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Phlebotomy Today

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June, 2015

Establishing a Preanalytical Quality Officer
The Empowered Healthcare Manager: The right thing
Product Spotlight: Customer Service DVD
Preanalytical Error Rates in Spain
This month in Phlebotomy Today
Survey Says: underfilled tubes
What Should We Do?: how to handle a vulgar coworker
Tip of the Month
: Five truths about post-venipuncture care


Establishing a Preanalytical Quality Officer (PQO)

PQObadge_263034980_300wMediocrity is expensive in any industry, but in the U.S. it can put a healthcare facility right out of business. That's because those that don't cut expenses and improve patient satisfaction don't get reimbursed for the care they provide nearly as much as those that do. If poor sample quality is plaguing your lab, squandering scarce resources, and dragging down the entire facility, it's probably time to appoint a PQO, Preanalytical Quality Officer (PQO).

Up to 93% of all laboratory errors occur in the drawing, transport, processing and handling of blood samples. Whatever your facility's rate is, it's not sustainable. Designating a PQO not only takes some of the pressure off of the lab or phlebotomy manager, but his/her salary can be quickly recouped. Consider these statistics: 

The role of the PQO is to increase sample quality, reduce sample rejection, decrease turnaround times for test results, enhance the patient experience, and proactively prevent errors that normally go undetected. Those objectives afford them the following responsibilities: 

  • monitor all preanalytical quality indicators including hemolysis, blood culture contamination, patient and sample identification, sample rejection, patient satisfaction, and preanalytical turnaround times for all who participate in the preanalytical process facility-wide;
  • develop and implement strategies to improve on all quality indicators;
  • participate in training and continuing education in regards to sample quality and customer service.

The PQO's effectiveness is easily assessed by monitoring reductions on key quality indicators. By focusing exclusively on sample quality, the PQO frees the laboratory manager or phlebotomy supervisor to dedicate more time to hiring those applicants who will be assets to the organization instead of liabilities, which would otherwise deteriorate sample quality further. Additionally, PQOs free managers to pursue other often-neglected responsibilities such as coordinating team-building activities, expanding the lab's outreach, coaching, mentoring and rewarding top performers, nurturing interdepartmental cooperation, updating policies and procedures, and pursuing their own professional growth.

If it's time to stop managing preanalytical errors and start eliminating them, establishing a PQO can easily and quickly pay for itself in reduced operational costs and increased productivity and staff morale. 


The Empowered Healthcare Manager: The right thing

Every month, Phlebotomy Today-STAT! reprints one of the prior month's posts to The Empowered Healthcare Manager blog, written by Dennis Ernst.

The right thing is almost always the hardest of your options. If it was the easiest, more people would do it. The road less-traveled would be the road most-traveled. But it isn't.

Doing the right thing means...

...correcting your top performer because you know inconsistent policy enforcement does far more damage than a correction. Besides, top performers aren't demotivated by corrections.

...not filling a position your team desperately needs filled because none of your candidates would be a good fit, and you know hiring the wrong person is worse than hiring no one.

...rejecting a compromised sample from a difficult draw because you know there's nothing compassionate about cheating a patient out of an accurate result.

...denying a vacation request from the one person who will object the loudest because her tantrum will have a lesser effect on the team than forcing them to work short.

...taking a stand against an administrative decision you know is misguided and threatens a core value---yours or the company's---because you know the road to mediocrity is paved with the acquiescence of invertebrates.

...giving one of your employees a task you know she'll fail at because you know the lesson she'll learn from the failure will be far better for her than succeeding at a lesser task.

The easy way is the highway to short-term gains and long-term mediocrity. The hard way is disruptive in the short-term, but pays long-term dividends that far exceed an instant payout.

If the right way was the easy way we'd all be exceptional, and, therefore, ordinary. 

 Subscribe to The Empowered Healthcare Manager.

Product Spotlight:  Customer Service DVD

CustomerServiceDVD_200wWhat does world-class customer service look like? If you can't identify it where you work, the latest video from the Center for Phlebotomy Education belongs in your video library for staff/students to view. 

