檢體采集作業(yè)流程病人同意課件

謝文祥

檢驗(yàn)結(jié)果異常的原因分析與臨床因應(yīng)謝文祥檢驗(yàn)結(jié)果異常的原因分析與臨床因應(yīng)2013Hospital

NationalPatientSafety

GoalsIdentifypatientcorrectlyImprovestaffcommunicationUsemedicinessafelyPreventinfectionCheckpatientmedicinesIdentifypatientsafetyrisksPreventmistakesinsurgeryTheJointCommissionAccreditationHospital2013Hospital

NationalPatient2013Laboratory

NationalPatientSafetyGoalsIdentifypatientcorrectlyImprovestaffcommunicationPreventinfectionTheJointCommissionAccreditationLaboratory2013Laboratory

NationalPatien年度目標(biāo)的演進(jìn)93年五大目標(biāo)94年六大目標(biāo)95～96年八大目標(biāo)1.避免藥物錯誤1.提升用藥安全1.提升用藥安全2.落實(shí)院內(nèi)感染控制2.落實(shí)院內(nèi)感染控制2.落實(shí)醫(yī)療機(jī)構(gòu)感染控制3.杜絕手術(shù)錯誤、病人錯誤及手術(shù)程序錯誤3.提升手術(shù)正確性3.提升手術(shù)正確性4.避免病人辨識錯誤4.提升病人辨識的正確性4.提升病人辨識的正確性5.預(yù)防病人跌倒5.預(yù)防病人跌倒5.預(yù)防病人跌倒6.鼓勵異常事件通報6.鼓勵異常事件通報7.改善交接病人之溝通與安全8.提升民眾參與病人安全TaiwanJointCommissiononHospitalAccreditation

年度目標(biāo)的演進(jìn)93年五大目標(biāo)94年六大目標(biāo)95～96年八大目2008-2009年度目標(biāo)的演進(jìn)1.提升用藥安全2.落實(shí)醫(yī)療機(jī)構(gòu)感染控制3.提升手術(shù)安全4.預(yù)防病人跌倒及降低傷害程度5.鼓勵異常事件通報及資料正確性6.提升醫(yī)療照護(hù)人員間溝通的有效性7.鼓勵病人及其家屬參與病人安全工作8.提升管路安全TaiwanJointCommissiononHospitalAccreditation2008-2009年度目標(biāo)的演進(jìn)1.提升用藥安全Taiwan2010-2011年度目標(biāo)的演進(jìn)提升用藥安全落實(shí)醫(yī)療機(jī)構(gòu)感染控制

