Klinisk Biokemi i Norden · 1 2017
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followed by item #10, where 13% did not use the
correct order of draw. At one phlebotomy session,
the patient identification process was not perfor-
med correct.
• At the hospital wards, the most frequent error was
also the new item #13 with 69% not inspecting
the venipuncture site correctly. The second-most
frequent was item #12, where 13% did not mix the
samples properly after drawing, followed by 11%
that did not use the correct order of draw (item #10).
The error frequencies that differed significantly
between the two phlebotomy settings (phlebotomy
ward and hospital ward) were items #13 (p=0.01), #12
(p=0.02), and #5 (p=0.03).
Differences between the pilot study and the follow-up
study
The number of phlebotomies with improper hand
hygiene were significantly lower in the follow-up
study, namely 10% vs 42% (both settings) in the pilot
study (p<0.01). Also, lack of tube mixing improved
from 19% at the phlebotomy ward to 3% (p<0.01)
and from 25% at the hospital wards to 13% (p=0.01).
Finally, the number of erroneous order of draw
declined significantly from 21% (mean for both set-
tings) to 12% (p=0.01). Unfortunately, the number of
samplings using the improper venipuncture device
(according to the standard operating procedure)
increased significantly from 8% to 20% at the phle-
botomy ward (0=0.01), while remaining unaltered at
the hospital wards.
Discussion
This observational study describes a continuously
used phlebotomy QC system based on the EFLMWG-
PRE guideline (9), first during an implementation
phase and later in a follow-up phase. The pilot study
revealed a number of items in need of focused atten-
tion and increased staff teaching, while the follow-up
study showed significant improvement for the three
major issues found in the pilot study, namely hand
hygiene, order of draw and mixing of samples. The
QC therefore seems to enable the laboratory to focus
on critical key issues, improve sampling quality, and
to ensure documentation of the sampling QC.
In the pilot study, hand hygiene was performed
erroneously in 42% of the phlebotomies performed at
both settings, while the follow-up study showed that
the error rate had declined significantly to 10%. In
comparison, the EFLMWG-PRE study revealed that
25.8% of the observed phlebotomies deviated from
the procedure recommended by CLSI regarding hand
hygiene (9). As the error frequency was the same at
the phlebotomy ward and at the hospitals ward, the
major reason does not seem to have been availability
of hand sanitizer, which one could have suspected, but
rather missing alertness on the issue. Hand hygiene
is traditionally regarded as the single most important
infection prevention, and all control measures availa-
ble must therefore be instituted to improve adherence
to the guidelines on this issue. Routine hand hygiene
audit by direct observation has been recommended in
order to identify local problems and improve practice
(
10
). This is however not specifically related to blood
sampling, but rather to health care personnel in gen-
eral and nurses in particular, where implementation
of automated group monitoring has been shown to
improve hand hygiene (
11
). Compatible with this we
found a significant improvement using the contin-
uous observational QC described here along with a
dedicated focus on the issue.
Another frequent error was the order of draw,
where 21% did not follow the correct procedure in
the pilot study (24% at the phlebotomy ward and 18%
at the hospital ward). There are no good explanation
for the significantly higher proportion of incorrect
draw-order at the phlebotomy clinic compared to the
hospital wards (p=0.03) as one would expect it to be
the opposite due to working conditions etc. However,
the actual difference in numbers are quite low (14 vs
12 phlebotomies), so it could be a coincidental differ-
ence. After the issue was addressed specifically, the
frequency of incorrect order of draw fell to 13% at the
phlebotomy ward and 11% at the hospital ward. This
is a little higher than the error frequency found in the
EFLM study (9), where 8.1% did not follow the cor-
rect order of draw, and a new procedure has therefore
recently been introduced, where the order of draw is
shown at the labels following the requisition, which
makes the correct order more evident. The impor-
tance of a specific order of draw as recommended in
the CLSI guideline H3-A6 (7) has often been ques-
tioned, and some studies has indicated that incorrect
order of draw under ideal phlebotomy conditions
does not cause contamination if a closed blood collec-
tion system is used (
12
,
13
). It is however evident that
a significant frequency of sample contamination does
occur (
14
,
15
), and as this study shows ideal phlebot-