"Everyone talks about the importance of customer service in healthcare, but few know how to deliver it on a world-class level," says Dennis J. Ernst MT(ASCP), director of the Center for Phlebotomy Education and producer of Delivering World-Class Customer Service

The DVD is the only customer service video specific to phlebotomy and those who perform it. "In this, one of my most popular lectures, I not only show what world-class customer service looks like," says Ernst, "but I coach phlebotomists how to deliver it and their managers how to inspire it." The video discusses key concepts in customer service excellence with an emphasis on telephone etiquette, how true professionals conduct themselves, positive patient interactions, and a discussion on how managers can inspire a culture of customer service excellence among their staff. The DVD includes access to CE questions for free inhouse use or P.A.C.E. credit for a nominal fee.

"Now that healthcare reimbursements to U.S. hospitals are tied to patient satisfaction scores, phlebotomy managers can't afford to be complacent about mediocre customer service anymore," says Ernst.

Preview and more information.


Preanalytical Error Rates in Spain

GlobeResearchers at a Spanish Hospital evaluated five years of data to determine their facility's overall preanalytical error rate, including critical errors. After assessing over 750,000 requests for laboratory analyses, the facility found they had a total rate of sampling errors of 13.5 percent. All samples were collected and processed by nursing personnel at the facility and its 19 clinics and outpatient draw stations.

Errors included hemolysis (8.8 percent of all samples), clotted samples (1.4), incorrect container (0.08), insufficient sample (0.35), sample not collected (2.96).

Among the errors, 287 (0.05 percent) were classified as "critical" with severe consequences for the patient. Half of those were determined to be samples collected from the wrong patient. On two occasions, samples from two pediatric patients were combined in the laboratory to increase sample volume. 

Full article


This Month in Phlebotomy Today:  

Here's what subscribers to Phlebotomy Today, the Center for Phlebotomy Education's flagship newsletter currently in its 15th year of publication, are reading about this month:

Feature Article
What the Gurus Want You to Know About Drawing Coags

On the Front Lines
Nurses drawing preops

Sticks, Staph, and Stuff
Why you should reduce syringe use

The Empowered Healthcare Manager
Things you won't hear an empowered manager say

45-degree angle of insertion

Subscribe to Phlebotomy Today and get this issue immediately.


Survey Says:  Underfilled tubes

Lady listeningLast month we asked subscribers and visitors to our web site if they ever submitted underfilled tubes to the laboratory and, if so, if the laboratory tested them or rejected them.

Of those who participated, a whopping 80 percent admitted to sending underfilled tubes to the lab. Fifty-nine percent said they have had the lab reject an underfilled tube they submitted for recollection on at least one occasion. Some comments:

  • Never a coagulation tube, but if it's a lavender for Hemo and drawn on a child, I will submit a half filled tube and let the techs decide if the baby should be redrawn.
  • Yes for serum samples but never for coags or hematology.
  • I work in Pediatrics. There are times when it is just a tough draw. I will send the underfilled tubes to our lab to see what they can do. Sometimes they are able to get results without doing another stick. I will either send a note or contact the lab and let them know the situation.
  • For patients who are difficult sticks, I will occasionally submit an underfilled lavender or green tube (never a coag tube) for testing if that's all the blood I could get. Then the lab techs can decide if the results would be reliable enough to be used or if the sample needs to be recollected.
  • Only rarely, and only if the draw becomes problematic (e.g. vein collapses, tiny veins, etc.).
  • We have a minimum protocol for very difficult draws. Tech approval is required
  • The only reason I would submit underfilled tubes is if the vein collapses or is blown. In some cases, the patient is too dehydrated for a good fill on tubes.
  • Rarely, if it is absolutely all I can get.
  • Never underfilled Citrate tubes, but if you can't fill a SST tube and I know the test requires only 0.5 - 1.5 mL serum, I know I don't have to stick the patient again.
  • Coag tubes- never. Powdered EDTA- I follow the rules of the facility. Serum- yes, I would submit these.
  • Sometimes it is necessary for a hard draw.
  • That's crazy! You're affecting testing if you do!
  • It does depend on how underfilled they are and what the testing on it will be.
  • Not unless there just wasn't enough at all. But CBCs will be accepted if it's filled to the bottom on the label.
  • As long as it meets the minimum specimen requirements, I have never had a lab reject an underfilled tube.

