Case studies of blood draw

Most phlebotomists don’t think that a venipuncture can land them in the witness chair desperately defending their technique; most phlebotomy supervisors don’t realize they can be called as the next witness to defend their hiring and training practices. In today’s litigious society, it would be easy to discount phlebotomy-related lawsuits as the frivolous pursuit of ill-gotten gains. Many patients, however, are suffering and suing with just cause.

Phlebotomy is one of the most underestimated procedures in health care. It’s a heavily detailed invasive procedure requiring the collector to perform a complex sequence of maneuvers to be performed properly and safely.

Labortory Manager Magazine has collected 12 interesting case studies of phlebotomy and related legal issues.


Read more:
Phlebotomy Meets The Law

Source: Laboratory Manager

Capillary blood sampling

National recommendations on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine

Capillary blood sampling is a medical procedure aimed at assisting in patient diagnosis, management and treatment, and is increasingly used worldwide, in part because of the increasing availability of point-of-care testing. It is also frequently used to obtain small blood volumes for laboratory testing because it minimizes pain. The capillary blood sampling procedure can influence the quality of the sample as well as the accuracy of test results, highlighting the need for immediate, widespread standardization. A recent nationwide survey of policies and practices related to capillary blood sampling in medical laboratories in Croatia has shown that capillary sampling procedures are not standardized and that only a small proportion of Croatian laboratories comply with guidelines from the Clinical Laboratory Standards Institute (CLSI) or the World Health Organization (WHO). The aim of this document is to provide recommendations for capillary blood sampling. This document has been produced by the Working Group for Capillary Blood Sampling within the Croatian Society of Medical Biochemistry and Laboratory Medicine. Our recommendations are based on existing available standards and recommendations (WHO Best Practices in Phlebotomy, CLSI GP42-A6 and CLSI C46-A2), which have been modified based on local logistical, cultural, legal and regulatory requirements.

Read more:
Capillary blood sampling: national recommendations on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine

Source: NCBI, Biochemica Medica
Image: Facebook via diagnosci.pl

Blood Sample Spontaneously Unhemolyzes Because Nurse Asks Nicely

PHILADELPHIA, PA – Sources from a local hospital are reporting a miracle, after a sample received by the laboratory spontaneously unhemolyzed following a discussion with the nurse.

The sample was drawn in the PICU, sent to the lab, and accessioned by medical laboratory technician Nancy Stewart. “After processing the specimen, I noticed the serum was pink, indicating gross hemolysis,” says Stewart. That meant having to call the PICU to request a new sample. Stewart says it’s the best part of her job. “I mean, who wouldn’t love getting yelled at for something they can’t control?”

But luckily for Stewart, PICU nurse Linda Nelson was in a good mood. “Normally, I would be pretty annoyed,” says Nelson. “I would berate the lab tech, accuse her of sabotage, and refuse to draw a new sample. But this time, instead of fighting, I just apologized and politely asked if she could recheck the sample. If it was still hemolyzed, I would gladly obtain a new specimen.”

Read more:
Blood Sample Spontaneously Unhemolyzes Because Nurse Asks Nicely

Source: GomerBlog

Pre-analytical Quiz - What's Your Hemolysis Quotient?

Take this 5 step quiz and check your basic knowledge of haemolysis as a sourcd of pre-analytical error in laboratory tests.

Take the quiz here
What's Your Hemolysis Quotient?

Source: qzzr.com

Patient Preparation to Blood Sample Collection

Labquality Days - Nordic Congress on Quality in Laboratory Medicine

Mads Nybo, M.D., Ph.D., Chief Physician, Department of Clinical Biochemistry and Pharmacology, University hospital of Odense, Denmark

The awareness of the importance of preanalytical factors increases exponentially these years as illustrated by this meeting. Many of these factors are difficult to control, among which patient preparation and blood sampling without doubt is crucial for a correct analysis result. However, information about patient preparation often takes place outside the “jurisdiction” of the laboratory, and blood sampling is also often performed by persons outside the laboratory, so these processes seems difficult to control by the laboratory. But the more difficult it seems, the more important it is that the laboratory plays an active role in information regarding these aspects: Knowledge on what influence erroneous patient preparation has on the analysis results and how correct blood sampling is vital for a reliable analysis result is sparse outside the laboratory; an important task is therefore to inform on these issues and to offer tools for quality assessment and quality control outside the lab.

