Associations between workplace affiliation and phlebotomy practices regarding patient identification and test request handling practices in primary healthcare centres: a multilevel model approach.

BACKGROUND: Clinical practice guidelines aim to enhance patient safety by reducing inappropriate variations in practice. Despite considerable efforts to enhance the use of clinical practice guidelines, adherence is often suboptimal. We investigated to what extent workplace affiliation explains variation of self-reported adherence to venous blood specimen collection regarding patient identification and test request handling practices, taking into consideration other primary healthcare centre and individual phlebotomist characteristics. METHODS: Data were collected through a questionnaire survey of 164 phlebotomy staff from 25 primary healthcare centres in northern Sweden. To prevent the impact of a large-scale education intervention in 2008, only baseline data, collected over a 3-month period in 2006-2007, were used and subjected to descriptive statistics and multilevel logistic analyses. RESULTS: In two patient identification outcomes, stable high median odds ratios (MOR) were found in both the empty model, and in the adjusted full model including both individual and workplace factors. Our findings suggest that variances among phlebotomy staff can be largely explained by primary healthcare centre affiliation also when individual and workplace demographic characteristics were taken in consideration. Analyses showed phlebotomy staff at medium and large primary healthcare centres to be more likely to adhere to guidelines than staff at small centres. Furthermore, staff employed shorter time at worksite to be more likely to adhere than staff employed longer. Finally, staff performing phlebotomy every week or less were more likely to adhere than staff performing phlebotomy on a daily basis. CONCLUSION: Workplace affiliation largely explains variances in self-reported adherence to venous blood specimen collection guidelines for patient identification and test request handling practices among phlebotomy staff. Characteristics of the workplace, as well as of the individual phlebotomist, need to be identified in order to design strategies to improve clinical practice in this and other areas.

Deviations from venous blood specimen collection guideline adherence among senior nursing students.

BACKGROUND: Despite considerable efforts to increase patient safety by supporting the use of best practice medical and nursing guidelines by healthcare staff, adherence is often suboptimal. Swedish nurses often deviate from venous blood specimen collection (VBSC) guideline adherence. We assessed the adherence to national VBSC guidelines among senior nursing students. METHODS: We conducted a cross-sectional, self-reported questionnaire survey among 101 out of 177 senior nursing students consisting of web-based students in their fifth semester and campus-based students in their fifth or sixth semester out of six. In regard to the VBSC procedures, we asked about adherence to the patient identification, test request handling, and test tube labelling protocols that the students had learned during their second semester and practiced thereafter. RESULTS: Guideline adherence to patient identification was reported by 81%, test request handling by 74%, and test tube labelling by 2% of the students. Students with no prior healthcare education reported to a higher extent that they operated within the guidelines regarding labelling the test tube before entering the patient's room compared to students with prior healthcare education. Using multiple logistic regression analysis, we found that fifth semester web-based program students adhered better to VBSC guidelines regarding comparing patient ID/test request/tube label compared to campus-based students. CONCLUSIONS: Senior nursing students were found to adhere to VBSC guidelines to a similar extent as registered nurses and other hospital ward staff in clinical healthcare. Thus student adherence to VBSC guidelines had deteriorated since their basic training in the second semester, and this can impact patient safety during university/clinical studies. The results of our study have implications for nursing practice education.

Impact of a large-scale educational intervention program on venous blood specimen collection practices.

