2010.
• Wu A. Tietz Clinical Guide to Laboratory Tests---Fourth Edition. Elsevier. St. Louis, Missouri. 2006.
• World Health Organization. Use of Anticoagulants in Diagnostic Laboratory Investigations. WHO. Geneva, Switzerland. 2002.

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The Empowered Healthcare Manager

Being Firm

A good question to ask all applicants is when was the last time you had to be firm with someone? It reveals character, the ability to stand up for what's right, the strength to defend (laws, rules, a code-of-conduct, decency, oneself, etc.).

It's also good for managers to ask themselves the same question. 

It's a mistake to think empowerment can only be bestowed. True empowerment comes from within. Sure, administrators have to empower their managers, but if the manager shrinks from using it, he/she remains a mere manager, destined to be yoked to a legacy of having been promoted by mistake.

Empowered healthcare managers, on the other hand, accept the gift of empowerment and give themselves permission to transform their position, their staff, and their organization. They give themselves permission to be firm. Here's what it sounds like:

• No, you can't have that day off. It will compromise the team.
• If I hear one more whisper of gossip, you'll be suspended.
• I've told you three times to hem up the cuffs of your scrubs. Find some safety pins and pin them up now. The next time you come in with them sweeping the floor you'll be sent home.
• I appreciate you letting me know of problems that require my attention. Going forward, I'd like for you to also to propose solutions at the same time. 

Firm is the enemy of mediocrity; mediocrity is the enemy of the empowered. The enemy of your enemy is your friend.

Subscribe to the Empowered Healthcare Manager blog.

What Should We Do?: Butterfly overuse

Question: Are there benchmarks on the percentage of straight vs butterfly needles that should be used? We'd like to see how we compare on in-house patients, outpatients, and nursing home usage. We conducted a study here that found 57% of draws were done using butterflies. Once people were aware and conscious of the issue, we were able to improve our numbers. We don't want to have to sign out butterfly needles yet as they do in other places. Do you have any ideas or tricks you can suggest to help us keep the rate dropping?

Our response: We are not aware of any national statistics on butterfly usage overall, much less on specific patient populations. We've conducted numerous surveys, however, and wrote many articles on the topic in this newsletter. (See links below.) We feel your 57% is high for an acute care facility. It's hard to believe most of your patients require them. You are to be commended for taking steps to get the rate down, as it is a hugely expensive problem. 

Assume you pay 20 cents for every tube holder/needle assembly and $1.25 for every butterfly set. For every phlebotomist who uses a butterfly when a tube holder assembly would suffice, you lose $1.05.

Now assume your phlebotomists average 6 patients per hour throughout the day. For an 8-hour day, that's 48 patients. If they're using butterfly sets on half the patients, and only half of them actually require it, it's costing your facility $12.60 per person for every 8-hour shift. Multiply that by the number of shifts and the number of phlebotomists at your facility, and over the course of a year you're burning through $5000 unnecessarily. Plug in your own numbers, but it's easy to find that butterfly overuse costs the average employer hundreds of dollars every day, and tens of thousands every year. Ouch.

You've probably already taken some of these steps, but we recommend bringing everyone together and articulate the problem in resource management you are experiencing, and how its crippling your facility. (Don't be afraid to mention how perpetuating butterfly overuse prevents administration from approving raises and benefit packages.) Let them know they are the collective solution, and you really need their help. The team, management included, have to feel this is only conquerable as a team. No individuals are exempt.

Set your benchmark, then set incremental goals, and your overall goal. Be ambitious and aggressive. Report progress, or lack thereof, toward the goal weekly from the outset, then monthly once you're getting good traction. Just like hemolysis and blood culture contamination, this is about process improvement, and the effort never ends. Above all, reward your team early and often when progress is made. Without it, your efforts will be futile. 

[Editor's note: each year, one of the most highly acclaimed presentations at the Phlebotomy Supervisor's Boot Camp is the "Squandered Resources and Low Hanging Fruit" presentation where we articulate strategies in detail to reduce butterfly overuse, hemolysis rates and blood culture contamination rates.]

 Related articles appear in these back issues of Phlebotomy Today-STAT!:

• April, 2007
• December 2008
• March 2010
• May 2010
• March 2011

Got a challenging phlebotomy situation or work-related question? Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)