Specimen Procurement Complications & QA 2011

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VPML 120 2011 ComplicationsVPML 120 2011 Complications 11

SPECIMENSPECIMEN

PROCUREMENTPROCUREMENT

VPML 120VPML 120Complications and Procedural ErrorsComplications and Procedural Errors

Quality AssuranceQuality Assurance


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ObjectivesObjectives

By the end of this class, the learner will be acquire theBy the end of this class, the learner will be acquire theknowledge aboutknowledge about

Procedural errors that lead to failure to draw bloodProcedural errors that lead to failure to draw blood

Complications and errors that adversely affect the patientComplications and errors that adversely affect the patient

Complications related to patient conditionsComplications related to patient conditions

Site selection variables that affect specimen qualitySite selection variables that affect specimen quality

Dealing with special populations of patientsDealing with special populations of patients

Occupational hazards to phlebotomistsOccupational hazards to phlebotomists

Quality assurance in phlebotomyQuality assurance in phlebotomy

Watch a video on venipunctureWatch a video on venipuncture


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Procedural Errors thatProcedural Errors that

Lead to Failure to Draw BloodLead to Failure to Draw Blood

Tube position and vacuumTube position and vacuum

Needle positionNeedle position

bevel against the vein wallbevel against the vein wall

too deeptoo deep

not deep enoughnot deep enough

beside the veinbeside the vein

undeterminedundetermined

Collapsed veinCollapsed vein


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Proper & Improper NeedleProper & Improper NeedlePositioningPositioning


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Limitations to Needle ManipulationLimitations to Needle Manipulation

by CLSIby CLSI When a blood sample cannot be obtained afterWhen a blood sample cannot be obtained after

a venipuncture attempt:a venipuncture attempt:

Pull the needle back a bit, or advance it further, orPull the needle back a bit, or advance it further, or

rotate half a turnrotate half a turn

Lateral needle relocation should never beLateral needle relocation should never beattempted on basilic vein, since the brachial arteryattempted on basilic vein, since the brachial arteryand nerves are in close proximityand nerves are in close proximity

Try another tube to ensure the tube selected is notTry another tube to ensure the tube selected is notdefectivedefective

Manipulation other than this is considered probingManipulation other than this is considered probing


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Complications and ErrorsComplications and Errors

Adversely Affecting the PatientAdversely Affecting the Patient Hematoma formationHematoma formation

Inadvertent arterial punctureInadvertent arterial puncture

Iatrogenic anemia: in infantsIatrogenic anemia: in infants-- >10% blood volume>10% blood volume Infection of veins: improper aseptic techniqueInfection of veins: improper aseptic technique--

PhlebitisPhlebitis

Nerve damageNerve damage

PainPain Reflux of anticoagulantReflux of anticoagulant

Vein damageVein damage


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Adversely Affecting the PatientAdversely Affecting the Patient Hematoma formation:Hematoma formation:

Most common complicationMost common complication

Caused by blood leakage in tissue causing swellingCaused by blood leakage in tissue causing swelling

Causes bruising, compression injuries to nervesCauses bruising, compression injuries to nerves

Immediately release tourniquet, withdraw the needle, holdImmediately release tourniquet, withdraw the needle, hold

pressure at the site for at least 2 minpressure at the site for at least 2 min

Inadvertent arterial punctureInadvertent arterial puncture

Not commonNot common

Brachial artery close to basilic veinBrachial artery close to basilic vein

Hold the site for at least 5 minHold the site for at least 5 min


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Adversely Affecting the PatientAdversely Affecting the Patient Nerve damageNerve damage ? Law suit? Law suit

Poor site selectionPoor site selection

Excessive blind probingExcessive blind probing

Vein damageVein damage::

repeated venipuncture at therepeated venipuncture at thesame sitesame site

PainPain

Some pain is always thereSome pain is always there

Reduce sting by dryingReduce sting by drying

alcohol before venipuncturealcohol before venipuncture

Avoid probingAvoid probing

IontophoresisIontophoresis lidocaine withlidocaine witha small current for 15a small current for 15--20 min20 min

Anticoagulant refluxAnticoagulant reflux Occurs when contents of theOccurs when contents of the

tube are in contact with needletube are in contact with needle

To prevent, always keepTo prevent, always keep

patients arm in downwardpatients arm in downwardpositionposition

Some patients may haveSome patients may haveadverse reaction to tubeadverse reaction to tubeadditives, esp EDTAadditives, esp EDTA


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Procedural ErrorsProcedural Errorsthat Affect Specimen Qualitythat Affect Specimen Quality

Hemoconcentration/Hemoconcentration/

Venous StasisVenous Stasis

Stagnation of blood flowStagnation of blood flow

Prolonged tourniquetProlonged tourniquetapplicationapplication

Plasma filters into tissuePlasma filters into tissue

HemolysisHemolysis

Unclean venipunctureUnclean venipuncture

Vigorous shakingVigorous shaking Unsuitable for tests such as K,Unsuitable for tests such as K,

Mg, enzymes, red cell countsMg, enzymes, red cell counts

Will Hgb be affected?Will Hgb be affected?

