A-344 Don't Get Rejected: Reduce Specimen rejection in Phlebotomy
Authors: Glomb A M , Suh-Lailam B 
Published: September 2023

Abstract

Background
Pre-analytical specimen rejection plagues laboratories, patient care decisions, and satisfaction. Rejection data used for quality improvement varies and often excludes pediatric-only populations. With an outdated benchmark of 2.2% total rejections, our phlebotomy department was maintaining a baseline rejection rate of 1.39%. We assessed only tests where a result was not able to be given for reasons of: Quantity Not Sufficient (QNS), Clotted, Hemolyzed, improperly collected or handled, and unlabeled or mislabeled. While our department exceeded current benchmarks, continued improvements were desired to provide the best care and experience. We collaborated with the Vascular access team (VAT) at our institution to improve our processes.

Methods
Specimen rejection was defined as any sample(s) collected for analysis not performed due to Quantity Not Sufficient (QNS), Clot, Hemolysis, improper collection/handling, and unlabeled/mislabeled specimens. Over the next 3 months, samples obtained by outpatient and inpatient phlebotomist draws were reviewed for pre-analytical errors. VAT and phlebotomy began meeting monthly and developed a 1-day shadow experience for new phlebotomy hires and a mechanism to identify DVA patients. In collaboration with Information Management, coping comfort plans (CCP) were implemented in patient medical record which documented patient preferences and staff observations for potentially painful procedures. The CCP paved updates tip sheets, purchases of transilluminators, and stock heat packs in phlebotomy stations. Additional aids were purchased for patient comfort in outpatient areas. A communication center installed and allowed for an area to write down room numbers of DVAs and to display current rejection rates. Improved staff communication regarding rejected samples was publicly posted on the communication center by phlebotomist name. These characterized type and number of rejections as well as a stoplight color coding to depict acceptable, at risk, and unacceptable errors by phlebotomists monthly. Goals were posted monthly in the communication center. 18 months was allotted for implementation of the final goal of ≤0.5% total rejections, allowing for quarterly reports, changes, and PDSA cycles.

Results
Initial staff surveys discovered 71% of staff were unaware of their rejected samples, 57% of staff were unaware this was a monitored metric, 100% of staff agreed importance. During quarter one of data reporting, it was assumed that all rejections would fall ≤1.25% monthly in Q2-Q3, ≤1.00% in Q4, and by Q2 of the following fiscal year to ≤0.50%. The average rejection rates were: Q1: 1.05%, Q2: 1.0%, Q3: 0.69%, Q4: 0.70%. In year 2 rejection rates were: Q1: 0.5%, Q2: 0.3%. Post-implementation survey conducted resulting in 100% of staff were aware of their rejected samples, aware of the metric, and agreed it was important. Staff additionally suggested improvements and have noted to have higher morale and trust within their group by partnering in this project to improve inpatient workflows. Average rejection rates were reviewed at 1- and 2-year post implementation: 0.05% and 0.42% respectively.

Conclusion
Rejection not only causes waste but a risk to patients as results and treatment can be delayed. By changing configurations in workflow, tools, communication and medical records, phlebotomy staff can be the key drivers of change