BACKGROUND: Phlebotomy performed with poor adherence to venous blood specimen collection (VBSC) guidelines jeopardizes patient safety and may lead to patient suffering and adverse events. A first questionnaire study demonstrated low compliance to VBSC guidelines, motivating an educational intervention of all phlebotomists within a county council. The aim was to evaluate the impact of a large-scale educational intervention program (EIP) on primary health care phlebotomists' adherence to VBSC guidelines. We hypothesised that the EIP would improve phlebotomists' VBSC practical performance. METHODS: The present study comprise primary health care centres (n = 61) from two county councils in northern Sweden. The final selected study group consisted of phlebotomists divided into an intervention group (n = 84) and a corresponding control group (n = 79). Both groups responded to a validated self-reported VBSC questionnaire twice. The EIP included three parts: guideline studies, an oral presentation, and an examination. Non-parametric statistics were used for comparison within and between the groups. RESULTS: Evaluating the EIP, we found significant improvements in the intervention group compared to the control group on self-reported questionnaire responses regarding information search (ES = 0.23-0.33, p < 0.001-0.003), and patient rest prior to phlebotomy (ES = 0.27, p = 0.004). Test request management, patient identity control, release of venous stasis, and test tube labelling had significantly improved in the intervention group but did not significantly differ from the control group (ES = 0.22- 0.49, p = < 0.001- 0.006). The control group showed no significant improvements at all (ES = 0-0.39, p = 0.016-0.961). CONCLUSIONS: The present study demonstrated several significant improvements on phlebotomists' adherence to VBSC practices. Still, guideline adherence improvement to several crucial phlebotomy practices is needed. We cannot conclude that the improvements are solely due to the EIP and suggest future efforts to improve VBSC. The program should provide time for reflections and discussions. Furthermore, a modular structure would allow directed educational intervention based on the specific VBSC guideline flaws existing at a specific unit. Such an approach is probably more effective at improving and sustaining adherence to VBSC guidelines than an EIP containing general pre-analytical practices.

Minor improvement of venous blood specimen collection practices in primary health care after a large-scale educational intervention.

BACKGROUND: Venous blood specimen collection is a common health care practice that has to follow strict guidelines, non-compliance among sampling staff may compromise patient safety. We evaluated a large-scale 2 h educational intervention that emphasised guideline adherence to assess possible improvements of venous blood specimen collection practices. METHODS: Blood specimen haemolysis is usually caused by inadequate venous blood specimen collection and handling, reflecting overall pre-analytical handling. We monitored haemolysis of serum samples with haemolysis index corresponding to ≥ 150 mg/L of free haemoglobin for specimens sent from 11 primary health care centres and analysed on a Vitros 5,1 clinical chemistry analyser before (2008, n = 6652 samples) and after (2010, n = 6121 samples) the intervention. RESULTS: The total percentage of haemolysed specimens was 11.8 % compared to 10.5 % (p = 0.022) before the intervention. As groups, rural primary health care centres demonstrated a significant reduction [Odds ratios (OR) = 0.744] of haemolysed specimens after intervention, whereas urban primary health care centres demonstrated a significant increase (OR = 1.451) of haemolysis. CONCLUSIONS: A large-scale 2 h educational intervention to make venous blood specimen collection staff comply with guideline practices had minor effects on collection practices. Educational interventions may be effective in wards/care centres demonstrating venous blood specimen collection practices with larger deviations from guidelines.

A content validated questionnaire for assessment of self reported venous blood sampling practices.

BACKGROUND: Venous blood sampling is a common procedure in health care. It is strictly regulated by national and international guidelines. Deviations from guidelines due to human mistakes can cause patient harm. Validated questionnaires for health care personnel can be used to assess preventable "near misses"--i.e. potential errors and nonconformities during venous blood sampling practices that could transform into adverse events. However, no validated questionnaire that assesses nonconformities in venous blood sampling has previously been presented. The aim was to test a recently developed questionnaire in self reported venous blood sampling practices for validity and reliability. FINDINGS: We developed a questionnaire to assess deviations from best practices during venous blood sampling. The questionnaire contained questions about patient identification, test request management, test tube labeling, test tube handling, information search procedures and frequencies of error reporting. For content validity, the questionnaire was confirmed by experts on questionnaires and venous blood sampling. For reliability, test-retest statistics were used on the questionnaire answered twice. The final venous blood sampling questionnaire included 19 questions out of which 9 had in total 34 underlying items. It was found to have content validity. The test-retest analysis demonstrated that the items were generally stable. In total, 82% of the items fulfilled the reliability acceptance criteria. CONCLUSIONS: The questionnaire could be used for assessment of "near miss" practices that could jeopardize patient safety and gives several benefits instead of assessing rare adverse events only. The higher frequencies of "near miss" practices allows for quantitative analysis of the effect of corrective interventions and to benchmark preanalytical quality not only at the laboratory/hospital level but also at the health care unit/hospital ward.

Blood sample collection and patient identification demand improvement: a questionnaire study of preanalytical practices in hospital wards and laboratories.