提升手術(shù)安全預(yù)防病人跌倒及降低傷害程度鼓勵異常事件通報及資料正確性

提升醫(yī)療照護(hù)人員間溝通的有效性鼓勵病人及其家屬參與病人安全工作提升管路安全加強(qiáng)醫(yī)院火災(zāi)預(yù)防與應(yīng)變TaiwanJointCommissiononHospitalAccreditation2010-2011年度目標(biāo)的演進(jìn)提升用藥安全TaiwanObjectivesIdentifythesignificantpre-analyticalerrorsthatcanoccurduringbloodspecimencollectionandtransport.Explainthevariousmeansofpre-analyticalerrorprevention.Listproactivestepstoreducepotentialpre-analyticalerrorsassociatedwithbloodcollectionandtransport.ObjectivesIdentifythesignifiIntroductionThreephasesoflaboratorytesting:pre-analytical,analytical,post-analyticalPre-analytical:specimencollection,transportandprocessingAnalytical:testingPost-analytical:testingresultstransmission,interpretation,follow-up,retestingIntroductionThreephasesoflPhlebotomyErrorsPhlebotomyisahighlycomplexskillrequiringexpertknowledge,dexterity,andcriticaljudgmentItisestimatedthatonebillionvein-puncturesareperformedannuallyintheU.S.PhlebotomyErrorsmaycauseharmtopatientsorresultinneedle-stickinjurytothePhlebotomistPhlebotomyErrorsPhlebotomyisPre-analyticalerrorsPre-andpost-analyticalerrorsareestimatedtoconstitute90%oferrorsErrorsatanystagesofthecollection,testingandreportingprocesscanpotentiallyleadtoaseriouspatientmisdiagnosisErrorsduringthecollectionprocessarenotinevitableandcanbepreventedwithadiligentapplicationofqualitycontrol,continuingeducationandeffectivecollectionsystemsPre-analyticalerrorsPre-andTypesofcollectionerrorsPatientIdentificationPhlebotomyTechniqueTestCollectionProceduresSpecimenTransportSpecimenProcessingTypesofcollectionerrorsPatiPatientIdentificationErrorsErrorsincorrectlyidentifyingthepatientareindefensibleReasonsforpatientidentificationerrors:ProperpositivepatientidentificationproceduresnotfollowedPatientidentificationfromidentificationbracelet(inpatients)Patientidentificationbyaskingpatienttostateorspelltheirfullname(inpatients/outpatients)Patientidentificationbystafforfamilymemberifpatientunabletoidentifyhim/herselfPatientIdentificationErrorsEPatientIdentificationErrorsSpecimentubesunlabeled:RequisitionorcollectiontubelabelsnotaffixedtotubesRequisitionorcollectiontubelabelsinbagcontainingcollectiontubesRequisitionorcollectiontubelabelsrubber-bandedtotubesCollectiontubelabelsnotaffixedtoalltubesSpecimencollectiontubeslabeledinsufficientlywithatminimumpatient’sfullname,date/timeofcollection,phlebotomist’sinitialsPatientIdentificationErrorsSPatientIdentificationErrorsCollectiontubeslabeledwiththewrongpatientWrongcomputerizedlabelsaffixedtocollectiontubesatbedsideCollectiontubesnotlabeledatthetimeofcollectionCollectiontubesincorrectlylabeledbysomeoneotherthanthephlebotomistwhocollectsthespecimenPatientIdentificationErrorsCPatientComplicationsSomepatientvariablesthataffectbloodspecimensDietFastingExerciseObesityAllergiestoalcoholoriodineusedtocleanvein-puncturesiteUsealternativecleansersuchaschlorhexidinPatientComplicationsSomepatiPhlebotomyTechniqueErrorsPhlebotomytechniqueisimportantEnsurestestresultvalidityMinimizestraumatopatientMinimizespotentialforphlebotomistinjuryReducesrecollectionsVeinselectionessentialforsuccessfulVein-punctureThreeveinsinantecubitalfossainorderofselection(1)mediancubital(2)cephalic(3)basilicPhlebotomyTechniqueErrorsPhlPhlebotomyTechniqueErrorsSiteSelectionAvoidsiteswithIVUsealternativearmordrawbelowIVtoavoidcontamination/dilutionfromIVDocumentarmifIVMastectomy—avoidsiteduetolymphostasisInfectionrisk/alterationinbodyfluidsandbloodanalytesEdematousareas—avoidduetoaccumulationofbodyfluidsPossiblecontamination/dilutionofspecimenPhlebotomyTechniqueErrorsSitPhlebotomyTechniqueErrorsVenousAccessDifficultiesObstructed,hardened,scarredveinsVeinsdifficulttolocateUseofAlternativesitesTopofhand/SideofwristAreastoavoidVeinCollapseUseofappropriateneedlesizeSmallerevacuatedcollectiontubePhlebotomyTechniqueErrorsVenPhlebotomyTechniqueErrorsTourniquetApplicationTourniquettiedtooclosetothevenipuncturesitecancausehematomaVeinsmaynotbecomeprominentiftourniquetistiedtoohigh(morethan3to4inchesabovevenipuncturesite)Tourniquetleftonlongerthanoneminutecanresultinhemoconcentration,affectingsometestresultsTourniquetshouldbereleasedassoonasneedleisinthelumenoftheveinandbloodflowestablishedPhlebotomyTechniqueErrorsTouPhlebotomyTechniqueErrorsCleansingofvenipuncturesiteThoroughcleaningwithalcoholAllowalcoholtodrycompletelytoavoidstingingsensationuponneedleentryandhemolysisofsampleSamplessuchasbloodculturesshouldbecollectedusingiodinetocleansesitetoensuresterilityofsampleRecollectionrateforbloodculturesrangesduetocontaminationisashighas50%inhospitalswithincreasedcosts,patientovertreatmentPhlebotomyTechniqueErrorsClePhlebotomyTechniqueErrorsCorrectcollectionsystemEvacuatedtubesystem(Vacutainer)forlargeveinsinantecubitalfossaSyringeforsmall,fragileveinsorveinsoutsideantecubitalfossaVenousaccessNeedleentryshouldbeat15to30degreesdependingondepthofveinNeedleentryshouldbeinsamedirectionasvein,centeredoverveinAnchorveintopreventmovementduringneedleentryandtoreducepaintopatientPhlebotomyTechniqueErrorsCorTestCollectionErrorsOrderofDrawOrderofdrawaffectsthequalityofthesampleandcanleadtoerroneoustestresultsduetocontaminationwiththeadditivefromthepreviousbloodcollectiontubeHemolysisBloodcollectedinsufficienttoamountofadditiveintubeTraumaticvenipunctureBloodcollectedfromareawithhematomaVigorousshakingoftubesaftercollectionMilkingthesitewhencollectingcapillarysamplesandbloodcollectedusingasmalldiameterneedle

