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Pre-analytical source of errors

Written by Ramaz Mitaishvili

Saturday, 05 May 2007

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Pre-analytical source of errors
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by Dr. Ramaz Mitaishvili
Pre - analytical - involves all issues from test request to processing sample
Patient Identification and labeling
"zero tolerance" for patient misidentification (positive patient identification is the No. 1 step in the entire phlebotomy practice)
identification bracelet and room number
when the patient is comatose or cannot communicate NOTE: If any preanalytical errors occur, specimen can not be processed.
Specimen Identification Errors
Nothing is more basic to safe and effective patient care than ensuring that the caregiver is performing the right procedure on the intended patient. Misidentification of patients, laboratory specimens, surgical sites, and medications is a fundamental defect throughout the healthcare system, causing many preventable adverse events. The effects of misidentification can be catastrophic.
July 2004 - Officials at a Florida hospital acknowledge that a woman was infused with the wrong type of blood in June. The woman died about a day after receiving the erroneous transfusion, which happened because a blood sample was mislabeled.
July 2003 - A woman who switched beds to be closer to the window died after she was given the wrong type of blood during surgery at a Virginia hospital. A technician had taken a blood sample from her roommate.
The medical personnel will identify an inpatient by asking them to state and spell their full name and state their birth date (year, month and day)
The medical personnel will identify an inpatient for blood collection by use of the hospital identification bracelet on his/her person.
In situations where it is not feasible for a patient to have an identification bracelet on their person, for example burn patients, the medical personnel will obtain the identification of the patient from the attending nurse or physician prior to blood collection. The identifying personnel will sign a form indicating that they identified the patient.
Determination of name and DOB (Be sure to properly identify the patient.
a) Does the name patient spelled match requisition?
b) Does the name on the patient’s chart match the name on the patient’s identification?
c) If more than one patient is present with the same first and last name, how do you determine which one is the test patient? (Look for possible gender differences, social security number, patient identification number, birthdates, different middle name, and relevance of the test to the patient’s history).
Checking ID bracelet (Additional information helping in proper identification (room number, bed number, physician’s name, Medical Record number, examples when same last and first name, moved bed, different physicians and etc.)
ID discrepancies (double check, nurse notification, identity verification)
Missing ID bands and requisition

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Last Updated ( Thursday, 21 June 2007 )