Partially Filled TubesPartially Filled Tubes

short drawsshort draws--partially filledpartially filled

tubestubes

Blood/anticoag ratio alteredBlood/anticoag ratio altered

Especially critical forEspecially critical for

coagulation studies LIGHTcoagulation studies LIGHT

BLUE (CITRATE) TUBEBLUE (CITRATE) TUBE

Specimen ContaminationSpecimen Contamination

alcoholalcohol PovidonePovidone high uric acid, Khigh uric acid, K

affects bacteria in theaffects bacteria in the

specimenspecimen


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ComplicationsComplications

Related to Patient ConditionsRelated to Patient Conditions Allergies to Antiseptics, AdhesivesAllergies to Antiseptics, Adhesives

Allergies to LatexAllergies to Latex

Excessive BleedingExcessive Bleeding

Fainting (Syncope)Fainting (Syncope)

Nausea/VomitingNausea/Vomiting

ObesityObesity PetechiaePetechiae

Seizures/ConvulsionSeizures/Convulsion


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Related to Patient ConditionsRelated to Patient Conditions Fainting (syncope)Fainting (syncope)

History of fainting, feeling week due to fastingHistory of fainting, feeling week due to fasting

Remove tourniquet, withdraw needleRemove tourniquet, withdraw needle Keep talking to the patient, have him/her lower theKeep talking to the patient, have him/her lower the

head in between legs, support patienthead in between legs, support patient

Loosen tight clothesLoosen tight clothes tie, tight collartie, tight collar

Apply cold compress/washcloth to back of theApply cold compress/washcloth to back of the

neck/foreheadneck/forehead no ammoniano ammonia

Call for designated firstCall for designated first--aid personnelaid personnel


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Related to Patient ConditionsRelated to Patient Conditions Nausea/vomittingNausea/vomitting

Nausea often precedes vomitingNausea often precedes vomiting

Ask patient to breathe slowly and deeplyAsk patient to breathe slowly and deeply

Apply cold compress/washclothApply cold compress/washcloth Give an emesis basinGive an emesis basin

Notify appropriate personnelNotify appropriate personnel

SeizureSeizure

Remove the needle immediately, press the siteRemove the needle immediately, press the site Restrict movements, do not put anything in the mouthRestrict movements, do not put anything in the mouth

Call for appropriate medical helpCall for appropriate medical help


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SITE SELECTION VARIABLES THATSITE SELECTION VARIABLES THAT

INFLUENCE SPECIMENINFLUENCE SPECIMEN

COMPOSITIONCOMPOSITION Physical Problem Areas to AvoidPhysical Problem Areas to Avoid

Burns, scars, and tattoosBurns, scars, and tattoos

Damaged veinsDamaged veins

SclerosedSclerosed hard, cordlikehard, cordlike

ThrombosedThrombosed recent clot formationrecent clot formation

EdemaEdema

HematomaHematoma MastectomyMastectomy

Lymphostasis, painLymphostasis, pain


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Vascular Access Areas &Vascular Access Areas &

Devices to Avoid in Site SelectionDevices to Avoid in Site Selection IV SitesIV Sites

Previously Active IV SitesPreviously Active IV Sites

Arterial LinesArterial Lines

AV Shunts (Fistulas)AV Shunts (Fistulas)

Heparin or Saline LocksHeparin or Saline Locks

Vascular Access DevicesVascular Access Devices


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Devices to Avoid in Site SelectionDevices to Avoid in Site Selection IV sitesIV sites

Blood should be collected from the other armBlood should be collected from the other arm

If unavailable, draw blood from BELOW

the IVIf unavailable, draw blood from BELOW

the IVsite, never abovesite, never above specimen dilutionspecimen dilution

Request nurse to stop IV fluid for 2 min beforeRequest nurse to stop IV fluid for 2 min before

collectioncollection

Record on the requisitionRecord on the requisition


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Devices to Avoid in Site SelectionDevices to Avoid in Site Selection AV Shunts or FistulasAV Shunts or Fistulas