TestCollectionErrorsOrderofTestCollectionErrorsTimingoffCollectionTimedDrawsTherapeuticDrugMonitoringPeakandtroughcollectiontimesBasalStateCollectionsFastingrequirements—nofoodorliquidexceptwaterSpecimensaffectedbytimeofday,forexample,cortisolTestCollectionErrorsTimingoTestCollectionErrorsImpropercollectiontubedrawnfortestorderedCollectiontubenotcompletelyfilledExample—lightbluetoptubeforCoagulationStudies.IncompletefillingresultsinspecimendilutionanderroneousProthrombinandaPTTtestresultsTestCollectionErrorsImproperTestCollectionErrorsCapillaryCollections—fingerstickorheelstickAppropriatesiteHeelstick—sidesofthebottomsurfaceoftheheelFingerstick—thirdorfourthfingers,perpendiculartofingerprintlinesonfleshypadsonfingersurfaceWarming—WarmbeforecollectiontoincreasecapillarybloodflownearskinsurfaceCleaning—cleansesitewithalcoholandallowtoairdryTestCollectionErrorsCapillarCapillaryCollectionsMassagingsitetoincreasebloodflowMilkingsitecancausehemolysisortissuefluidcontaminationFingersticks—rollfingerstowardfingertipat1stfingerjointseveraltimesHeelsticks—gentlysqueezeinfant’sheelbeforeperformingpuncture.PerformpuncturewhilefirmlysqueezingfingerorheelWipeawayfirsttwodropsofbloodEnsurethatfullblooddropwellsupeachtimeCapillaryCollectionsMassagingCapillaryCollectionsAvoidtouchingcapillarycollectiontubeormicrocollectiontubetoskinorscrapingskinsurfaceContaminatespuncturesiteBloodmaybecomehemolyzedMixingmicrocollectiontubeswithadditivefrequentlytoavoidmicroclotsCollectingtubeswithadditivesfirstProtectingtubesforbilirubinfromlightCapillaryCollectionsAvoidtouGoodSampleHandlingDrawthecorrectvolumeMix:It’sessentialAllowtimetoclotSpinunderthecorrectconditionsAspirate,Don’tpourRefertotheproductinsertorpackagelabelingsuppliedbythemanufactureofanybloodcollectionproductforcompleterecommendationsonsamplecollectionandprocessingReference:CLSI(H3-A6)2008/CLSI(H18-A3)2004

GoodSampleHandlingDrawthecBloodSpecimenTransportErrorsTransportofbloodspecimensinthepropermanneraftercollectionensuresthequalityofthesampleTimingSomespecimensmustbetransportedimmediatelyaftercollection,forexampleArterialBloodGases.SpecimensforserumorplasmachemistrytestingshouldbecentrifugedandseparatedwithintwohoursBloodSpecimenTransportErrorTransportErrorsTemperatureSpecimensmustbetransportedattheappropriatetemperaturefortherequiredtestOnice—ABGs,AmmoniaWarmed--98.6degrees(37C),cryoglobulinsAvoidtemperatureextremesiftransportedfromviavehiclefromothercollectionsiteTransportContainerSomesamplesneedtobeprotectedfromlight,forexample,bilirubinTransportinleak-proofplasticbagsinlockablerigidcontainersTransportErrorsTemperatureErrorPreventionPhlebotomyEducationPhlebotomistsshouldhavecompletedastandardacademiccourseinphlebotomyandundergothoroughon-the-jobtrainingunderthesupervisionofaseniorphlebotomistContinuingEducationPhlebotomistsshouldparticipateinregulareducationalcompetencyassessments(writtenandobservational)ProfessionalLicensurePhlebotomyStaffingAdequatestaffingtomaintaincollectionstandardsTechnologyUseofbarcodescannersforpatientidentificationErrorPreventionPhlebotomyEduQuestionsandDiscussionHowarepre-analyticalerrorspreventedinyourlaboratory?Whattechnologydoyouusetopreventhumanerror?Whatsystemsdoesyourhospitalusetopreventerrorsbynon-laboratorystaffcollectingblood?Whatpro-activeimprovementswouldreducethenumberofpre-analyticalerrors?QuestionsandDiscussionHowar檢體採集作業(yè)流程病人同意：醫(yī)療或研究需求？病人辨識：原則、方法(時機(jī)、頻率)病人保護(hù)：隱私、安全(消毒、暈針)衛(wèi)教說明：口頭、單張、媒體、手冊正確採集：檢體量、檢體種類保存?zhèn)魉停罕４鎰?抗凝劑)、溫度、包裝檢體訂定允收原則的必要與省思？檢體重採的限制與省思？TaiwanHospitalAssociation2007檢體採集作業(yè)流程病人同意：醫(yī)療或研究需求？TaiwanHo檢驗(yàn)前流程(程序)Pre-examinationProcedure(Process)檢驗(yàn)前流程(程序)EfficiencyandEffectiveness

