Download - Specimen Procurement Complications & QA 2011
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VPML 120 2011 ComplicationsVPML 120 2011 Complications 11
SPECIMENSPECIMEN
PROCUREMENTPROCUREMENT
VPML 120VPML 120Complications and Procedural ErrorsComplications and Procedural Errors
Quality AssuranceQuality Assurance
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ObjectivesObjectives
By the end of this class, the learner will be acquire theBy the end of this class, the learner will be acquire theknowledge aboutknowledge about
Procedural errors that lead to failure to draw bloodProcedural errors that lead to failure to draw blood
Complications and errors that adversely affect the patientComplications and errors that adversely affect the patient
Complications related to patient conditionsComplications related to patient conditions
Site selection variables that affect specimen qualitySite selection variables that affect specimen quality
Dealing with special populations of patientsDealing with special populations of patients
Occupational hazards to phlebotomistsOccupational hazards to phlebotomists
Quality assurance in phlebotomyQuality assurance in phlebotomy
Watch a video on venipunctureWatch a video on venipuncture
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Procedural Errors thatProcedural Errors that
Lead to Failure to Draw BloodLead to Failure to Draw Blood
Tube position and vacuumTube position and vacuum
Needle positionNeedle position
bevel against the vein wallbevel against the vein wall
too deeptoo deep
not deep enoughnot deep enough
beside the veinbeside the vein
undeterminedundetermined
Collapsed veinCollapsed vein
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Proper & Improper NeedleProper & Improper NeedlePositioningPositioning
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Limitations to Needle ManipulationLimitations to Needle Manipulation
by CLSIby CLSI When a blood sample cannot be obtained afterWhen a blood sample cannot be obtained after
a venipuncture attempt:a venipuncture attempt:
Pull the needle back a bit, or advance it further, orPull the needle back a bit, or advance it further, or
rotate half a turnrotate half a turn
Lateral needle relocation should never beLateral needle relocation should never beattempted on basilic vein, since the brachial arteryattempted on basilic vein, since the brachial arteryand nerves are in close proximityand nerves are in close proximity
Try another tube to ensure the tube selected is notTry another tube to ensure the tube selected is notdefectivedefective
Manipulation other than this is considered probingManipulation other than this is considered probing
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Complications and ErrorsComplications and Errors
Adversely Affecting the PatientAdversely Affecting the Patient Hematoma formationHematoma formation
Inadvertent arterial punctureInadvertent arterial puncture
Iatrogenic anemia: in infantsIatrogenic anemia: in infants-- >10% blood volume>10% blood volume Infection of veins: improper aseptic techniqueInfection of veins: improper aseptic technique--
PhlebitisPhlebitis
Nerve damageNerve damage
PainPain Reflux of anticoagulantReflux of anticoagulant
Vein damageVein damage
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Complications and ErrorsComplications and Errors
Adversely Affecting the PatientAdversely Affecting the Patient Hematoma formation:Hematoma formation:
Most common complicationMost common complication
Caused by blood leakage in tissue causing swellingCaused by blood leakage in tissue causing swelling
Causes bruising, compression injuries to nervesCauses bruising, compression injuries to nerves
Immediately release tourniquet, withdraw the needle, holdImmediately release tourniquet, withdraw the needle, hold
pressure at the site for at least 2 minpressure at the site for at least 2 min
Inadvertent arterial punctureInadvertent arterial puncture
Not commonNot common
Brachial artery close to basilic veinBrachial artery close to basilic vein
Hold the site for at least 5 minHold the site for at least 5 min
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Complications and ErrorsComplications and Errors
Adversely Affecting the PatientAdversely Affecting the Patient Nerve damageNerve damage ? Law suit? Law suit
Poor site selectionPoor site selection
Excessive blind probingExcessive blind probing
Vein damageVein damage::
repeated venipuncture at therepeated venipuncture at thesame sitesame site
PainPain
Some pain is always thereSome pain is always there
Reduce sting by dryingReduce sting by drying
alcohol before venipuncturealcohol before venipuncture
Avoid probingAvoid probing
IontophoresisIontophoresis lidocaine withlidocaine witha small current for 15a small current for 15--20 min20 min
Anticoagulant refluxAnticoagulant reflux Occurs when contents of theOccurs when contents of the
tube are in contact with needletube are in contact with needle
To prevent, always keepTo prevent, always keep
patients arm in downwardpatients arm in downwardpositionposition
Some patients may haveSome patients may haveadverse reaction to tubeadverse reaction to tubeadditives, esp EDTAadditives, esp EDTA
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Procedural ErrorsProcedural Errorsthat Affect Specimen Qualitythat Affect Specimen Quality
Hemoconcentration/Hemoconcentration/
Venous StasisVenous Stasis
Stagnation of blood flowStagnation of blood flow
Prolonged tourniquetProlonged tourniquetapplicationapplication
Plasma filters into tissuePlasma filters into tissue
HemolysisHemolysis
Unclean venipunctureUnclean venipuncture
Vigorous shakingVigorous shaking Unsuitable for tests such as K,Unsuitable for tests such as K,
Mg, enzymes, red cell countsMg, enzymes, red cell counts
Will Hgb be affected?Will Hgb be affected?
