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Role of Nursing Personnel in Laboratory Testing

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Annals of Nursing and Primary Care Case Report
Published: 27 May, 2018

Role of Nursing Personnel in Laboratory Testing

Rateesh Sareen1*, Akanksha Dutt2
1
Consultant Pathology, SDM Hospital, Jaipur, India
2
Consultant Anesthesiology, Khandaka Hospital, Jaipur, India

Abstract
In modern medicine, doctors rely heavily on diagnostic testing to assist them with patient
management, making or excluding diagnosis and implementing an appropriate treatment plan.
It is therefore important that the laboratory produces quality test results. As laboratory testing
errors mainly occur outside the analytical process, they are likely to span the current branches or
subspecialties of laboratory medicine, including clinical biochemistry, hematology, coagulation,
immunometric and molecular biology. Inappropriateness of the samples especially due to blood
drawing errors generally occurs when the blood samples are drawn by nurses whose experiences
and training are not sufficient for blood drawing in clinics comparing to the phlebotomists who
are a group of more stable staff. Inappropriate laboratory utilization ultimately increases healthcare
costs, harms patients and perpetuates the vision of laboratory testing as a commodity. The paper
highlights the various factors affecting laboratory results some that can be controlled by training and
learning while others that arise out of biological variations thus non modifiable.
Keywords: Preanalytical errors; Nursing training; Phlebotomy

Introduction
The advancement in instrument technology, automation and manpower skills have simplified
the laboratory testing. The laboratory testing of any analytic comprises of three phases namely -
Preanalytical, Analytical and Post analytical phases. The preanalytical errors are the errors that
occur from the time a laboratory test is ordered by the clinician until the sample is ready for analysis.
This stage of laboratory testing is most prone to errors with 46-71% errors encountered during the
testing process [1,2]. The preanalytical phase involves people beyond the limits of laboratory and
in hospitals/clinics the nursing personnel are often entrusted with the responsibility of collecting
blood samples from the patients and sending them to the laboratory for analysis. The nursing staff
need not be expert in technical details of laboratory analysis but awareness of common preanalytical
variables is favorable as their knowledge has significant effect on sample collection process and
OPEN ACCESS subsequently the laboratory test results. Insufficient quantity and inappropriate quality of specimen
may account for over 60% of preanalytical errors [3]. The lack of understanding of blood collection
*Correspondence: process [4], errors in patient identification and preparation [5], defect in sample collection device/
Rateesh Sareen, Consultant Pathology, container [6] and error in sample handling ultimately compromise laboratory results. These errors
SDM Hospital, Jaipur, India, can seriously affect reliability of test result and affect patient care adversely. As the sample collection
E-mail: [email protected] is performed by nursing staff these errors can rarely be identified by the laboratory. The role of
Received Date: 13 Apr 2018 ‘human factor’ in sample collection makes the elimination of errors unrealistic but awareness and
Accepted Date: 18 May 2018 identification of areas of possible error with adequate, repetitive, continual professional training can
Published Date: 27 May 2018 significantly reduce them [7]. The purpose of this article is to highlight the common variables and to
Citation: enlighten the nursing staff of common pre analytical variables that affect test results. The common
Sareen R, Dutt A. Role of Nursing
variables pertaining to samples of blood are elucidated in the following paragraphs (Table 1).
Personnel in Laboratory Testing. Ann Identification of patient: It is of utmost importance to identify correct patient so as to collect the
Nurs Primary Care. 2018; 1(1): 1004. correct sample. Whenever identification of patient is done it is always prudent to use two identifiers
Copyright © 2018 Rateesh Sareen. like name of the patient & unique identification number with date of birth8 and the in house patients
This is an open access article should wear wrist bands with the above identification information which is verified by the staff time
distributed under the Creative and again the samples are collected from the patient [8]. Identification of critically ill, comatose
Commons Attribution License, which
patients or children should be carried out with extra precaution by adopting stringent vigilant
methodology to ensure that there is no error as any lax attitude could not only result in wrong
permits unrestricted use, distribution,
sampling but also unreliable laboratory result ultimately affecting patient care and in unfortunate
and reproduction in any medium,
cases an error in judgment inviting medical negligence [9].
provided the original work is properly
cited. Container labeling: Incorrect labeling of sample will inadvertently have incorrect laboratory

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Rateesh Sareen, et al., Annals of Nursing and Primary Care

Table 1: Common errors in sample collection and their consequences.