Surgical procedure to fuse vein and artery together, usuallySurgical procedure to fuse vein and artery together, usuallyfor dialysisfor dialysis

Can be easily felt under the skinCan be easily felt under the skin NEVER apply tourniquet on a shuntNEVER apply tourniquet on a shunt

Heparin/saline locksHeparin/saline locks

Cannula left in patients vein for up to 48 hrsCannula left in patients vein for up to 48 hrs

Used for IV medication

Used for IV medication

Should be avoided as far as possibleShould be avoided as far as possible

Always draw 5 ml DISCARD TUBE before bloodAlways draw 5 ml DISCARD TUBE before bloodcollectioncollection


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Devices to Avoid in Site SelectionDevices to Avoid in Site SelectionVascular Access DeviseVascular Access Devise

A vascular access catheter is a long, thin tubeA vascular access catheter is a long, thin tubethat is placed in a vein in the arm, in the neckthat is placed in a vein in the arm, in the neckor in the chest just beneath the collarbone.or in the chest just beneath the collarbone.

These soThese so--calledcalled central catheterscentral catheters can remaincan remainin place for weeks, months or even years.in place for weeks, months or even years.

Blood from VADBlood from VAD blood cultureblood culturecontamination, air embolism, hemolysis,contamination, air embolism, hemolysis,infection, dilution of specimeninfection, dilution of specimen


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Inability to Obtain SpecimenInability to Obtain Specimen Procedure for failure to get bloodProcedure for failure to get blood

evaluate situationevaluate situation

find new locationfind new location

only two attempts allowedonly two attempts allowed

never probenever probe

Patient unavailablePatient unavailable

Patient refusesPatient refuses Follows QA procedures in reportingFollows QA procedures in reporting


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Geriatric VenipunctureGeriatric Venipuncture

ChallengesChallenges

Skin changesSkin changes

Hearing impairmentHearing impairment Visual impairmentVisual impairment

Mental impairmentMental impairment

Effects of diseaseEffects of disease

Infection of veinInfection of vein --

phlebitisphlebitis


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Effects of DiseaseEffects of Disease

Diseases that affect elderlyDiseases that affect elderly

ArthritisArthritis

Coagulation problemsCoagulation problems

DiabetesDiabetes

Parkinsons and strokeParkinsons and stroke

Pulmonary function problemsPulmonary function problems

Other problems:Other problems:

Loss of immune functionsLoss of immune functions

Poor nutritionPoor nutrition


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Special Population PatientsSpecial Population Patients

LongLong--Term CareTerm Care

PatientsPatients

Home Care PatientsHome Care Patients Traveling phlebotomistTraveling phlebotomist

Brings necessaryBrings necessary

supplies to patientsupplies to patient

Hospice PatientsHospice Patients--

terminally illterminally ill


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Occupational Hazard toOccupational Hazard to

PhlebotomistsPhlebotomists

Occupational exposure to bloodbourneOccupational exposure to bloodbourne

pathogenspathogens

Skin pierced by a contaminated sharpSkin pierced by a contaminated sharp

object/needleobject/needle

Blood or other body fluid splashed into eyes, nose,Blood or other body fluid splashed into eyes, nose,

mouthmouth

Blood or other body fluid comes in contact with aBlood or other body fluid comes in contact with acut, scratch, abrasioncut, scratch, abrasion

A human bite breaks the skinA human bite breaks the skin


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Procedure for Needlesticks andProcedure for Needlesticks and

other Exposure Incidentsother Exposure Incidents

Phlebotomists responsibilityPhlebotomists responsibility

Immediately decontaminate needlestick site withImmediately decontaminate needlestick site with

povidonepovidone--iodine for at least 30 seciodine for at least 30 sec

If mucous membrane exposed, flush with water forIf mucous membrane exposed, flush with water for

at least 10 minat least 10 min

Report the incident to supervisorReport the incident to supervisor


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Employers responsibilityEmployers responsibility

: Medical evaluation: Medical evaluation

Employees blood tested for HIVEmployees blood tested for HIV

Source patients blood tested for HIV, HBVSource patients blood tested for HIV, HBV patientspatients

permission requiredpermission required If source patient refuses or HBV positive, employee is givenIf source patient refuses or HBV positive, employee is given

immune globulin/HBV vaccineimmune globulin/HBV vaccine

If source is HIV positive, employee is counseled and tested forIf source is HIV positive, employee is counseled and tested for