(aboutQualityandUtility)SamplingIdentificationBarcodelabelingSingletube(CloseContainerSystem)InsideAliquot(Auto-Centrifugation)TLA(Auto-Transportation)EfficiencyandEffectiveness

案例一病人晚上掛急診，白血球(WBC)報告為630，第二天上午主治醫(yī)師請CCU再追蹤一次WBC，病人的報告為17530，因兩次報告差異大，所以CCU?？谱o(hù)理師打電話至檢驗(yàn)科，請醫(yī)檢師重驗(yàn)前一天於急診所驗(yàn)的WBC，但醫(yī)檢師表示因當(dāng)時所抽的血量不夠，無法再重驗(yàn)，所以也無法確認(rèn)前一天急診WBC報告是否正確?案例一病人晚上掛急診，白血球(WBC)報告為630，第二天抽錯病人編號錯誤(貼錯標(biāo)籤)血液稀釋血液凝固用錯試管(抗凝劑錯)操作錯誤/儀器故障(吸取不足)

儀器故障/試劑變質(zhì)報告填錯抽錯病人案例二病人因頭部鈍傷，頭暈至急診就醫(yī)，醫(yī)師診視後，給予打上點(diǎn)滴，抽CBC、生化檢驗(yàn)，隨後醫(yī)檢師通報危險值，告知醫(yī)師血紅素3.8，詢問病人表示平時無貧血癥狀且還有在捐血，故依照醫(yī)矚再抽第二次CBC，血紅素:13.3?案例二病人因頭部鈍傷，頭暈至急診就醫(yī)，醫(yī)師診視後，給予打上點(diǎn)抽錯病人編號錯誤(貼錯標(biāo)籤)血液稀釋血液凝固用錯試管(抗凝劑錯)操作錯誤/儀器故障(吸取不足)

儀器故障/試劑變質(zhì)報告填錯抽錯病人檢驗(yàn)流程(程序)ExaminationProcedure(Process)檢驗(yàn)流程(程序)EfficiencyandEffectiveness

(aboutQualityandUtility)CalibrationInternalQualityAssessment(QC)ExternalQualityAssessment(PT)EfficiencyandEffectiveness

案例三於03：53抽血aPTTdata180.4sec，當(dāng)時血液室電話告知通報危險值，護(hù)理人員立即告知主治醫(yī)師及住院醫(yī)師，主治醫(yī)師立即囑輸注FFP2UIVDst、vitK11ampIVDst，並請住院醫(yī)師追蹤aPTTprolong原因，住院醫(yī)師詳細(xì)評估後，囑recheckaPTT、PTdata，表示第二次追蹤若真的是有延長情形，預(yù)備檢驗(yàn)其他凝血功能。於05：39再驗(yàn)結(jié)果aPTT34.7sec、PT14.4sec（抽血時尚未執(zhí)行FFP及K1醫(yī)囑），電話詢問血液室人員為何兩次檢驗(yàn)數(shù)值差距大?檢驗(yàn)室人員才表示第一次檢驗(yàn)數(shù)值是因?yàn)闄C(jī)臺故障（未主動告知SICU），故第二次檢驗(yàn)數(shù)值才以人工計數(shù)執(zhí)行。[如何發(fā)現(xiàn)機(jī)臺故障，補(bǔ)救程序?yàn)楹?]案例三於03：53抽血aPTTdata180.4se抽錯病人編號錯誤(貼錯標(biāo)籤)血液稀釋血液凝固用錯試管(抗凝劑錯)操作錯誤/儀器故障(吸取不足)