Error Consequences

Patient identification Misdiagnosis, Delayed diagnosis

Patient preparation  

Diurnal variation Falsely low or high values

Collection after meal in place of fasting Altered glucose & lipid profile

Site of blood collection ABG analysis altered

Tourniquet application Prolonged application cause falsely high calcium level, excessive probing can cause hemolysis.

Order of draw Falsely elevated potassium level

Specimen volume Altered Prothrombin time

Handling of specimen Unstable samples poor handling result in ACTH, ACE level alteration

Table 2: Effect of biological variables.

Variable Increase Decrease

Fasting Amino acids, Fatty acids, Ketone, Lactate, Bilirubin, Growth Hormone, Glucagon, Triglyceride Glucose, HDL, Lactate dehydrogenase, Insulin

Exercise AST, Bilirubin, Creatine kinase, HDL, Lactate, LDH, Uric acid  

result. The staff should abide with correct sample labeling techniques
with labeling of tubes done immediately after sample collection at
bedside as enshrined in The Clinical & Laboratory Standards Institute
(CLSI) guidelines [10].
Specimen discrepancy: Specimen discrepancy or inconsistency
can be a labeling error (requisition, container/ vacutainer or both);
lack of mention of anatomical site in surgical pathology samples;
discordance in requisition form verse container; incomplete clinical
information on form; specimen designation not clearly mentioned
or improperly prepared specimen prior to arrival in the laboratory.
The severity of discrepancy will determine the degree to which the
patient can be affected. These errors are particularly more common
in surgical pathology and quick identification is needed to abate
potential harm to patients. The nursing staff working in operation
theatres and surgical areas handling tissue specimens should be aware
of the effects of mislabeling of the containers and inappropriately filled
forms in particular. The lack of information on the requisition form
prevents laboratory from further processing the samples ultimately
delaying diagnosis and patient care. Labeling errors are generally of
three types [11]. Firstly, an unlabeled container or requisition arriving
in surgical pathology meaning that the container or requisition form
may lack proper patient identification. Second type of errors can be Figure 1: Hemolysed sample.
like the container is identified as one patient while the accompanying
requisition states a different patient. Third type, the cruelest one Site selection: The site of venipuncture can compromise the
involves, a labeled requisition and container with the same patient quality of sample. The most commonly selected site is the median
identified but it is the wrong patient. This error could only be cubital vein followed by cephalic vein and lastly the basilica vein.
recognized by the individual who was responsible for it independent Sampling from basilica vein should be done with caution as there is
of laboratory intervention. The only way to minimize labeling errors risk of damage to the neighboring brachial artery and median nerve.
is to implement a ‘double check system’ before specimens’ leave The venipuncture site should be cleaned with alcohol beginning with
clinical setting implemented by clinical staff including nursing staff. the center of site and continuing outwards in concentric circles.
There should be an appointed member of the clinical staff to recheck Alcohol should be allowed to air dry before starting venipuncture
each specimen in the area to ensure accuracy. A log sheet bearing as contamination with alcohol can lead to hemolysis resulting in
initial of both staff members should be recorded for tracking purpose. spurious elevations of levels of analytic such as potassium, Lactate
‘To err is human’, but the only way to overcome these errors is by Dehydrogenase (LDH) and magnesium (Figure 1,2).
communication, education and collaboration [12].
Tourniquet: The tourniquet should be applied 3-4 inches above
Patient preparation: The collection of clinical chemistry samples the venipuncture site. It creates an increase in pressure below the site
for fasting glucose estimation and lipid profile requires overnight of application resulting in increase in concentration of protein bound
fasting (at least 12 hours), these considerations must be given by the non diffusible analyte [13,14]. It is generally accepted that tourniquet
nursing staff while collecting blood samples. should not be kept for more than one minute. renowned and colleagues

