What document contains information about laboratory schedules patient preparation and specimen handling?

UC Irvine Pathology Services has established a uniform policy for specimen acceptance/rejection that:

Has a positive impact on patient care
Protects specimen quality
Eliminates risk of exposure to the healthcare worker
Complies with all accreditation standards

To protect patients from adverse errors made due to improperly labeled specimens, the laboratory policy demands that proper labeling criteria are always met. Every specimen brought to the laboratory must have a label on the container in which it is held. It is not acceptable to label only the lid, transport bag, or other container used to transport the specimen. The label must contain the following legible information:

Patient name
Patient medical record number, with check digit
Patient location
Collection date and time
Specimen type and/or source
Test required (note any special handling required)
Ordering physician

When available, use the addressograph to enter all data on a prepared label being sure to fill in the additional information required that is not on the addressograph plate.

For patient safety, it is essential that the following be adhered to when submitting blood specimens for CROSSMATCHING purposes. Use special pink-top (EDTA) tubes.

Take a Crossmatch/Transfusion form, patient printed labels with the patient's first and last name, patient file number (PF#) or medical record number (MR#), and 1 pink-top (EDTA) tube to the patient's bedside.
Verify the patient's identity by asking the patient to state and spell his/her name, if able, while comparing the patient's identification band with the addressographed Crossmatch/Transfusion form and the patient's printed label.
The patient's name and PF# or MR# must be obtained from the patient's identification wristband. If the patient does not have a wristband, a wristband must be obtained prior to drawing the patient's blood.
Write the following data on the patient's printed or computer-generated gummed label at the bedside:
- Date of phlebotomy
- Time of phlebotomy
- Legibly printed last name of phlebotomist
Affix the patient's printed gummed label to the specimen tube at the patient's bedside.
Send the labeled specimen tube with the Crossmatch/Transfusion form to the Blood Bank.

If the Blood Bank does not have a previous ABO/Rh on file for the patient, and the patient's initial blood type is other than type O, the Blood Bank will request a second sample to be collected for an ABO/Rh confirmation.

Failure to properly label the tubes will require that the specimens be redrawn. If the patient requires blood as an emergency and another sample cannot be drawn, an Emergency Release Form must be signed for uncrossmatched group O blood.

Specimens must be accompanied with a specimen transmittal or clinic encounter form that must match the specimen label. All handwritten requisitions accompanying specimens must have the following legible information:

Last, first, and middle name of patient
Medical record number (8 digits)
Patient’s date of birth
Last and first name of ordering physician
Nursing station or clinic originating requestTest(s) or procedure(s) requestedSpecimen source and body site
Date and time of specimen collection

Specimens must be submitted in the correct tube type or appropriate transport material in a leak-proof container. It is the caregiver’s responsibility to understand the correct specimen and transport requirements prior to collecting specimens.

All patient specimens MUST be placed in biohazard bags for transport to the Laboratory.

Laboratory procedures will not be performed on unacceptable specimens. Specimens collected using the incorrect tube type and transport material will not be tested. Specimens received showing evidence of leakage will not be tested. The nursing station from which the specimen originated will be notified.

Mislabeled Specimens

Specimens received unlabeled, double labeled, or with a requisition bearing a name and/or medical record number different than what is affixed to the specimen will not be tested. The patient’s nurse and/or physician will be notified to recollect the specimen.

Any specimen is unlabeled if the container holding the specimen (test tube, urine container, surgical specimen container, etc.) does not have the patient’s first and last name, medical record number, collection date and time, specimen type, and test required on it.
A specimen is mislabeled if it arrives in the laboratory with a requisition bearing different names on the requisition and the label OR if the name in the computer does not match the label. The laboratory will consider a mislabeled specimen an unlabeled specimen.
Blood Bank sample labels (crossmatch or type & hold) must be handwritten. Addressograph labels must not be placed on crossmatch specimens.

A specimen is incompletely labeled if some of the required information is missing:

If the name and the medical record number are missing, the specimen will be considered unlabeled and handled as such.
If there is any other information missing, the location where the specimen originated will be called to supply the information.