儀器故障/試劑變質(zhì)報告填錯抽錯病人案例四病人3/28由ER入,因H/D3/30轉(zhuǎn)床,病人CPK、CK-MB、Troponin-I一直偏高所以Q6h追蹤。3/316:28Na:129、K:3.2、BUN:35、Cr:1.1、CPK:36,CK-MB:6、Troponin-I:0.04，早上7點(diǎn)向值班醫(yī)師報data時，值班醫(yī)師覺得報告值差異太大，囑咐護(hù)理人員再抽血重驗(yàn)一次CPK、CK-MB、Troponin-I，data為CPK:12364、CK-MB:268、Troponin-I:＞30，9點(diǎn)多檢驗(yàn)科人員來電表示，檢驗(yàn)科夜班人員可能做錯檢體，故要再重新做一次(用早上6點(diǎn)多的檢體)，10:17檢驗(yàn)人員再補(bǔ)發(fā)早上6:28報告為Na:142、K:3.9、BUN:21、Cre:3.1、CPK:12136、CK-MB:268、Troponin-I:＞30，已告知值班醫(yī)師及單位主管。[另一檢體也是錯誤，是否有處理？]案例四病人3/28由ER入,因H/D3/30轉(zhuǎn)床,病人CPK抽錯病人編號錯誤(貼錯標(biāo)籤)血液稀釋血液凝固用錯試管(抗凝劑錯)操作錯誤(拿錯檢體)/儀器故障(吸取不足)

儀器故障/試劑變質(zhì)報告填錯抽錯病人檢驗(yàn)後流程(程序)Post-examinationProcedure(Process)檢驗(yàn)後流程(程序)EfficiencyandEffectiveness

(aboutQualityandUtility)SystematicalReviewofResultsAuto-StorageofSamplesAuto-ValidationofResultsHRRR(Critical/AlertReports)EfficiencyandEffectiveness

案例五病人有滴注抗凝劑之藥物，醫(yī)囑開立需依計算aPTT之倍數(shù)來微調(diào)滴數(shù)，跨班人員發(fā)現(xiàn)檢驗(yàn)數(shù)值與前班之?dāng)?shù)據(jù)差距相當(dāng)大而發(fā)現(xiàn)前一班計算結(jié)果錯誤。[為何要算?]案例五病人有滴注抗凝劑之藥物，醫(yī)囑開立需依計算aPTT之倍數(shù)抽錯病人編號錯誤(貼錯標(biāo)籤)血液稀釋血液凝固用錯試管(抗凝劑錯)操作錯誤(拿錯檢體)/儀器故障(吸取不足)

儀器故障/試劑變質(zhì)報告填錯(計算錯誤)抽錯病人案例六因creatindata:7.0，醫(yī)師懷疑因藥物引起的急性腎衰竭，預(yù)安排腹部超音波及會診腎臟內(nèi)科，並停止抗生素的使用，但患者U/O:3.15ml/kg/hr，小便淡黃清澈，為慎重起見，醫(yī)囑再次抽血BUN/Cr，檢體送出後，檢驗(yàn)科人員電話告知，Crdata錯誤，正確值為0.7，值班醫(yī)師知情後，緊急停止所有相關(guān)檢查。[是否用新檢體?]案例六因creatindata:7.0，醫(yī)師懷疑因藥物引抽錯病人編號錯誤(貼錯標(biāo)籤)血液稀釋血液凝固用錯試管(抗凝劑錯)操作錯誤(拿錯檢體)/儀器故障(吸取不足)

儀器故障/試劑變質(zhì)報告填錯(計算錯誤)抽錯病人檢體可重做?YesorNo檢體重抽合宜嗎?YesorNo檢體可重做?YesorNo敬請指教EMMANUEL敬請指教EMMANUEL謝文祥

檢驗(yàn)結(jié)果異常的原因分析與臨床因應(yīng)謝文祥檢驗(yàn)結(jié)果異常的原因分析與臨床因應(yīng)2013Hospital

NationalPatientSafety

GoalsIdentifypatientcorrectlyImprovestaffcommunicationUsemedicinessafelyPreventinfectionCheckpatientmedicinesIdentifypatientsafetyrisksPreventmistakesinsurgeryTheJointCommissionAccreditationHospital2013Hospital

NationalPatient2013Laboratory

NationalPatientSafetyGoalsIdentifypatientcorrectlyImprovestaffcommunicationPreventinfectionTheJointCommissionAccreditationLaboratory2013Laboratory