Partially Filled TubesPartially Filled Tubes
short drawsshort draws--partially filledpartially filled
tubestubes
Blood/anticoag ratio alteredBlood/anticoag ratio altered
Especially critical forEspecially critical for
coagulation studies LIGHTcoagulation studies LIGHT
BLUE (CITRATE) TUBEBLUE (CITRATE) TUBE
Specimen ContaminationSpecimen Contamination
alcoholalcohol PovidonePovidone high uric acid, Khigh uric acid, K
affects bacteria in theaffects bacteria in the
specimenspecimen
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ComplicationsComplications
Related to Patient ConditionsRelated to Patient Conditions Allergies to Antiseptics, AdhesivesAllergies to Antiseptics, Adhesives
Allergies to LatexAllergies to Latex
Excessive BleedingExcessive Bleeding
Fainting (Syncope)Fainting (Syncope)
Nausea/VomitingNausea/Vomiting
ObesityObesity PetechiaePetechiae
Seizures/ConvulsionSeizures/Convulsion
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ComplicationsComplications
Related to Patient ConditionsRelated to Patient Conditions Fainting (syncope)Fainting (syncope)
History of fainting, feeling week due to fastingHistory of fainting, feeling week due to fasting
Remove tourniquet, withdraw needleRemove tourniquet, withdraw needle Keep talking to the patient, have him/her lower theKeep talking to the patient, have him/her lower the
head in between legs, support patienthead in between legs, support patient
Loosen tight clothesLoosen tight clothes tie, tight collartie, tight collar
Apply cold compress/washcloth to back of theApply cold compress/washcloth to back of the
neck/foreheadneck/forehead no ammoniano ammonia
Call for designated firstCall for designated first--aid personnelaid personnel
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ComplicationsComplications
Related to Patient ConditionsRelated to Patient Conditions Nausea/vomittingNausea/vomitting
Nausea often precedes vomitingNausea often precedes vomiting
Ask patient to breathe slowly and deeplyAsk patient to breathe slowly and deeply
Apply cold compress/washclothApply cold compress/washcloth Give an emesis basinGive an emesis basin
Notify appropriate personnelNotify appropriate personnel
SeizureSeizure
Remove the needle immediately, press the siteRemove the needle immediately, press the site Restrict movements, do not put anything in the mouthRestrict movements, do not put anything in the mouth
Call for appropriate medical helpCall for appropriate medical help
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SITE SELECTION VARIABLES THATSITE SELECTION VARIABLES THAT
INFLUENCE SPECIMENINFLUENCE SPECIMEN
COMPOSITIONCOMPOSITION Physical Problem Areas to AvoidPhysical Problem Areas to Avoid
Burns, scars, and tattoosBurns, scars, and tattoos
Damaged veinsDamaged veins
SclerosedSclerosed hard, cordlikehard, cordlike
ThrombosedThrombosed recent clot formationrecent clot formation
EdemaEdema
HematomaHematoma MastectomyMastectomy
Lymphostasis, painLymphostasis, pain
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Vascular Access Areas &Vascular Access Areas &
Devices to Avoid in Site SelectionDevices to Avoid in Site Selection IV SitesIV Sites
Previously Active IV SitesPreviously Active IV Sites
Arterial LinesArterial Lines
AV Shunts (Fistulas)AV Shunts (Fistulas)
Heparin or Saline LocksHeparin or Saline Locks
Vascular Access DevicesVascular Access Devices
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Vascular Access Areas &Vascular Access Areas &
Devices to Avoid in Site SelectionDevices to Avoid in Site Selection IV sitesIV sites
Blood should be collected from the other armBlood should be collected from the other arm
If unavailable, draw blood from BELOW
the IVIf unavailable, draw blood from BELOW
the IVsite, never abovesite, never above specimen dilutionspecimen dilution
Request nurse to stop IV fluid for 2 min beforeRequest nurse to stop IV fluid for 2 min before
collectioncollection
Record on the requisitionRecord on the requisition
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Vascular Access Areas &Vascular Access Areas &
Devices to Avoid in Site SelectionDevices to Avoid in Site Selection AV Shunts or FistulasAV Shunts or Fistulas
Surgical procedure to fuse vein and artery together, usuallySurgical procedure to fuse vein and artery together, usuallyfor dialysisfor dialysis
Can be easily felt under the skinCan be easily felt under the skin NEVER apply tourniquet on a shuntNEVER apply tourniquet on a shunt
Heparin/saline locksHeparin/saline locks
Cannula left in patients vein for up to 48 hrsCannula left in patients vein for up to 48 hrs
Used for IV medication
Used for IV medication
Should be avoided as far as possibleShould be avoided as far as possible
Always draw 5 ml DISCARD TUBE before bloodAlways draw 5 ml DISCARD TUBE before bloodcollectioncollection
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Vascular Access Areas &Vascular Access Areas &
Devices to Avoid in Site SelectionDevices to Avoid in Site SelectionVascular Access DeviseVascular Access Devise
A vascular access catheter is a long, thin tubeA vascular access catheter is a long, thin tubethat is placed in a vein in the arm, in the neckthat is placed in a vein in the arm, in the neckor in the chest just beneath the collarbone.or in the chest just beneath the collarbone.