Read more and find full presentation here:
How to guide and prepare the patient and the importance of sampling 

Sourde: Labquality Days
Image credits: Mads Nybo

Standardization of the colors of the blood collection tube caps

Are you in favor of the standardized colors of the blood collection tube caps?

The European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) working group for the Standardization of the colors of the blood collection tube closures (TFG-STCC) was established in June 2015, with the aim to initiate and manage a dialog between interested parties in order to achieve the global harmonization of the color coding for blood collection tube closures (caps) and labels.

The TFG-STCC has recently started a close collaboration with the ISO TC76/WG1 on ‘Transfusion, infusion and injection, and blood processing equipment for medical and pharmaceutical use’, which is currently working on the revision of the ISO 6710 standard: 'Single-use containers for venous blood specimen collection’. This revision of ISO 6710 would also replace the current European standard EN 14820.

As we are aware that some barriers and obstacles could put this important project at risk of full implementation, we have decided to set up this short survey in order to gather some feedback from laboratory professionals on the importance and acceptance of such a colour code.

The main aim of the survey is to learn whether EFLM National Societies would be willing to accept an EFLM proposal for the colour coding of the blood tube caps as the European standard. Moreover, if there are institutions, laboratories or individuals which are not in favor of such standardization we would be very interested to understand possible reasons for this.

The results of this survey will provide us an overview of the opportunities and potential barriers for this project.

Open survey here: https://www.surveymonkey.com/r/TFG-STCC

Source: EFLM, Ana-Maria Simundic, chair of the EFLM TFG-STCC

Preanalytical Nightmare 4

A person who collected the sample kept blood sample warm....... in boiling water

Source: Facebook via Abbie Poirier‎

Preanalytical nightmare 3

Have you seen this before?

Source: Facebook via Hillary Dodenbier Parkinson‎

New Microfluidic Blood-draw Device Could Replace Needle Sticks

Tasso is revolutionizing diagnostics by creating technologies for blood sample collection that place the user at the center of process. Our wearable blood collection system, the HemoLinkTM, is being developed to improve the user experience as well as enable both healthcare consumers and providers with convenient access to reliable laboratory test results.

In a process known as “capillary action,” HemoLink leverages microfluidics to create a slight vacuum that pulls blood from capillaries though tiny channels in the skin into a small tube, noted a Gizmag report. The device collects 0.15 cubic centimeters of blood, which is enough to test for cholesterol, infections, cancer cells, blood sugar and other conditions.

Pathologists and clinical laboratory professionals will be watching the eventual launch of HemoLink to learn how its developers have overcome the problems affecting lab test accuracy that can be caused by the interstitial fluid that often accompanies capillary blood when such specimens are collected. How the lab test technology used by Theranos addresses this same problem has been an ongoing point of interest among medical laboratory professionals.

Read more:
New Microfluidic Blood-draw Device Could Replace Needle Sticks and Venipunctures at Medical Laboratories

Source: Dark Daily

Drop-to-Drop Variation in the Cellular Components of Fingerprick Blood

Blood obtained via fingerprick is commonly used in point-of-care assays, but few studies have assessed variability in parameters obtained from successive drops of fingerprick blood, which may cause problems for clinical decision making and for assessing accuracy of point-of-care tests.

