Studies show clinical laboratories still grapple with sub-optimal specimens from emergency departments and better phlebotomy skills are part of the solution

Improving the quality of medical laboratory specimens collected by the staff of emergency departments is an ongoing goal at most American hospitals. Now everyone associated with phlebotomy will be interested in a study released in the United Kingdom (UK) that recommends that emergency department doctors in that country would benefit from a refresher course on correct specimen collection technique.

Clinical laboratory managers and phlebotomists in most developed nations are well acquainted with the problem of faulty specimens sent from the emergency department. That is the problem highlighted by this UK study.

Hospitals Seek Safe and Efficient Clinical Laboratory Specimen Collection

The BBC News reported that the UK’s Association for Clinical Biochemistry has called for better training of physicians throughout the country to avoid mistakes in blood specimens taken in hospital A&E (accident and emergency) departments. For phlebotomists, in particular, the findings of this study will be particular interest.

In the United Kingdom, a study of problems in the collection of medical laboratory blood specimens was published by the Association for Clinical Biochemistry (ACB). The study was conducted at the Birmingham City Hospital in Birmingham, England. Researchers determined that, more than 50% of the junior doctors and nurses were collected using the wrong equipment. (photo copyright

In the United Kingdom, a study of problems in the collection of medical laboratory blood specimens was published by the Association for Clinical Biochemistry (ACB). The study was conducted at the Birmingham City Hospital in Birmingham, England. Researchers determined that, more than 50% of the junior doctors and nurses were collected using the wrong equipment. (photo copyright

The study was produced following an audit at Birmingham City Hospital (BCH), an acute care hospital in the West Midlands of England. Birmingham is England’s second most populated city.

“Junior doctors have surprisingly little training in taking blood,” stated Jonathan Berg, M.D., Director of Pathology at BCH. He was quoted by the BBC reporter and he helped to carry out the study. “This is an issue across the country.”

The Annals of Clinical Biochemistry published the study, which focused on the problem of mistakes in A&E specimen collection. Over a two-week period, researchers followed the collection of 50 samples from some of the most critical cases in the A&E. The specimens were collected by junior A&E doctors and nurses.

The study found that more than 50% of the clinical laboratory samples were collected with the wrong equipment, such as using syringes, instead of vacuum tubes with special needles. Researchers also found that about half of the samples were mishandled for laboratory testing, raising the risk of contamination.

ED Phlebotomy Standardization Is Key to Preventing Hemolysis

The UK is not alone in seeking to improve quality of specimen collection in fast-paced, high-pressure emergency departments (ED). Several studies have addressed this identical problem, with similar findings.

Study sites include the Department of Laboratory Medicine at the University Hospital of Padua, Italy, and the Albert Einstein School of Medicine and Montefiore Medical Center in New York, New York.

Additionally, the problem of poor quality laboratory test specimens has attracted the concern of healthcare leaders from various sectors. Medical technology and manufacturing company, Becton Dickinson (BD) (NYSE: BDX), weighed in on the issue in its clinical laboratory newsletter LabNotes. The Pennsylvania Patient Safety Authority issued a Patient Safety Advisory to bring attention to the problem. A former CEO of a large Boston hospital wrote a blog about two studies of problems with the proper collection of clinical laboratory specimens at his institution.

The following paragraphs summarize the findings and recommendations of these institutions. Some basic statistics presented in these papers are as follows:

  • Preanalytical errors have been reported to account for more than two-thirds of all laboratory errors.
  • Hemolyzed specimens are the most common reason for sample rejection and account for about 60% of rejected specimens. This is five times the second most common cause of rejection.
  • The rate of hemolysis in samples drawn in emergency departments exceeds those drawn by professional laboratory phlebotomists.

Hemolyzed specimens are a critical pre-analytical problem. Reducing the number of hemolyzed specimens requires well-designed and properly-implemented clinical laboratory guidelines and recommendations. Hemolysis of blood samples can cause inaccurate medical laboratory results, with corresponding delays in patient care, as well as erroneous diagnosis and inappropriate treatment.

The study at Albert Einstein looked at 4,021 patients. It examined hemolysis in two sample populations: a hospital medical ward and the ED. It also compared 202 blood-drawing techniques for hemolysis-causing factors. Additionally, the researchers performed a retrospective analysis of data on 2,992 chemistry panels from the ED and 1,029 from a routine medical ward in an acute teaching hospital, over a period of 11 weeks.

The study found that hemolysis among ED-drawn specimens was 12.4%, compared to 1.6% among specimens drawn by clinical laboratory personnel. It also found that “site of puncture” and wrong needle gauge were two main causes of hemolysis.

University of Padua researchers concluded that standardized protocols for blood drawing can reduce the rate of pre-analytic hemolysis by more than 7-fold.

Similarly, the Boston study showed a hemolysis rate for ED specimens of 22.4%, compared to 3.9% among inpatient units. The study also pointed out that, because patients’ hemolyzed specimens often had to be recollected and retested, wait time for results increased an average of 56 minutes.

The study also noted that ED staff worried about having to restick patients. This prompted ED staff to make blood draws from IV equipment. In fact, hemolysis necessitated resticks almost 30% of the time in the Boston study.

The Boston researchers also found that specimens collected during IV insertion showed a much higher rate of hemolysis, especially when using a vacutainer (which the authors noted was the preferred method in the ED at the time of the study).

The promotion of quality measures and continuous improvement of the total testing process is an essential element of an effective clinical laboratory service. Some medical laboratories are implementing solutions that improve the quality of laboratory specimens. These solutions range from retraining ED personnel to the standards of pathology venipuncture to having the clinical laboratory staff attend ED huddles. In this latter instance, it often requires setting aside departmental issues to achieve quality outcomes in specimen collection that inure to the benefit of all.

—Pamela Scherer McLeod

P.S: Pathology laboratory professionals in Europe and the UK who want to learn more about innovations in clinical laboratory and pathology management and operations will want to make plans to attend the annual Frontiers in Laboratory Medicine (FiLM) conference. It will take place in Birmingham, England on January 1-February 2, 2012. Now in its tenth year, FiLM is produced by The Association for Clinical Biochemistry and The Dark Report. Click here for the full agenda and to register, or visit the FiLM website
Related Information:

Call for more training to improve blood tests in A&E

Hemolyzed Specimens: A Reason for Rejection or a Clinical Challenge?

Hemolysis In ED Samples