These soThese so--calledcalled central catheterscentral catheters can remaincan remainin place for weeks, months or even years.in place for weeks, months or even years.
Blood from VADBlood from VAD blood cultureblood culturecontamination, air embolism, hemolysis,contamination, air embolism, hemolysis,infection, dilution of specimeninfection, dilution of specimen
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Inability to Obtain SpecimenInability to Obtain Specimen Procedure for failure to get bloodProcedure for failure to get blood
evaluate situationevaluate situation
find new locationfind new location
only two attempts allowedonly two attempts allowed
never probenever probe
Patient unavailablePatient unavailable
Patient refusesPatient refuses Follows QA procedures in reportingFollows QA procedures in reporting
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Geriatric VenipunctureGeriatric Venipuncture
ChallengesChallenges
Skin changesSkin changes
Hearing impairmentHearing impairment Visual impairmentVisual impairment
Mental impairmentMental impairment
Effects of diseaseEffects of disease
Infection of veinInfection of vein --
phlebitisphlebitis
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VPML 120 2011 ComplicationsVPML 120 2011 Complications 2020
Effects of DiseaseEffects of Disease
Diseases that affect elderlyDiseases that affect elderly
ArthritisArthritis
Coagulation problemsCoagulation problems
DiabetesDiabetes
Parkinsons and strokeParkinsons and stroke
Pulmonary function problemsPulmonary function problems
Other problems:Other problems:
Loss of immune functionsLoss of immune functions
Poor nutritionPoor nutrition
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Special Population PatientsSpecial Population Patients
LongLong--Term CareTerm Care
PatientsPatients
Home Care PatientsHome Care Patients Traveling phlebotomistTraveling phlebotomist
Brings necessaryBrings necessary
supplies to patientsupplies to patient
Hospice PatientsHospice Patients--
terminally illterminally ill
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Occupational Hazard toOccupational Hazard to
PhlebotomistsPhlebotomists
Occupational exposure to bloodbourneOccupational exposure to bloodbourne
pathogenspathogens
Skin pierced by a contaminated sharpSkin pierced by a contaminated sharp
object/needleobject/needle
Blood or other body fluid splashed into eyes, nose,Blood or other body fluid splashed into eyes, nose,
mouthmouth
Blood or other body fluid comes in contact with aBlood or other body fluid comes in contact with acut, scratch, abrasioncut, scratch, abrasion
A human bite breaks the skinA human bite breaks the skin
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Procedure for Needlesticks andProcedure for Needlesticks and
other Exposure Incidentsother Exposure Incidents
Phlebotomists responsibilityPhlebotomists responsibility
Immediately decontaminate needlestick site withImmediately decontaminate needlestick site with
povidonepovidone--iodine for at least 30 seciodine for at least 30 sec
If mucous membrane exposed, flush with water forIf mucous membrane exposed, flush with water for
at least 10 minat least 10 min
Report the incident to supervisorReport the incident to supervisor
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Employers responsibilityEmployers responsibility
: Medical evaluation: Medical evaluation
Employees blood tested for HIVEmployees blood tested for HIV
Source patients blood tested for HIV, HBVSource patients blood tested for HIV, HBV patientspatients
permission requiredpermission required If source patient refuses or HBV positive, employee is givenIf source patient refuses or HBV positive, employee is given
immune globulin/HBV vaccineimmune globulin/HBV vaccine
If source is HIV positive, employee is counseled and tested forIf source is HIV positive, employee is counseled and tested for
HIV immediately, and atHIV immediately, and at 6 weeks, 12 weeks, 6 months and 12 months after exposure6 weeks, 12 weeks, 6 months and 12 months after exposure
Employee may be given HIV therapy viz azidothymidine(AZT)Employee may be given HIV therapy viz azidothymidine(AZT)
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QualityAssuranceinQualityAssurancein
HealthcareHealthcareQuality improvement (QI) process is part ofQuality improvement (QI) process is part of
accreditation requirements for all types of healthcareaccreditation requirements for all types of healthcare
facilities and found in every aspect of healthcare.facilities and found in every aspect of healthcare.