NationalPatien年度目標(biāo)的演進(jìn)93年五大目標(biāo)94年六大目標(biāo)95～96年八大目標(biāo)1.避免藥物錯誤1.提升用藥安全1.提升用藥安全2.落實(shí)院內(nèi)感染控制2.落實(shí)院內(nèi)感染控制2.落實(shí)醫(yī)療機(jī)構(gòu)感染控制3.杜絕手術(shù)錯誤、病人錯誤及手術(shù)程序錯誤3.提升手術(shù)正確性3.提升手術(shù)正確性4.避免病人辨識錯誤4.提升病人辨識的正確性4.提升病人辨識的正確性5.預(yù)防病人跌倒5.預(yù)防病人跌倒5.預(yù)防病人跌倒6.鼓勵異常事件通報6.鼓勵異常事件通報7.改善交接病人之溝通與安全8.提升民眾參與病人安全TaiwanJointCommissiononHospitalAccreditation

年度目標(biāo)的演進(jìn)93年五大目標(biāo)94年六大目標(biāo)95～96年八大目2008-2009年度目標(biāo)的演進(jìn)1.提升用藥安全2.落實(shí)醫(yī)療機(jī)構(gòu)感染控制3.提升手術(shù)安全4.預(yù)防病人跌倒及降低傷害程度5.鼓勵異常事件通報及資料正確性6.提升醫(yī)療照護(hù)人員間溝通的有效性7.鼓勵病人及其家屬參與病人安全工作8.提升管路安全TaiwanJointCommissiononHospitalAccreditation2008-2009年度目標(biāo)的演進(jìn)1.提升用藥安全Taiwan2010-2011年度目標(biāo)的演進(jìn)提升用藥安全落實(shí)醫(yī)療機(jī)構(gòu)感染控制