Specimens identified as precious specimens such as ascites fluid, amniotic fluid, cerebrospinal fluid, joint fluid, pleural fluid, surgical tissue/aspirate and certain timed specimens where the specimen cannot be recollected without undue harm to the patient will be tested only if the following conditions have been satisfied:

The patient’s physician must be notified. He/she must agree to accept responsibility for the specimen and give written authorization for testing.
In addition, the pathologist on call must be notified. He or she must review the circumstances and give written authorization for testing.A licensed caregiver designated by the patient’s physician must identify and correctly label the specimen.
It will be documented in the laboratory computer system that the test was performed on an unlabeled specimen so that this information appears on the preliminary and final reports.

Receipt time of the specimen in the laboratory will be the time all information is obtained, not the time the incorrectly submitted specimen was first brought to the laboratory.

The Blood Bank requires a new specimen for each unlabeled or mislabeled specimen, no exceptions.

Cards Return to Set Details

Term

Define Quality Assurance (QA), quality control (QC), total quality management (TQM) and continuous qulaity improvement, and discuss their differences and roles in quality phlebotomy

Definition

Quality Assurance (QA) the larger set of methods used to guarantee quality patient care, including the methods used for patient preparation and collection and transportation protocols. Both technical and nontechnicalQuality Control (QC) refers to the quantitative methods used to monitor the quality of procedures such as regular inspection and and calibration of equipment to ensure accurate test results.Total quality Management (TQM) the entire set of approaches used by the institution to provide patient satisfaction. Both quality control (QC) and Quality Assistance (QA) are included in total qualtiy management (TQM)Total Quality management focuses on gradual continual improvements in the quality of services provided by the lab. It sees the potential for improvement in every area, no matter how high the current performance area level, to improve services provided to customers.
The phlebotomist is the member of the lab team with the most direct patient contact and therefore most responsible for customer service satisfaction in this area (TQM)

Term

Describe the contents of the procedural manual, and explain how the phlebotomist can use it

Definition

the procedure manual is located in the lab at all times It contains protocols and other information about the test performed in the lab, including the principle behind the test, the purpose of performing it, the specimen type the test requires, the collection method, and the equipment and supplies needed.
(QA) quality assurance procedures relevant to the procedure manual include updating the standards and protocols to comply with advances in the field, training for lab members in the proper performance of procedures, scheduling testing of standard samples, and monitoring of results

Term

Explain the role of the directory of services, and describe the information it contains

Definition

The role of the directory of service is to monitor the number of incomplete or duplicate requisitions received, collecting statistics on the number of missed or delayed collections, and recording the time between a test request and a result report.
The directory of services may be available in hard copy or online at the laboratory web site. It includes laboratory schedules, early morning collection schedules, and written notification of any changes, plus information on patient preparation, specimen type and handling, and normal values

Term

List three types of analytic variables

Definition

Preanalytic variables- occur before the specimen and occur in each area of the phlebotomists duties beginning with test ordering and requisition handling. Requisition must be accurately and completely filled out with the patient number, test ordered and priority. variables to be controlled include duplicate or missing requisitions, test left off the requisition, missing patient number, missing doctor name, or priority not indicated.Analytic values those that occur during specimen analysis, they can be affected by preanalytic variables, such as collection time or transport conditions.Examples of analytic variables are making sure tubes not expired, choosing correct site location without scars, burns, using proper equipment
Postanalytic variables- which occur after specimen collection which include delays in reporting results or improper entry of results in the data bank also may be part of phlebotomists duties. Examples can include; using wrong tube , wrong additive, not transferred on time, hemolyzed

Term

Describe at least five errors that may occur as a result of improper requisition handling, and explain QA position for monitoring them.

Definition

Five errors that may occur due to requisition handling include, duplication or missing requisition, test left off of requisition, missing patient number, missing doctor name, or priority not indicated.If insurance information is omitted or is inaccurate, there is a delay in the reporting results, introducing a postanalytic variable.
QA procedures for these variables include recording and counting the number of each type of requisition error

Term

Describe the procedures that should be followed for (QC) Quality control of phlebotomy equipment?

Definition

Phlebotomy equipment is designed and manufactured to be free of defects and minimized variability. nonetheless, errors do occur and it is up to the phlebotomist to identify and eliminate them before they interfere with patient care.Tubes should be checked for lot number and expiration date. Never use an expired tubeStoppers should be checked for cracks or improper seating. Reject any tubes with defective stoppersTubes may lose vacuum without any visible sign of defect. When filling a tube, be aware of incomplete filling because of loss of vacuum. CLSI guidelines indicate that the volume should be +/- 10% of the stated draw.Needles should always be inspected for defects, including blunt points or burrs. Never use a defective needle or one from a package with a broken seal.
Syringe plunger must move freely in the barrel. Reject a syringe with a sticky plunger.