HIV immediately, and atHIV immediately, and at 6 weeks, 12 weeks, 6 months and 12 months after exposure6 weeks, 12 weeks, 6 months and 12 months after exposure

Employee may be given HIV therapy viz azidothymidine(AZT)Employee may be given HIV therapy viz azidothymidine(AZT)


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QualityAssuranceinQualityAssurancein

HealthcareHealthcareQuality improvement (QI) process is part ofQuality improvement (QI) process is part of

accreditation requirements for all types of healthcareaccreditation requirements for all types of healthcare

facilities and found in every aspect of healthcare.facilities and found in every aspect of healthcare.


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Process/OutcomesProcess/Outcomes

Outcome only gives us numbersOutcome only gives us numbers

Process tells how to change outcomesProcess tells how to change outcomes E.g. how many redraws in a month?E.g. how many redraws in a month?

QC DefinedQC Defined A component of a QA processA component of a QA process

A form of procedure controlA form of procedure control

Example:Example:phlebotomy QC involves checking operationphlebotomy QC involves checking operation

proceduresprocedures

QA in PhlebotomyQA in Phlebotomy(continued)(continued)


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Areas in PhlebotomyAreas in PhlebotomySubject to QCSubject to QC

Patient Preparation ProceduresPatient Preparation Procedures

LaboratoryUser ManualLaboratoryUser Manual describes patientdescribes patientpreparation and other special instructions forpreparation and other special instructions for

specimen collectionspecimen collection Specimen Collections ProceduresSpecimen Collections Procedures

IdentificationIdentification

EquipmentEquipment

Puncture DevicesPuncture Devices

Evacuated TubesEvacuated Tubes


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Specimen Collection ProceduresSpecimen Collection Procedures

LabelingLabeling Must be exactMust be exact

Computer labels mayComputer labels mayassure accuracyassure accuracy

Specimen TubeSpecimen Tubewith Barcode Labelwith Barcode Label


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TechniqueTechnique

Incident ReportIncident Report

Collection PrioritiesCollection Priorities

Delta ChecksDelta Checks

Compares current results of a lab test with previousCompares current results of a lab test with previous

results for same test on same patientresults for same test on same patient

Specimen Collection ProceduresSpecimen Collection Procedures(continued)(continued)


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PrePre--analytical Errors:analytical Errors:Before CollectionBefore Collection

Patient misidentificationPatient misidentification

Improper time of collectionImproper time of collection

Wrong tubeWrong tube NonNon--sterile site preparationsterile site preparation

Improper patient preparationImproper patient preparation

Inadequate fastInadequate fast ExerciseExercise

No coordination with medicationNo coordination with medication


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PrePre--analytical Errors:analytical Errors:During CollectionDuring Collection

Prolonged tourniquet timeProlonged tourniquet time

HemolysisHemolysis

Order of drawOrder of draw Failure to mix tubes with anticoagulantFailure to mix tubes with anticoagulant

Faulty techniqueFaulty technique

Underfilling tubesUnderfilling tubes


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PrePre--analytical Errors:analytical Errors:After CollectionAfter Collection

Failure to separate serum from cells in timeFailure to separate serum from cells in time

Improper use of serum separatorsImproper use of serum separators

Processing delaysProcessing delays Exposure to lightExposure to light

Improper storage conditionsImproper storage conditions

Rimming clotsRimming clots


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Tube Handling ErrorsTube Handling Errors

Manually pouring contents from one tube to anotherManually pouring contents from one tube to another

Vigorous mixingVigorous mixing

Incorrect order of drawIncorrect order of draw

Manually removing additive (exception?)Manually removing additive (exception?)

Removing a clot from a tube containing anticoagulantRemoving a clot from a tube containing anticoagulant sending the specimensending the specimen

Underfilling tubes with anticoagulantUnderfilling tubes with anticoagulant

Overfilling tubes with additivesOverfilling tubes with additives

Recentrifuging a gel tubeRecentrifuging a gel tube


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Accreditation standards require facility toAccreditation standards require facility to

show documentation on all QC checksshow documentation on all QC checks

Quality Assurance FormsQuality Assurance Forms Equipment Check FormsEquipment Check Forms

Internal ReportsInternal Reports

Incident ReportsIncident Reports

Employee Action RecordEmployee Action Record

Occurrence ReportsOccurrence Reports

DocumentationDocumentation


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Incident ReportIncident Report

Specimen Procurement Complications & QA 2011

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