提升手術(shù)安全預(yù)防病人跌倒及降低傷害程度鼓勵異常事件通報及資料正確性

提升醫(yī)療照護(hù)人員間溝通的有效性鼓勵病人及其家屬參與病人安全工作提升管路安全加強(qiáng)醫(yī)院火災(zāi)預(yù)防與應(yīng)變TaiwanJointCommissiononHospitalAccreditation2010-2011年度目標(biāo)的演進(jìn)提升用藥安全TaiwanObjectivesIdentifythesignificantpre-analyticalerrorsthatcanoccurduringbloodspecimencollectionandtransport.Explainthevariousmeansofpre-analyticalerrorprevention.Listproactivestepstoreducepotentialpre-analyticalerrorsassociatedwithbloodcollectionandtransport.ObjectivesIdentifythesignifiIntroductionThreephasesoflaboratorytesting:pre-analytical,analytical,post-analyticalPre-analytical:specimencollection,transportandprocessingAnalytical:testingPost-analytical:testingresultstransmission,interpretation,follow-up,retestingIntroductionThreephasesoflPhlebotomyErrorsPhlebotomyisahighlycomplexskillrequiringexpertknowledge,dexterity,andcriticaljudgmentItisestimatedthatonebillionvein-puncturesareperformedannuallyintheU.S.PhlebotomyErrorsmaycauseharmtopatientsorresultinneedle-stickinjurytothePhlebotomistPhlebotomyErrorsPhlebotomyisPre-analyticalerrorsPre-andpost-analyticalerrorsareestimatedtoconstitute90%oferrorsErrorsatanystagesofthecollection,testingandreportingprocesscanpotentiallyleadtoaseriouspatientmisdiagnosisErrorsduringthecollectionprocessarenotinevitableandcanbepreventedwithadiligentapplicationofqualitycontrol,continuingeducationandeffectivecollectionsystemsPre-analyticalerrorsPre-andTypesofcollectionerrorsPatientIdentificationPhlebotomyTechniqueTestCollectionProceduresSpecimenTransportSpecimenProcessingTypesofcollectionerrorsPatiPatientIdentificationErrorsErrorsincorrectlyidentifyingthepatientareindefensibleReasonsforpatientidentificationerrors:ProperpositivepatientidentificationproceduresnotfollowedPatientidentificationfromidentificationbracelet(inpatients)Patientidentificationbyaskingpatienttostateorspelltheirfullname(inpatients/outpatients)Patientidentificationbystafforfamilymemberifpatientunabletoidentifyhim/herselfPatientIdentificationErrorsEPatientIdentificationErrorsSpecimentubesunlabeled:RequisitionorcollectiontubelabelsnotaffixedtotubesRequisitionorcollectiontubelabelsinbagcontainingcollectiontubesRequisitionorcollectiontubelabelsrubber-bandedtotubesCollectiontubelabelsnotaffixedtoalltubesSpecimencollectiontubeslabeledinsufficientlywithatminimumpatient’sfullname,date/timeofcollection,phlebotomist’sinitialsPatientIdentificationErrorsSPatientIdentificationErrorsCollectiontubeslabeledwiththewrongpatientWrongcomputerizedlabelsaffixedtocollectiontubesatbedsideCollectiontubesnotlabeledatthetimeofcollectionCollectiontubesincorrectlylabeledbysomeoneotherthanthephlebotomistwhocollectsthespecimenPatientIdentificationErrorsCPatientComplicationsSomepatientvariablesthataffectbloodspecimensDietFastingExerciseObesityAllergiestoalcoholoriodineusedtocleanvein-puncturesiteUsealternativecleansersuchaschlorhexidinPatientComplicationsSomepatiPhlebotomyTechniqueErrorsPhlebotomytechniqueisimportantEnsurestestresultvalidityMinimizestraumatopatientMinimizespotentialforphlebotomistinjuryReducesrecollectionsVeinselectionessentialforsuccessfulVein-punctureThreeveinsinantecubitalfossainorderofselection(1)mediancubital(2)cephalic(3)basilicPhlebotomyTechniqueErrorsPhlPhlebotomyTechniqueErrorsSiteSelectionAvoidsiteswithIVUsealternativearmordrawbelowIVtoavoidcontamination/dilutionfromIVDocumentarmifIVMastectomy—avoidsiteduetolymphostasisInfectionrisk/alterationinbodyfluidsandbloodanalytesEdematousareas—avoidduetoaccumulationofbodyfluidsPossiblecontamination/dilutionofspecimenPhlebotomyTechniqueErrorsSitPhlebotomyTechniqueErrorsVenousAccessDifficultiesObstructed,hardened,scarredveinsVeinsdifficulttolocateUseofAlternativesitesTopofhand/SideofwristAreastoavoidVeinCollapseUseofappropriateneedlesizeSmallerevacuatedcollectiontubePhlebotomyTechniqueErrorsVenPhlebotomyTechniqueErrorsTourniquetApplicationTourniquettiedtooclosetothevenipuncturesitecancausehematomaVeinsmaynotbecomeprominentiftourniquetistiedtoohigh(morethan3to4inchesabovevenipuncturesite)Tourniquetleftonlongerthanoneminutecanresultinhemoconcentration,affectingsometestresultsTourniquetshouldbereleasedassoonasneedleisinthelumenoftheveinandbloodflowestablishedPhlebotomyTechniqueErrorsTouPhlebotomyTechniqueErrorsCleansingofvenipuncturesiteThoroughcleaningwithalcoholAllowalcoholtodrycompletelytoavoidstingingsensationuponneedleentryandhemolysisofsampleSamplessuchasbloodculturesshouldbecollectedusingiodinetocleansesitetoensuresterilityofsampleRecollectionrateforbloodculturesrangesduetocontaminationisashighas50%inhospitalswithincreasedcosts,patientovertreatmentPhlebotomyTechniqueErrorsClePhlebotomyTechniqueErrorsCorrectcollectionsystemEvacuatedtubesystem(Vacutainer)forlargeveinsinantecubitalfossaSyringeforsmall,fragileveinsorveinsoutsideantecubitalfossaVenousaccessNeedleentryshouldbeat15to30degreesdependingondepthofveinNeedleentryshouldbeinsamedirectionasvein,centeredoverveinAnchorveintopreventmovementduringneedleentryandtoreducepaintopatientPhlebotomyTechniqueErrorsCorTestCollectionErrorsOrderofDrawOrderofdrawaffectsthequalityofthesampleandcanleadtoerroneoustestresultsduetocontaminationwiththeadditivefromthepreviousbloodcollectiontubeHemolysisBloodcollectedinsufficienttoamountofadditiveintubeTraumaticvenipunctureBloodcollectedfromareawithhematomaVigorousshakingoftubesaftercollectionMilkingthesitewhencollectingcapillarysamplesandbloodcollectedusingasmalldiameterneedle

