Dr SHYAM PRAKASH DEPARTMENT OF LABORATORY MEDICINE ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI

1. CEUTEH‘16
Dr Shyam Prakash
• M.Sc, Ph.D
Assistant Professor, Department of Laboratory Medicine, All
India Institute of Medical Sciences
• Authored a book, Health and Dietary aspects of Mustard ,oil.
Eds. 2001
• Has many national and international publication
• JRF by Council of Scientific and Industrial Research (UGC-
CSIR), India,1989
• SRF by CSIR, India,1992

2. Cost Effective Technology of
Medical Health Care in Medical
Institutions

3. • Inappropriate advanced medical technology
• Patient involvement in decision-making
• Payment system distortions
• Over-use, high prices for health care services
• Not aligned with national needs
• Excessive administrative costs
• Medical liability and defensive medicine
What are the Major Drivers of Health Care Costs?
Why Do We Need to Control Health Care Costs ?

4. • Reduce avoidable, ineffective, and
duplicate use of services—
including technology that does not
improve patient care
• Pilot test and adopt new models to
encourage with desired outcomes.
• Pay appropriately for health care
services, and encourage adoption
of innovative models of health
care delivery.
• Reduce administrative costs
• Encourage patient responsibility
for health to promote wellness,
prevention, chronic care
management, changes in
unhealthy behaviors

5. • An online platform provides all benefit information, forms,
formularies, and prior approval information could be accessed
and completed online with as little disruption to medical
practices as possible.
• Hospital – many systems
– Computer-based Provider Order Entry (CPOE)
– Electronic Medication Administration Record (eMAR)
– Clinical Data Repositories
– Ancillary Systems (Lab-chemistry, Lab-micro, Blood Bank, Radiology,
Pharmacy, Pathology, etc).
• Clinic
– Electronic Health Records (Electronic Medical Records)
– Practice Management System
• Patient : Personal Health Records
Health Information Technology

6. • Wide range of information system
• EHR can be used at primary, secondary & tertiary care
• Data can access at any time : Daily charting, Medication
administration, Nursing care plan, Physical examination, Diagnosis,
Tests, Procedures, Treatments, History, Findings etc
• Provide the important information for planning of health policy
• Data sharing has the potential to improve quality of health care by
reducing error & lowering cost.
Electronic Health Records

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Phlebotomy: Historical Practice

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11. • Phlebotomy is the most commonly performed procedure
worldwide
• Laboratory testing is a highly complex skill requiring expert
knowledge, and critical judgment
• Venipuncture is a frequent medical procedure.
• Phlebotomy errors may cause harm to patients or result in
needle prick injury to the phlebotomist
• Must be proactive

12. • Pre-analytical—Specimen collection, transport and processing,
storage, ethical clearance
• Analytical—Testing, Equipments, SOP, QA, method of assessing
quality of lab data
• Post- Post analytical—Testing results transmission,
interpretation, follow-up, Retesting, statistical evaluation of Lab
data
Stages of Laboratory Testing

13. The steps of the pre analytical phase
Preparation prior to
sampling
Sampling/handling
Storage/transport
Preparation prior to
analysis
The steps of the pre analytical phase

15. Collection of Sample
• Locate Patient
• Patient preparation
• Draw Sample
• Label
• Dispose of supplies
• Safety
The Pre-Analytical process

16. When identifying the patient, have them provide their full
name, address, identification number and/or date of birth.
Hospital No in patients should be wearing an identification
band with the above information, which the phlebotomist
should confirm before the venipuncture.
Patient identification

17. Test Collection
• Timing of Collection
– Therapeutic Drug Monitoring
• Peak and trough collection times
– Basal State Collections
• Fasting requirements—no food or liquid except water(9-
11h)
• 2h postprandial, from the start of food .
– Specimens affected by time of day, for example, cortisol,
iron and TSH.

21. Phlebotomy Technique
• Cleaning of venipuncture site
– Thorough cleaning with alcohol
– Allow alcohol to dry completely to avoid stinging sensation
upon needle entry and hemolysis of sample
– Samples such as blood cultures should be collected using
iodine to cleanse site to ensure sterility of sample
• Recollection rate for blood cultures ranges due to
contamination is as high as 50% in hospitals with
increased costs, patient overtreatment

22. Phlebotomy Technique Errors
• Tourniquet Application
• Tourniquet tied too close to the venipuncture site can cause
hematoma
• Veins may not become prominent if tourniquet is tied too high
(more than 3 to 4 inches above venipuncture site)
• Tourniquet left on longer than one minute can result in
hemoconcentration, affecting some test results
Tourniquet should be released as soon as needle is in the
lumen of the vein and blood flow established

25. 
×

26. • Patient Identification
• It is important to identify a patient accurately so that blood
is collected from the correct person.
• Drawing blood from the wrong person, or labeling the
correct patient’s sample with a different patient’s label can
certainly contribute to laboratory error. (Mislabeling ???)
Effects of Pre-analytical Variables

27. Pre-analytical errors
• Errors at any stage of the collection, testing and reporting
process can potentially lead to misdiagnosis
• Errors during the collection process are not predictable but
can be prevented with a thorough application of quality
control, continuing education and effective collection systems.

