Patient safety and quality outcomes during the preanalytic phase of venous blood collection.

In 1999, the Institute of Medicine [IOM] released its report, To Err is Human: Building a Safer Health System, which stated that as many as 98,000 people die annu- ally as the result of medical errors (Kohn, Corrigan, & Donald, 1999). Although medical management decisions are often dependent on laboratory testing results, the field of diagnostic medicine has received little recognition for its contribution to medical errors. The most significant error rate occurs during the preanalytic phase of specimen testing, both in hospitals and primary health care (PHC) centers. This phase is significant because it occurs outside the laboratory's supervision and control. Patient and specimen identification as well as collection and handling by nursing staff are a significant aspect of the patient's hospitalization. The patient's diagnosis, evaluation, and management may be dependent on laboratory testing results. A delay in treatment or inappropriate interventions can have a deleterious effect on patient outcomes as well as health care costs.An increased risk of error affecting patient safety is associated with preanalytic venous blood collection (VBC) procedures, including patient identification. In one survey (Wallin et al., 2010), Swedish laboratory staff compared to clinical ward staff reported better practices with respect to specimen collection and handling, but both clinical ward and laboratory staff indicated a failure to consistently follow standardized instructions for patient identification. Swedish PHC laboratory staff reported better performance than clinical staff for patient identification and VBC procedures, but important risks exist for patient misidentification and inaccurate test results, which can seriously affect the diagnosis and treatment of patients (Soderberg, Wallin, Grankvist, & Brulin, 2010). According to Carraro, Zago, and Plebani (2012), there was a high relative frequency of preanalytic errors, including patient misidentification and unacceptable samples, observed during the workflow on three Italian hospital wards.Reducing preanalytic VBC errors is difficult because of the complexity of the initial phase of the total testing process. Acute care preanalytic VBC practices are outside the laboratory's control and are not covered by the same regulated and documented procedures (Carraro et al., 2012; Wallin et al., 2010). According to Soderberg and colleagues (2010), laboratory staff undergo mandatory competency education based on regulated documented procedures that may have contributed to their superior performance regarding VBC practice. All three studies stressed the need to recognize blood sample results as a product of the total testing process with several error-prone steps (Carraro et al., 2012; Soderberg et al., 2010; Wallin et al., 2010).Collaborative laboratory and clinical quality improvement (QI) initiatives including ongoing monitoring, process redesign, and staff training and education are necessary to improve VBC practices. Wallin et al. (2010) stressed the importance of collaborative efforts between acute care and laboratory staff in ongoing competency training of all clinical staff about preanalytic VBC practice. Soderberg et al. (2010) also stressed the need for collaborative efforts between laboratory and PHC staff as a way to reduce VBC errors. A systems approach, involving all phases of the total testing process, is needed to improve the quality of VBC practices. Ongoing monitoring of compliance with an evidence-based protocol for specimen collection and identification should be performed after clinical and laboratory staff collaborate in the development and standardization of such protocols regarding VBC procedures (Carraro et al., 2012).In an attempt to decrease error in the preanalytic phase of specimen collection, a process called "Critical Check" was developed and implemented by six South Carolina hospitals with a sustained 90% patient-label mismatch error reduction more than 90 days ("Hospitals seek 90% reduction," 2012). …