Term

Explain why expired tubes should not be used.

Definition

You may not be able to get a full draw (the full amount needed to perform test) and may not be able to mix additives with specimen properly

Term

describe delta check and explain its use in (QA) Quality assurance

Definition

A delta check is a QA procedure that helps spot identification errors. This check compares previous patient results with current results. If the difference "delta" between the two sets of results is outside the limit of expected variation, it alerts the lab personnel to the possibility of error. Improper identification can lead to injury or death.

Term

List nine patient activities that may affect laboratory results, and give at least one example of a test affected by each

Definition

The Phlebotomist has no control over most of these variables but may note their presence to aid in the interpretation of the test results.1. Posture. A sample collected from an errect patient has higher concentration of large molecules such as enzymes and albumin as well as WBCs and RBCs.2.Short term exercise. Exercise increases muscle enzymes such as creatine kinase, as well as WBC, creatinine, and fatty acids3. Long term exercise. A prolonged exercise regimen increases sex hormones, as well as many other values increased by short term exercise.4. Medications and medical treatments. Certain medications affect test results directly. Aspirin is the most common one, prolonging bleeding times. Other treatments to be aware of include the administration of radiographic dyes, blood transfusions, or IV fluids. Anticoagulants (warfarin and heparin) cause prolonged bleeding after puncture. It is important to know this since it requires extra time after the puncture to apply pressure at the site and thus avoid compartment syndrome.5. Alcohol consumption-moderate amounts of alcohol do not affect the test results (except of course for alcohol test), glucose is slightly elevated, and chronic consumption can lead to increased values on liver function test, as well as interfering with platelet aggregation studies.6. Smoking-Smoking increases catecholamines, cortisol, WBCs, mean corpuscular volume, and hemoglobin, and it decreases eosinophils. Smoking also affects arterial blood gases (ABGs).7. Stress-Anxiety, crying, or hyperventilating may affect test results, including the stress hormones produced by the adrenal cortex. Prolonged crying or hyperventilating alters ABGs, and crying can increase WBCs.8. Diurnal variation-Certain specimens must be collected at specific times of the day because of significant changes throughout the day.Such specimens include cortisol (2 times higher am) and iron (lower in am).9. Fasting-8-12 hours without having food or drink. Caffeinated beverages should also be avoided as they cause a transient rise in blood sugar. A patient not in the in the fasting state may produce a sample that is lipemic which is serum and plasma makes the sample appear turbid. Turbidity is caused by an increase of blood triglycerides, interfers with many test that rely on photometry, or the passage of light through a sample.High-speed centrifugation may be used to pretreat lipemic specimens to overcome interference, but in cases of gross lipemia the sample may have to be recollected. cloudy-did not fast, very cloudy-just ate10. Age-Many lab values vary with age. For instance, because organ function declines with advancing age, values affected by kidney or liver function are different for the elderly than for young patients. Cholesterol and tryglycerides values increase with age, where as the sex hormones may rise then fall. Both RBC and WBC values are higher in infants than adults. For this reason it is important that the patients date of birth be documented on the requisition form.11. Altitude-Patients living at higher altitudes have less oxygen available to breathe, so the body compensates by producing a higher RBC mass. Therefore patients living in the mountains have higher counts of RBCs, hemoglobin, and hematocrits.12. Dehydration-Prolonged diarrhea or vomiting causes loss of fluid from the intravascular circulation. This results in hemoconcentration because of loss of water from plasma. Hemoconcentration produces a false increase in many analytes, including RBCs, enzymes,calcium and sodium.13. Sex-The normal range of some analytes differ for males and females. males have higher hemoglobin, hematocrit and RBC counts than females do.
14. Pregnancy-The changes that occur in pregnancy affect lab values. The presence of the fetus and increased water retention causes a dilution effect that is reflected in falsely lower hemoglobin and RBC counts as well as other analytes.

Term

List at least four blood collection sites that may lead to sample contamination

Definition

Sites that can cause specimen contamination include hematomas or areas with edema and the side of the body that has undergone a mastectomy or is currently receiving IV fluids

Term

six sites that may result in pain or injury to the patient during specimen collection.