28. Association of errors
. and compromise
the diagnosis and
treatment of the
patient
• may influence
the quality of the
final measured
results ...
• Errors made in the
period prior to the
analysis of the
sample ...
It is better NOT to report

29. Factor Affecting Lab Result
• Some patient variables that affect test results
a) Age h) Genetic variation
b) Gender i) Nutrition status
c) Diet j) Diagnostic and therapeutic
d) Stress procedures, endoscopy
e) Exercise k) Obesity
f) Posture l) Tourniquet & fist pressure
g) Haemolysis, lipemia & icterus

31. Error Prevention
• Phlebotomy Education
– Phlebotomists should have completed a standard academic
course in phlebotomy and undergo thorough on-the-job
training under the supervision of a senior phlebotomist
• Continuing Education
– Phlebotomists should participate in regular educational
competency assessments (written and observational)
• Phlebotomy Staffing
– Adequate staffing to maintain collection standards
• Technology
– Use of barcode scanners for patient identification

32. Specimen Transport
Temperature
Light
Time

33. Blood Specimen Transport
• Transport of blood specimens in the proper manner after
collection ensures the quality of the sample
• Timing
– Some specimens must be transported immediately after
collection, for example Arterial Blood Gases.
– Specimens for serum or plasma chemistry testing should
be centrifuged and separated within two hours

34. Transport Errors
• Temperature
– Specimens must be transported at the appropriate
temperature for the required test
• On ice—ABGs, Ammonia
• Warmed -- (370 C), Cryoglobulins
• Avoid temperature extremes if transported via vehicle from other
collection site
• Transport Container
– Some samples need to be protected from light, for
example, Bilirubin, Vitamin A
– Transport in leak-proof plastic bags in lockable rigid
containers, avoid agitation.

35. Insufficient Mixing With Heparin
• Insufficient mixing can cause
coagulation of the sample
• It is recommended to mix the
blood sample thoroughly with
heparin
• Invert the syringe 10 times and
roll it between your palms

36. Although the
anticoagulants serve
many purposes, we
should keep in mind that
they are chemicals after
all and can interfere with
various tests !!!

37. • All blood collection tubes need to be filled to the correct
volume.
• This will ensure the proper amount of blood for the amount of
additive in the tube (blood to additive ratio).
• For example, if a 5 mL draw heparin tube is only filled with 3
mL of blood, the heparin concentration is erroneously high and
may potentially interfere with some chemistry analytes, tube
for Coagulation Studies incomplete filling results in specimen
dilution and erroneous Prothrombin and aPTT test results.
Correct Specimen Volume

38.  Inaccuracy in labeling of specimen
 Labeling lost during transport
 Transport media improperly prepared
 Specimen heated or cooled during transport
 Delays or inconsistent transport time
 Specimen lost during transport to laboratory
Transportation Errors : Specimen to Laboratory

39. Potential pre-analytical errors
Preparation
prior
to sampling
1. Misidentification of Patients
2. Mislabeling of specimen
3. Short draw /wrong anticoagulant/
blood ratio
4. Mixing problems/ clot
5. Wrong tube/ wrong anticoagulant
6. Hemolysis / lipemia
7. Hemoconcentration
8. Exposure to light/ extreme
temperature
9. Improperly timed specimen/ delayed
delivery to the lab
10. Processing errors: incomplete
centrifugation, incorrect log-in,
improper storage

40. • Certain chemistry analytes will require the tube of blood
to be chilled after collection in order to maintain the
stability of the analyte.
• A slurry of ice is recommended for chilling the tubes of
blood.
• Examples :
– Adrenocorticotropic hormone (ACTH)
– Angiotensin converting enzyme (ACE)
– Acetone
– Ammonia
– Catecholamines
– Free fatty acids
– Lactic acid
– Pyruvate
– Renin, PTH etc.
Special Handling of Blood Specimens:

41.  Keep precious biological samples safe and in a secure place
 Check and log freezers temperature daily.
 Locate samples quickly and easily through computer base program
to access sample reporting and retrieval easily.
 Retrieval and shipping of biological samples while maintaining the
cold environment.
 Trained and certified personnel with compliance to IATA, DOT and
ICAO regulations should ship the specimen.
•The process of collecting, maintaining, and sharing
biological samples is viewed as an essential tool in the
modern landscape of the genetic, medical, and behavioral
sciences and we should;
Storage, Repository or Biobank

42. Specimen Rejection
• Clotted
• Hemolyzed
• Underfilled,
overfilled
• Insufficient quantity
• Incorrect labeling
• Unlabeled specimen
• Incorrect patient
• Incorrect specimen
• Contaminated
• Lost sample
• Too old to process
• Broken and leaking

43. KIOSK
Advances

44. AdvancesBar Code Scanner

45. Collection site

46. Automation In Blood Collection

47. Management of Preanalytical phase
• Unnecessary Laboratory Testing
• Management of Test request
• Needle stick injury prevention
• Influence of physical activity
• Medical contrast media on in vitro diagnostic
testing
• Optimization of training
• Utilization of laboratory resources
• Concept of demand restriction and demand
adequacy

48. Clinical Question Biochemical Answer

49. Finally…
• The human role in sample collection makes
complete elimination of errors associated
with laboratory testing unrealistic
• However, good practices and compliance
with the new strategies for error prevention
can lead to a substantial reduction in pre-
analytical errors and cost in medical health
care at medical Institutions.

50. Quality system begins and ends
with the patient