UNLABELLED: Scand J Caring Sci; 2010; 24; 581-591 Blood sample collection and patient identification demand improvement: a questionnaire study of preanalytical practices in hospital wards and laboratories BACKGROUND: Most errors in venous blood testing result from human mistakes occurring before the sample reach the laboratory. AIMS: To survey venous blood sampling (VBS) practices in hospital wards and to compare practices with hospital laboratories. METHODS: Staff in two hospitals (all wards) and two hospital laboratories (314 respondents, response rate 94%), completed a questionnaire addressing issues relevant to the collection of venous blood samples for clinical chemistry testing. RESULTS: The findings suggest that instructions for patient identification and the collection of venous blood samples were not always followed. For example, 79% of the respondents reported the undesirable practice (UDP) of not always using wristbands for patient identification. Similarly, 87% of the respondents noted the UDP of removing venous stasis after the sampling is finished. Compared with the ward staff, a significantly higher proportion of the laboratory staff reported desirable practices regarding the collection of venous blood samples. Neither education nor the existence of established sampling routines was clearly associated with VBS practices among the ward staff. CONCLUSIONS: The results of this study, the first of its kind, suggest that a clinically important risk of error is associated with VBS in the surveyed wards. Most important is the risk of misidentification of patients. Quality improvement of blood sample collection is clearly needed, particularly in hospital wards.

Is the test result correct? A questionnaire study of blood collection practices in primary health care.

RATIONALE, AIMS AND OBJECTIVES: Venous blood tests are important for clinical decision making. Most errors in blood testing are due to human errors before the blood samples reach the laboratory. The present study was designed to investigate venous blood sampling (VBS) practices in primary health care centres (PHCs) compared with clinical laboratory staff. METHOD: A cross-sectional survey of 70 PHCs and two clinical laboratories is conducted. All staff responsible for VBS (317 respondents, response rate 94%) completed a questionnaire on VBS practices. RESULTS: Instructions for VBS were not followed in the surveyed PHCs. For example, only 54% reported that they always identified the patient by using name/Swedish identification number and only 5% reported that they always used photo-ID, the two preferred means for patient identification. Only 12% reported that they always released venous stasis as soon as possible. Fewer PHC staff than clinical laboratory staff reported correct VBS practices. For example, 54% of the PHC staff reported that they always identified the patient by name and Swedish identification number, as compared with 95% of the clinical laboratory staff (P < 0.001). Documented VBS routines and re-education in VBS were not clearly associated with reported correct VBS practices. CONCLUSIONS: In the surveyed PHCs, there are clinically important risks for misidentification of patients and erroneous test results, with consequences for the diagnosis and treatment of patients. Quality interventions, aimed at improving VBS practices, are needed to ensure patient safety.

Incident reporting practices in the preanalytical phase: Low reported frequencies in the primary health care setting.

OBJECTIVE: Incident reporting is commonly used to improve patient safety. The preanalytical phase of laboratory testing contains several manual error-prone tasks where mistakes can affect patient outcomes. However, the practical use of incident reports in this area has not been previously investigated in the primary health care setting, where the majority of the patients come in contact with health care. MATERIAL AND METHODS: All staff responsible for venous blood sampling in 70 primary health care centres and in two hospital clinical laboratories (317 respondents, response rate 94%) completed a questionnaire. RESULTS: Of the primary health care staff, 69% reported that they had never filed an incident report regarding venous blood sampling. Barriers for not filing incident reports often/always included lack of time (44%) and a complicated reporting procedure (27%). A higher proportion of staff with re-education (43%) had filed at least one incident report as compared to those without re-education (20%, p < 0.001). No differences in incident reporting practices were found between primary health care and hospital clinical laboratory staff. CONCLUSIONS: The investigated incident reporting system is likely to underreport incidents in the preanalytical phase. Therefore, the ability to discover preventable system vulnerabilities needs refinement.

Haemolysis index--an estimate of preanalytical quality in primary health care.

