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Klinisk Biokemi i Norden · 1 2017
Figure 4.
Results from the follow-up study.
The numbers on the abscissa refer to
the observation items in Figure 2.
White bars: Blood sampling item con-
ducted erroneously at the phlebotomy
ward; black bars: Blood sampling item
conducted erroneously at hospital
wards.
Figure 3.
Results from the pilot study.
The numbers on the abscissa refer to
the observation items in Figure 1.
White bars: Blood sampling item con-
ducted erroneously at the phlebotomy
ward; black bars: Blood sampling item
conducted erroneously at hospital
wards.
frequent was that 24% did not follow the correct
order of draw (item #13), followed by improper
mixing of samples by 19% (item #15).
• At the hospital wards, the most frequent error was
also 42% performing hand hygiene erroneously
(item #3), while the second-most frequent was the
25% that did not mix the samples properly after
drawing blood (item #15). Finally, 18% did not
follow the correct order of draw (item #13). An
infrequent, but crucial error is the patient identi-
fication process, which was performed incorrect in
two instances at the hospital wards.
Altogether, the three most frequent errors were identi-
cal at the two settings. Two of them did however differ
significantly between the two phlebotomy settings,
as incorrect order of draw were more frequent at the
phlebotomy ward (p=0.04), while mixing of tubes
were more frequent at the hospital wards (p=0.04). No
other errors differed significantly between settings.
Follow-up study
In the follow-up study, a total of 84 phlebotomies, 30
at the phlebotomy ward and 54 at the hospital ward,
were performed by 34 different phlebotomists. The
errors are shown in Figure 4.
• At the phlebotomy ward, the by far most frequent
error was the new item #13, where only one out
of thirty inspected the venipuncture site for blee-
ding before sending the patient off (Figure 4). The
second-most frequent error was that 20% did not
use the appropriate venipuncture device (item #5),