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Process/OutcomesProcess/Outcomes
Outcome only gives us numbersOutcome only gives us numbers
Process tells how to change outcomesProcess tells how to change outcomes E.g. how many redraws in a month?E.g. how many redraws in a month?
QC DefinedQC Defined A component of a QA processA component of a QA process
A form of procedure controlA form of procedure control
Example:Example:phlebotomy QC involves checking operationphlebotomy QC involves checking operation
proceduresprocedures
QA in PhlebotomyQA in Phlebotomy(continued)(continued)
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Areas in PhlebotomyAreas in PhlebotomySubject to QCSubject to QC
Patient Preparation ProceduresPatient Preparation Procedures
LaboratoryUser ManualLaboratoryUser Manual describes patientdescribes patientpreparation and other special instructions forpreparation and other special instructions for
specimen collectionspecimen collection Specimen Collections ProceduresSpecimen Collections Procedures
IdentificationIdentification
EquipmentEquipment
Puncture DevicesPuncture Devices
Evacuated TubesEvacuated Tubes
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Specimen Collection ProceduresSpecimen Collection Procedures
LabelingLabeling Must be exactMust be exact
Computer labels mayComputer labels mayassure accuracyassure accuracy
Specimen TubeSpecimen Tubewith Barcode Labelwith Barcode Label
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TechniqueTechnique
Incident ReportIncident Report
Collection PrioritiesCollection Priorities
Delta ChecksDelta Checks
Compares current results of a lab test with previousCompares current results of a lab test with previous
results for same test on same patientresults for same test on same patient
Specimen Collection ProceduresSpecimen Collection Procedures(continued)(continued)
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PrePre--analytical Errors:analytical Errors:Before CollectionBefore Collection
Patient misidentificationPatient misidentification
Improper time of collectionImproper time of collection
Wrong tubeWrong tube NonNon--sterile site preparationsterile site preparation
Improper patient preparationImproper patient preparation
Inadequate fastInadequate fast ExerciseExercise
No coordination with medicationNo coordination with medication
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PrePre--analytical Errors:analytical Errors:During CollectionDuring Collection
Prolonged tourniquet timeProlonged tourniquet time
HemolysisHemolysis
Order of drawOrder of draw Failure to mix tubes with anticoagulantFailure to mix tubes with anticoagulant
Faulty techniqueFaulty technique
Underfilling tubesUnderfilling tubes
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PrePre--analytical Errors:analytical Errors:After CollectionAfter Collection
Failure to separate serum from cells in timeFailure to separate serum from cells in time
Improper use of serum separatorsImproper use of serum separators
Processing delaysProcessing delays Exposure to lightExposure to light
Improper storage conditionsImproper storage conditions
Rimming clotsRimming clots
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Tube Handling ErrorsTube Handling Errors
Manually pouring contents from one tube to anotherManually pouring contents from one tube to another
Vigorous mixingVigorous mixing
Incorrect order of drawIncorrect order of draw
Manually removing additive (exception?)Manually removing additive (exception?)
Removing a clot from a tube containing anticoagulantRemoving a clot from a tube containing anticoagulant sending the specimensending the specimen
Underfilling tubes with anticoagulantUnderfilling tubes with anticoagulant
Overfilling tubes with additivesOverfilling tubes with additives
Recentrifuging a gel tubeRecentrifuging a gel tube
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Accreditation standards require facility toAccreditation standards require facility to
show documentation on all QC checksshow documentation on all QC checks
Quality Assurance FormsQuality Assurance Forms Equipment Check FormsEquipment Check Forms
Internal ReportsInternal Reports
Incident ReportsIncident Reports
Employee Action RecordEmployee Action Record
Occurrence ReportsOccurrence Reports
DocumentationDocumentation
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Incident ReportIncident Report