BACKGROUND: Haemolysis is usually caused by inadequate specimen collection or preanalytical handling, and is suggested to be a suitable indicator of pre-analytical quality. We investigated the prevalence of detectable haemolysis in all routine venous blood samples to identify differences in preanalytical quality. METHODS: Haemolysis index (HI) values were obtained from a Vitros 5,1 in the routine clinical chemistry laboratory for samples collected in primary health care centres (PHCs), nursing homes, and a hospital emergency department (ED). Haemolysis was defined as a HI > or =15 (detection limit). RESULTS: Samples from the PHC with the highest prevalence of haemolysis were 6.1 times (95% confidence interval (CI) 4.0-9.2) more often haemolysed compared to the centre with the lowest prevalence. Of the samples collected in primary health care, 10.4% were haemolysed compared to 31.1% in the ED (p<0.001). A notable difference in haemolysed samples was found between the ED section staffed by emergency medicine physicians and the section staffed by primary health care physicians (34.8% vs. 11.3%, p<0.001). CONCLUSIONS: The significant variation in haemolysis indices among the investigated units is likely to reflect varying preanalytical conditions. The HI is a valuable tool for estimation and follow-up of preanalytical quality in primary health care.

Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling.

BACKGROUND: Most errors in laboratory medicine occur in the preanalytical phase and are the result of human mistakes. This study investigated information search procedures, test request management and test tube labelling in primary healthcare compared to the same procedures amongst clinical laboratory staff. METHODS: A questionnaire was completed by 317 venous blood sampling staff in 70 primary healthcare centres and in two clinical laboratories (response rate = 94%). RESULTS: Correct procedures were not always followed. Only 60% of the primary healthcare staff reported that they always sought information in the updated, online laboratory manual. Only 12% reported that they always labelled the test tubes prior to drawing blood samples. No major differences between primary healthcare centres and clinical laboratories were found, except for test tube labelling, whereby the laboratory staff reported better practices. Re-education and access to documented routines were not clearly associated with better practices. CONCLUSIONS: The preanalytical procedure in the surveyed primary healthcare centres was associated with a risk of errors which could affect patient safety. To improve patient safety in laboratory testing, all healthcare providers should survey their preanalytical procedures and improve the total testing process with a systems perspective.

Preanalytical effects of pneumatic tube transport on routine haematology, coagulation parameters, platelet function and global coagulation.

BACKGROUND: Pneumatic tube transport of blood samples reduces turnaround times and labour. However, the preanalytical effects on new clinical chemistry parameters and instruments are not fully known. The aim of this study was to evaluate the effect of pneumatic tube transport on haematology and coagulation parameters, including platelet function with PFA-100, and global coagulation with a thromboelastograph. METHODS: Paired venous blood samples from healthy volunteers were obtained before and after 1 week of treatment with acetylsalicylic acid. One sample was transported by pneumatic tube transport, while the other remained in the laboratory. RESULTS: No preanalytical effect of pneumatic tube transport could be seen for most haematology and coagulation parameters, as well as analysis with PFA-100. For the thromboelastographic analysis, time to clot formation was shorter (-16%, p=0.037) in the transported samples. Treatment with acetylsalicylic acid had no effect on the majority of the test results. CONCLUSIONS: Pneumatic tube transport does not introduce preanalytical errors when transporting samples for analysis of routine haematology, coagulation parameters and platelet function with the PFA-100. We recommend manual transport of samples for analysis with thromboelastographic techniques.

Preanalytical venous blood sampling practices demand improvement--a survey of test-request management, test-tube labelling and information search procedures.

BACKGROUND: Most errors in laboratory medicine are preanalytical in nature. In the present study, we aimed to survey preanalytical steps in venous blood sampling, prior to actual sample collection. These steps included test-request management and test-tube labelling, as well as information search procedures. METHODS: Venous blood sampling staff (n=314, response rate 94%) in hospital wards and laboratories completed a questionnaire related to clinical chemistry testing. RESULTS: Instructions for test-request management and test-tube labelling were not always followed. For example, only 66% of the ward staff reported always checking the test-request if someone else completed it, compared to 90% of the laboratory staff (p=0.003). As few as 16% of the ward staff reported desirable practices regarding test-tube labelling, compared to 100% of the laboratory staff (p<0.001). Furthermore, 18% of the ward staff reported always using online manuals (the only source of updated information), compared to 63% of the laboratory staff (p<0.001). CONCLUSIONS: Our results indicate a substantial risk of preanalytical error in test-request management, test-tube labelling, and information search practices, particularly in the wards. Our findings thus underscore the importance of quality control in venous blood sampling, in order to increase patient safety in modern health care.