UnderfilledCBCgboNearly all who responded knew submitting an underfilled citrate (blue-stopper) tube meant automatic rejection. Not so much for heparin and EDTA tubes. Studies have found underfilled heparin tubes, if tested, can lead to erroneous CK and GGT results. Another study found significant variations in ALT, amylase, AST, lipase, and potassium results. According to Tietz Clinical Guide to Laboratory Tests, troponin and electrolytes bind to excess heparin in underfilled tubes.

Studies have not found underfilled tubes with clot activators to yield altered results.

In the second part of our survey, we asked how people react when the first tube they apply in the tube holder doesn't fill. Four percent said "I pour two tubes together as long as the stoppers are the same color." Fifty-seven percent said they submit it to see if the lab will reject it. Ninety-six percent said they try another tube of the same color stopper in case the first one lost its vacuum. Comments include:

  • I'll attempt a very slight change in my needle angle just in case the needle is up against the wall of the vein.
  • I restick for better location [so the tube is] at least full
  • You never pull from one tube to the next. Who would do such a thing?

Combining the contents of two tube of the same stopper color is likely to be just as detrimental to test results as submitting an underfilled tube. That's because combining two partially filled tubes doubles the concentration of the additive. When EDTA, for example, is highly concentrated by this practice, it shrinks red blood cells leading to falsely lower hematocrit and MCV results.

In this month's survey, we want to know the compress you use to apply post-venipuncture care, (i.e., gauze or cotton balls), how you store them prior to use, and to what extent you check the site for bleeding before you bandage.

Take the survey


November 4-6, 2015, Charlotte, North Carolina


What Should We Do?:  Vulgar coworker

Right way wrong way sign What Should We Do? gives you the opportunity to ask our team of technical experts for advice on your most pressing phlebotomy challenges. Whether technical or management in nature, we'll carefully consider solutions and suggestions based on the industry's best practices so that you and those in other facilities with the same problem can benefit, all the while maintaining your facility's anonymity. What Should We Do? is your opportunity to ask us for suggestions on the best way to handle your real-life dilemmas.

This month's case study: How do you deal with someone who curses all the time at work from the moment they walk in until they leave at the end of the day?

Our response: We've had first-hand experience with this and find the best approach starts with a personal request to the offending party to tone it down. Give the person the benefit of the doubt that he/she knows what constitutes vulgar speech, that it isn't appropriate in the workplace, or even that it offends you. He/she may not realize any of these. 

Politely address the "curse-apotomus," stating you're offended and that it is against the policy where you work (assuming it is). Even if it is not a policy at your facility, your request should be enough for any person who respects you. If it fails, be forgiving, but be insistent. Bad habits are hard to break, so apply plenty of patience and reminders.

If it becomes clear no serious attempt is being made to honor your civilized request, it's time to go up the ladder of authority. Ask your supervisor to intervene. If she is unsympathetic, she is participating in a hostile work environment to the extent that intervention by your facility's human resources department is required. 

You have a right to a professional working environment. It is completely and entirely in your right to demand a workplace free of vulgarities, off-color humor and sexual innuendos. You may be ostracized by your coworkers, but nobody has the right to create an environment you, as an employee, find offensive. 

Feel free to print and post this Tip of the Month from the Phlebotomy Today archives.

If pleading your case up the chain of command doesn't work, you can always do what I (Dennis) did when I found myself in the same situation: quit your job and start a phlebotomy education company.

 Each month, our "What Should We Do?" panel of experts collaborates on a response to one of the many compelling problems submitted by our readers. Panelists include:


Got a challenging phlebotomy situation or work-related question? Answers just ahead sign

Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)


Tip of the Month

Click here for this month's featured Tip of the Month: Five Truths About Post-venipuncture Care