Definition

Sites that can cause injury or pain to the patient include burns, scars, previous puncture sites, the arm near a mastectomy, sites near fistulas or shunts, and the back of the heel or other regions close to the bone.

Term

Discuss two errors that may result from improper tourniquet application

Definition

Tourniquets should be left on no longer than 1 minute to reduce hemoconcentration. Hemoconcentration cause the false increase of large molecules such as proteins and cholesterols and the false decrease of chloride and potassium. Tourniquets applied too tightly can cause petechiae.

Term

Explain the risk of failing to cleanse the puncture site carefully, and describe one method to monitor for such errors.

Definition

Proper cleansing reduces the risk of infection. Blood culture collections require special care to prevent contamination of the sample with skin flora. As part of (QA) quality assurance program, the microbiology department keeps records of contaminated samples. Iodine must be removed from skin after collection because it can irritate the skin. Iodine should not be used for dermal puncture, because it is virtually impossible to keep out of sample. Iodine interferes with bilirubin, uric acid, potassium and phosphorus test (BURPP)

Term

Discuss at least 8 precautions that must be taken in collecting and labeling specimens

Definition

Specimens must be collected in the right tube for the test ordered and in the right order. The sample volume must be matched to the quantity of additives to the tube, and the tube size should be choosen to provide adequate volume for the requested test. The specimen must be mixed gently and thoroughly by inversion immediately after being drawn.
Incorrect or incomplete labeling makes a specimen useless and requires redrawing the specimen at a later date. label tubes immediately after they are drawn, before leaving the patients room. Be sure that the labeling is complete and note any special patient conditions on the requisition.

Term

Explain the phlebotomist role in ensuring a positive patient perception of the level of care received?

Definition

You should strive to avoid painful probing, unsuccessful punctures, and repeated draws and be scrupulously careful regarding site selection, accidental arterial puncture, and nerve injury. In addition infection control procedures must always be followed. Break the chain of infection by performing hand washing hygiene upon entering the room and after finish procedure and by wearing gloves during the procedure.

Term

Explain the steps to be followed in the case of an accidental needle stick, and describe (QA) quality assurance procedures that may be used

Definition

Accidental puncture with a used needle must be reported immediately to a supervisor. Immediate and follow up testing for bloodborne pathogens, plus counseling, is standard protocol for accidental needle sticks
QA procedure includes monitoring the number of accidental punctures and instituting additional training or equipment modifications in the event of frequent accidents.

Term

Discuss the monitoring of variables during sample transport

Definition

Samples requiring either cold or warm temperatures must be handled so that the appropriate temperature is maintained throughout the transport process. Stat specimens should be delivered for immediate analysis.
Pneumatic tube systems require special monitoring as specimens that are overly agitated during transport can cause hemolysis. It is the phlebotomist responsibility to ensure proper handling of the specimen. The directory of services contain this type of information they are located on each floor

Term

Explain the effects of sample-processing variables on sample quality (separation times and centrifuge)

Definition

No more than 2 hours should elapse between the time a specimen is collected and the time serum or plasma is separated from formed elements.Even less time should be allowed for determinations of potassium, ammonia, adrenocorticotropic hormone, or cortisol.
The exception is serum separator tubes which are stable once they are spun and a good gel seal is in place.

Term

describe how refrigerators and freezers are monitored

Definition

Fluctuation in cold storage units can degrade sample quality. Temperature of refrigerators and freezers must be monitored daily with the temperature recorded automatically or manually (document and initial) at specific times of the day. Temps of too high or low indicate the unit needs maintenance or replacement.

Term

Explain how multiple aliquots prepared from a single sample should be handled.

Definition

Multiple aliquots prepared from a single specimen allow different departments to share a single sample for multiple test. Each aliquot must be properly labeled as to the source and additives present. Specimens with different additives should never be combined in a single aliquot

Term

Samples should not be left uncovered any longer than necessary during processing it can lead to

Definition

evaporation of liquid, especially from small samples and can affect ABGs, alcohol, and ammonia amoung other test

Term

Contamination may occur while the sample is

Definition

uncovered arising from airborne dust or talc from gloves.Contamination may also occur from incomplete seperation, such as when RBCs are left in the sample after incomplete centrifugation.

Term

Centrifuges must be calibrated every 3 months with a tachometer to ensure that they are running at the reported speed.
Variation may indicate the need to replace worn parts. Spinning samples below the required speed may result in incomplete separation of liquid from formed elements, affecting test results

Definition

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