Quality Patient Care Begins Earlier Than You Think

Many of us might think patient care begins when the patient receives a diagnosis. However, proper patient preparation, specimen collection, and sample handling are critical to quality care. The highly automated environment of today’s laboratories ensures accurate testing, so to continue increasing quality, we must shift our focus to other parts of the process.

THE STAKES

If we establish adequate laboratory procedures that ensure care in managing the pre-analytical phase of laboratory testing, we minimize the chance of human error negatively affecting our testing outcomes. Medical errors are the third leading cause of death in the United States. With statistics like that, we need to do everything we can to eliminate errors stemming from the laboratory. Most human errors can be greatly reduced, if not eliminated, by following strict processes and procedures based on proven best practices.

HISTORY OF QUALITY MANAGEMENT

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From “Improving Diagnosis in Health Care” (2015), by contributors National Academies of Sciences, Engineering, and Medicine; Institute of Medicine; Board on Health Care Services; Committee on Diagnostic Error in Health Care; Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors

In 1997, George Lundberg introduced the concept of the “brain-to-brain loop” in one of the first efforts to improve quality management with a process that included nine steps involving laboratory testing:

  1. test ordering
  2. specimen collection
  3. patient identification
  4. logistical specimen transportation
  5. specimen separation
  6. test result analysis
  7. test result reporting
  8. physician interpretation
  9. action (physician orders, treatment decisions, etc)

Based on George Lundberg’s model, the concept of the Total Testing Process (TTP) was born. The TTP includes all the elements of the pre-analytic, analytic, and post-analytic phases of testing. As a result of intense quality management programs such as these, laboratory errors have been reduced over the past ten years by as much as 75%. We are on the right track, but more work needs to be done to further reduce commonly recurring errors.

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From “Diagnosis: Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)” Editor-in-Chief: Graber, Mark L. / Plebani, Mario; Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / McDonald, Kathryn / Singh, MD, Hardeep

WHERE THINGS STAND TODAY

Some of the most common errors plaguing the laboratory happen as a part of the initial patient encounter process — even before the pre-analytic phase begins. Some of the most common errors include having the wrong test ordered, order-entry mistakes, incorrect patient identifiers, specimen collection errors, and improper specimen handling or problems with transportation to the laboratory. These simple errors can cost a hospital over $1 million a year in quality assurance investigations, specimen recollection, repeat testing, and management oversight.

FOR EXAMPLE

One of the least invasive procedures for a patient is phlebotomy, yet the blood draw can be the most significant contributor to poor patient care. Misidentifying a patient or not fully understanding the health status of a patient can negatively influence the testing results.

An easy step to eliminate error is to confirm at least two patient identifiers, including accurate spelling of the patient’s name and date of birth and properly labeling each specimen. Additionally, asking about the patient’s fasting status, medical history and diagnosis can help medical staff ensure the correct test has been ordered. Best practice mandates that the physiological effects of factors like fasting, diet, supplements taken, exercise and posture be considered when evaluating the patient as well. Why?

  • Fasting can cause an increase in amino acids, growth hormones and triglycerides.
  • Alcohol can increase liver enzymes and decrease glucose and cortisol.
  • Caffeine may increase glucose and vitamin D levels among other things.
  • Herbal supplements, many of which are not regulated by the FDA, have been known to interfere with therapeutic drugs and some laboratory testing.

We also need to evaluate patients for any other potentially interfering substances or circumstances, such as:

  • When triglycerides exceed 300 mg/dL, Lipemia occurs, causing difficulties in measuring hemoglobin, white blood cells and platelets.
  • Prolonged tourniquet use can affect potassium, magnesium and protein levels, among other things.

Phlebotomists should also be ever mindful about decontamination. Alcohol that has not been allowed the proper drying time can destroy red cells. The order of draw is another critical factor in proper phlebotomy. Blood cultures should be drawn first followed by light blue, red, green, lavender, yellow and finally gray tubes. Extra caution should always be taken with regard to tubes containing anticoagulants, as improper usage will definitely affect test results.

SOLUTIONS FOR THE FUTURE

Clearly, human error is a problem, but we can do everything in our power to eliminate it. Proper and thorough preparation of the patient and careful phlebotomy practices and procedures will eliminate or control many of the variables we need to navigate to produce accurate laboratory test results. Accurate blood collection procedures and establishing quality assurance monitors help us minimize the risk of human error and the resulting adverse testing outcomes.

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