A study used a hematology analyzer to analyze the hemoglobin concentration, total WBC count, three-part WBC differential, and platelet count in six successive drops of blood collected from one fingerprick from each of 11 donors, and we used a hemoglobinometer to measure the hemoglobin concentration of 10 drops of fingerprick blood from each of 7 donors.

The average percent coefficient of variation (CV) for successive drops of fingerprick blood was higher by up to 3.4 times for hemoglobin, 5.7 times for WBC count, 3 times for lymphocyte count, 7.7 times for granulocyte count, and 4 times for platelets than in venous controls measured using a hematology analyzer. The average percent CV for fingerprick blood was up to 5 times higher for hemoglobin than venous blood measured using a point-of-care hemoglobinometer. Fluctuations in blood parameters with increasing volume of fingerprick blood are within instrument variability for volumes equal to or greater than 60 to 100 μL.

These data suggest caution when using measurements from a single drop of fingerprick blood.

Read more:
Drop-to-Drop Variation in the Cellular Components of Fingerprick Blood

Source: American Journal of Clinical Pathology

Preanalytical Nightmare, Part 2

At least they remembered to lable the urine sample. Shame the lable is on the inside of the container.



Source: Facebook
Image credits: Meghann Bruce-Merrie‎

Automated Retest Interval Rejection Rule for CRP

Repeat serum C-reactive protein (CRP) measurements on the same day or on consecutive days are of limited clinical value. Minimum retesting intervals are recommended for managing unnecessary repeat testing. As not previously reported, we studied the effect of minimum retesting interval test rejection on laboratory workload and expenditure and on clinician-requesting behaviour.

In a prospective study, we evaluated the effect of an automated 48 h CRP minimum retesting interval rule on inpatient and outpatient CRP workload and costs. Control data on inpatient and outpatient serum urea and electrolytes (UE) workload were collected during the study.

Over 1 year, there was a 7.0% and 12.3% decrease in CRP requests and CRP tests analysed, respectively, following the introduction of the minimum retesting interval rule when compared to the 1 year baseline period. This equated to an estimated annual reduction in revenue costs of £10 500, but cash savings in consumable costs of £3000. There was no significant change in UE requests.

This study group reported, for the first time, that automated minimum retesting interval rejection rules as a stand-alone strategy are a cheap and sustainable method for reducing unnecessary repeat CRP tests, resulting in small laboratory cash savings, more efficient use of laboratory resources and standardisation of patient care pathways. The minimum retesting interval rejection rule also altered clinician test-requesting behaviour towards more appropriate requesting.

Read more:
An automated minimum retest interval rejection rule reduces repeat CRP workload and expenditure, and influences clinician-requesting behaviour.

Source: Journal of Clinical Pathology

Can falling in love be considered as a preanalytical risk factor for laboratory tests?

What happens when we fall in love? The most common symptoms known to the lovesick are racing heartbeats, nervousness, obsessive focus and loss of appetite. We can say that our body is going through many changes and it is far away from "normal" state.


Read more:
Saint Valentine`s Day - Labquality

Source: Labquality
Image credits: Minna Varhala

Patient guidance for laboratory tests

In Finland, about 70 million laboratory tests are conducted each year. Based on statistics, it is thought that the biggest potential for error in the laboratory process is before the analysis of a specimen is performed. This pre-analytical phase is therefore the riskiest point in the patient’s laboratory process, and it has been estimated that each year up to 1.3 million laboratory tests (1.8%) contain a pre-analytical error. These errors account for 50-70% of all laboratory test errors, and entail significant costs in terms of money and delayed or inappropriate treatment.

The cost to Finnish health care for re-sampling these errors is estimated to be about EUR 10 million per year. In addition, much higher indirect costs are incurred when patients have to make repeated visits to the laboratory or doctor’s surgery. As a result of incorrect results or where results are misattributed, patients may undergo unnecessary further investigation or be subject to incorrect treatment. Patient guidance for laboratory sampling is therefore an important part of the pre-analytical phase of laboratory testing. In helping to ensure that correct procedures are followed, patient guidance can be used to improve patient safety in the laboratory process.