TestCollectionErrorsOrderofTestCollectionErrorsTimingoffCollectionTimedDrawsTherapeuticDrugMonitoringPeakandtroughcollectiontimesBasalStateCollectionsFastingrequirements—nofoodorliquidexceptwaterSpecimensaffectedbytimeofday,forexample,cortisolTestCollectionErrorsTimingoTestCollectionErrorsImpropercollectiontubedrawnfortestorderedCollectiontubenotcompletelyfilledExample—lightbluetoptubeforCoagulationStudies.IncompletefillingresultsinspecimendilutionanderroneousProthrombinandaPTTtestresultsTestCollectionErrorsImproperTestCollectionErrorsCapillaryCollections—fingerstickorheelstickAppropriatesiteHeelstick—sidesofthebottomsurfaceoftheheelFingerstick—thirdorfourthfingers,perpendiculartofingerprintlinesonfleshypadsonfingersurfaceWarming—WarmbeforecollectiontoincreasecapillarybloodflownearskinsurfaceCleaning—cleansesitewithalcoholandallowtoairdryTestCollectionErrorsCapillarCapillaryCollectionsMassagingsitetoincreasebloodflowMilkingsitecancausehemolysisortissuefluidcontaminationFingersticks—rollfingerstowardfingertipat1stfingerjointseveraltimesHeelsticks—gentlysqueezeinfant’sheelbeforeperformingpuncture.PerformpuncturewhilefirmlysqueezingfingerorheelWipeawayfirsttwodropsofbloodEnsurethatfullblooddropwellsupeachtimeCapillaryCollectionsMassagingCapillaryCollectionsAvoidtouchingcapillarycollectiontubeormicrocollectiontubetoskinorscrapingskinsurfaceContaminatespuncturesiteBloodmaybecomehemolyzedMixingmicrocollectiontubeswithadditivefrequentlytoavoidmicroclotsCollectingtubeswithadditivesfirstProtectingtubesforbilirubinfromlightCapillaryCollectionsAvoidtouGoodSampleHandlingDrawthecorrectvolumeMix:It’sessentialAllowtimetoclotSpinunderthecorrectconditionsAspirate,Don’tpourRefertotheproductinsertorpackagelabelingsuppliedbythemanufactureofanybloodcollectionproductforcompleterecommendationsonsamplecollectionandprocessingReference:CLSI(H3-A6)2008/CLSI(H18-A3)2004

GoodSampleHandlingDrawthecBloodSpecimenTransportErrorsTransportofbloodspecimensinthepropermanneraftercollectionensuresthequalityofthesampleTimingSomespecimensmustbetransportedimmediatelyaftercollection,forexampleArterialBloodGases.SpecimensforserumorplasmachemistrytestingshouldbecentrifugedandseparatedwithintwohoursBloodSpecimenTransportErrorTransportErrorsTemperatureSpecimensmustbetransportedattheappropriatetemperaturefortherequiredtestOnice—ABGs,AmmoniaWarmed--98.6degrees(37C),cryoglobulinsAvoidtemperatureextremesiftransportedfromviavehiclefromothercollectionsiteTransportContainerSomesamplesneedtobeprotectedfromlight,forexample,bilirubinTransportinleak-proofplasticbagsinlockablerigidcontainersTransportErrorsTemperatureErrorPreventionPhlebotomyEducationPhlebotomistsshouldhavecompletedastandardacademiccourseinphlebotomyandundergothoroughon-the-jobtrainingunderthesupervisionofaseniorphlebotomistContinuingEducationPhlebotomistsshouldparticipateinregulareducationalcompetencyassessments(writtenandobservational)ProfessionalLicensurePhlebotomyStaffingAdequatestaffingtomaintaincollectionstandardsTechnologyUseofbarcodescannersforpatientidentificationErrorPreventionPhlebotomyEduQuestionsandDiscussionHowarepre-analyticalerrorspreventedinyourlaboratory?Whattechnologydoyouusetopreventhumanerror?Whatsystemsdoesyourhospitalusetopreventerrorsbynon-laboratorystaffcollectingblood?Whatpro-activeimprovementswouldreducethenumberofpre-analyticalerrors?QuestionsandDiscussionHowar檢體採集作業(yè)流程病人同意：醫(yī)療或研究需求？病人辨識：原則、方法(時機(jī)、頻率)病人保護(hù)：隱私、安全(消毒、暈針)衛(wèi)教說明：口頭、單張、媒體、手冊正確採集：檢體量、檢體種類保存?zhèn)魉停罕４鎰?抗凝劑)、溫度、包裝檢體訂定允收原則的必要與省思？檢體重採的限制與省思？TaiwanHospitalAssociation2007檢體採集作業(yè)流程病人同意：醫(yī)療或研究需求？TaiwanHo檢驗(yàn)前流程(程序)Pre-examinationProcedure(Process)檢驗(yàn)前流程(程序)EfficiencyandEffectiveness

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