I had the distinct pleasure recently of leading a small team of high-profile lab leaders---real movers and shakers in the laboratory industry---to write an opinion piece for the Annals of Blood. The issue: when should blood samples be labeled, before or after they are filled? I've summarized the arguments earlier in this month's issue, but I think you'd enjoy hearing the back story.

I'm no stranger to this dispute. As chairholder of the CLSI committee that recently revised the standard by which blood should be drawn for clinical testing, my committee was challenged to allow for tubes to be labeled prior to filling, breaking 27 years of precedent. It seemed healthcare professionals in some European countries routinely label tubes before they are filled as a matter of national policy (Sweden) or tradition (Germany). Since the standard my committee was revising was a global standard, it was a reasonable request.

At the end of the day, my committee's decision was unanimous: blood tubes must only be labeled after they are filled. 

While all this was playing out, the European Federation of Clinical Chemistry and Laboratory Medicine's Working Group on Preanalytics (EFLM-WGP) published a "call for harmonization" on the issue. I have engaged in a passionate but respectful discourse with EFLM-WGP representatives on the topic over the years; we've agreed to disagree. So I've heard all the arguments, which is why I embraced the opportunity to lead coagulation gurus George Fritsma and David McGlasson in writing the post-collection labeling position for Annals of Blood. 

Our first draft presented a compelling and passionate argument with plenty of references to back up our claims. I was more than a little stunned when it came back from the editor with a request: Revise it without the passion.

Without the passion? This is an opinion piece! I might be able to have a dispassionate opinion about my favorite flavor of ice cream (blue moon), but we're talking about a change in a medical procedure here that can precipitate serious medical mistakes. Mistakes that can even lead to patient death. Anyone who can write an opinion on such a matter without passion has no business writing it in the first place. Passion is required on such things. I was totally flummoxed.

But I got over it. We removed most of our "passion," but we admit it wasn't easy. After submitting a toned-down article, my coauthors and I all agreed it was a solid, albeit emotionless, position paper. The editor accepted it, and we all awaited the publication of the opposing view. It was released in November, equally devoid of passion. Not surprisingly, the authors misinterpreted the World Health Organization's Guidelines for Drawing Blood: Best Practices in Phlebotomy, Those who favor pre-collection labeling do so routinely. But if you look at page 19 in the WHO guideline, its step-by-step instructions on drawing blood from adults for laboratory testing shows the tube-labeling step as coming after the tube is filled. The sequence is repeated on Page 39 for pediatric draws, solidifying proof of the WHO's position. Only for blood donor draws does the WHO (oddly) suggest labeling tubes prior to filling. Therefore, if one were to say the WHO favors pre-collection labeling, they would be technically correct, but misleading, since the organization does not hold that position for diagnostic sampling. So we were not terribly surprised when our Annals counterparts claimed the WHO agrees with their position. But we were surprised the moderator let them slide.

Those who argue for pre-collection labeling also often claim the support of  two other European organizations: the European Federation of Clinical Chemistry and Laboratory Medicine, and the Italian Society of Clinical Biochemistry and Clinical Molecular Biology. That sounds pretty impressive until you scratch the surface and find those who are making the claim typically hold positions of significant influence with the same organizations. In reality, no scientific organization on the face of the earth thinks pre-collection labeling is a good idea.unless they have ties to those who claim their support.

I only call these things to your attention because this issue will not likely ever be resolved. In a world where it seems increasingly acceptable to package half-truths, and sometimes blatant misrepresentations, in hopes they will become blindly accepted by the masses as fact, I feel I need to call it out when I see it. My readers depend on the Center for Phlebotomy Education  to provide accurate information in all regards. To filter through the body of knowledge and present verifiable facts on all aspects of phlebotomy and preanalytic science. Whenever I can enlighten my readers as to the whole and complete picture, I feel it is my duty to do so.

The world will continue to label tubes differently and publications will continue to require careful reading and critical thinking. Since no study has shown precollection labeling reduces labeling errors or is safer for the patient, the rational to change a practice that has been the prevailing standard for nearly 30 years has to be beyond opinion. Even mine.

Respectfully,

Dennis J. Ernst MT(ASCP), NCPT(NCCT)
Editor