Read more:
Clinical Guideline - Patient guidance for laboratory tests.pdf

Source: Hotus

Preanalytical Nightmare

Very innovative solution to take a sample for HbA1c

Source Facebook
Image credits:  Emilie Dubé Blaquière‎

All colours of blood plasma

There are a lot of variation in blood plasma colour. Most weird is the green one.

Glucose Preanalytical Challenge

Case: 13 years old girl from Belgium is weak and have been feeling dizzy lately. Family doctor sent her to lab for a blood sugar screening. He requested plasma glucose and instructed patient to fast 12 hours before the blood test. Next morning the phlebotomist welcomed the patien and confirmed the patient identity. Bloot test was taken at 07:30 in the morning. Picture of the blood test is below.

Can you find any preanalytical errors from this case?

Correct answer is below the image


(Click image to enlarge)

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CORRECT ANSWER: Thera are many errors in this case. The most serious errors are: 12h fasting for potential young diabetic girl, the phlebotomist did not ask if the patient were fasting and a wrong sample was taken (capillary blood insted of plasma).

Also the finger prick sample was taken from the wrong finger, from the wrong location (center of the finger) and phlebotomist´s grip of the finger is not optimal. In some countries the use of gloves is requirement as well.

Preanalytical Case of Thyroid Screening

Case: 35 years old marketing manager from Oulu, Finland was sent to a laboratory for blood draw of thyroid fuction screening. TSH, and FT4 were requested. Specimen were collected 28th of December, 2015 at 15:00. Patient were don´t have any medication.

Do you find any preanalytical errors based on case description and image of the blood draw? 

Correct answer is below the image

(Click image to enlarge)

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Correct answer: Preanalytical errors: Wrong tube (EDTA) and wrong timing for TSH (diurnal variation:Thyroid stimulatin hormone levels fluctuate during the day ) Sample should have been taken in the morning (before 14:00). New sample should have been requested.

Other notes. The tournique is tight during the blood draw (should have been released) and the phlebotomist do not hve gloves to protect her (requirement in some countries).

Preanalytical Errors in Clinical Chemistry Laboratory

There are many factors that contribute to accurate test results in the chemistry laboratory. These factors can be broken down into three areas: preanalytical, analytical and post analytical. Preanalytical variables account for 32-75% of laboratory errors, and encompass the time from
when the test is ordered by the physician until the sample is ready for analysis. The focus of this article will be preanalytical variables that can occur during a venipuncture and specimen processing and how they relate to testing in the clinical chemistry laboratory.

There are many variables that can contribute to the quality of a chemistry specimen. This article will investigate the variables that may have contributed to the gelatinous specimen in the case of the cardiac patient, as well as the other variables that are important to specimen quality. The focus will be on the preanalytical phase of the blood collection and sample handling, up until the time that the sample is to be run on the chemistry instrument.

Preanalytical variables:

• Patient Identification
• Patient Preparation
• Selecting the Site
• Site Preparation
• Tourniquet Application and Time
• Proper Venipuncture Technique
• Order of Draw
• Proper Tube Mixing
• Correct Specimen Volume
• Proper Tube Handling and Specimen Processing
• Centrifugation
• Special Handling of Blood Specimens
• Stability for Whole Blood, Serum and Plasma             

Read more:
Preanalytical Variables in the Chemistry Laboratory


Source: BD

Preanalytical Challenge

What do you say about this sample?
by Marcin Balasa‎



CORRECT ANSWER: This sample was taken to open tube among with other samples. The phlebotomists mixed the caps by mistake after filling the tubes. This is a plasma separating tube (PST). The gele is clearly visible between the serum and cells.

As a conclusion new sample is requested because of potential potassium contamination of K2EDTA tube cap.

Source: Facebook via Diagnosci.pl
Image credits: Marcin Balasa‎