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demonstrated maximum changes in analyte concentration occurred

at the time of tourniquet release and therefore recommended that
samples be collected when tourniquet was in place or at least 1 minute
after its release [15]. The national committee for clinical laboratory
standards guideline for blood specimen collection states that the
tourniquet should be released as soon as blood flow is established
to minimize the time the tourniquet is in place [16]. Each institute
should determine a standard approach to be used for all collections.
It is recommended to minimize occlusion time and avoidance of
pumping of fist. Prolonged tourniquet application causes changes
in concentration of analyte like total protein, calcium, alanine
aminotransferase, aspartate aminotransferase, creatinine kinas,
bilirubin and protein [17]. The person drawing the blood should not
probe to find vein as it causes hemolysis and poor quality of samples.
Order of draw: The order of draw as recommended by CLSI for
evaluation blood collection tubes: tube for blood culture, citrate tube,
serum separator/serum tube, heparin, ethylenediamine tetra acetic
acid and fluoride tube8. The contamination of K2 or K3 EDTA on the
needle from the lavender top tube to chemistry tube can lead to high
serum potassium level.
Tube mixing: Tubes containing additives should be mixed
Figure 2: Lipidemic sample.
by inverting tubes at least 8-10 times for proper uniform mixing
of anticoagulant with patient blood. They should not be shaken
vigorously as it might cause hemolysis. The vacutainers should not Delay in Transport and Processing
be expired before use as it may cause loss of vacuum resulting in All samples should be processed promptly after collection as
inappropriately volume and changes in blood to additive ratio [18,19]. allowing cells to remain in contact with the plasma or serum can
Time of sampling: There are number of analyte that have shown cause increase in concentration of some analytes like Creatine kinase,
circadian rhythm of their plasma concentration during 24 hour lactate, LDH, Ammonia and phosphate. Glucose, bicarbonate and
period in response to meals, sleep, posture and stress changes. Serial acid phosphate concentration may decrease on standing. Acid base
collection at similar times of the day will minimize differences due analysis samples from arterial line need to be sent immediately as
to diurnal variations. The timing of collection is crucial especially soon as possible to the laboratory at lower temperatures, similarly
for drugs in the therapeutic window are small. Such examples sample for platelet functional analysis needs to be sent immediately
include like concentration of potassium is lower in afternoon than without shaking else the result quality will be compromised. Both the
in the beginning of the day and for cortisol it is vice versa [20]. For above mentioned special requirements of transport of samples should
infections where shedding is irregular timing of sampling is crucial. be taught and put in to practice by nursing or personnel collecting
Say for instance shedding precedes fever and chills by up to 1 hour. In blood samples. Samples in glass tubes take 20-30 minutes for clotting
such case, temperature curve or fever pattern of the particular patient whereas it takes slightly longer time for samples in plastic tube. The
may permit prediction of new spike and blood sampling time can be tube should be held upright and as a general rule plasma separation
adjusted so that culture sample is collected at the time of maximum should be done within 1 hour of collection and serum separation in
probability of detecting the infectious agent. 2 hours of collection. The centrifugation time and speed should be in
compliance with manufacturer recommendation.
Working in senses: Nursing staff should be vigilant especially
during sample collection and should not work mechanically rather Temperature
with an alert inquisitive mind. Serum separator tubes might be
The nursing staff is entrusted with the responsibility of transport
unacceptable for some analytes [21,22] therefore they mandate
of specimen at the desired temperature. Analyte like ammonia, blood
disclosure by manufacturer. If possible in house studies should be
gas, acid phosphatase, lactate, pyruvate, gastrin and parathyroid
done to demonstrate suitability of gel containing collection tubes for
hormones are temperature labile and need stringent conditions of
analytes that are not evaluate by tube manufacturers.
transport [23]. A brief knowledge of preanalytical errors by nursing
Intravenous Infusions staff helps in understanding rationale behind collection and processing
requirements to ensure that right specimen in drawn by right person
The collection of blood samples from ongoing Intravenous (IV) in right manner under right set of conditions, transported at right
infusion is highly problematic. It is best to collect the sample from time to laboratory.
alternative site or by capillary puncture. In cases where alternative site
is not available and sample needs to be collected from the arm having Biological Factors
IV infusion it is recommended to first turn off the IV infusion for
Apart from above mentioned factors there are long term
minimum of 2 minutes then apply tourniquet and then collect blood
biological variables that cannot be supervised accurately but at the
sample from vein below the IV site. The interference from dilution
same it is important to be aware of them as they affect laboratory
by IV fluid can be minimized if 5 ml of blood is discarded before
results (Table 2). These variables include age, gender, race, effect
collection.

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of menstrual cycle, pregnancy, diet, exercise, alcohol intake, use factors affecting results. Nursing staff, phlebotomist, junior doctors,
of caffeine, smoking and postural changes [24]. The newborn consultants, laboratory staff and pathologist all must act in tandem as
have increased hemoglobin concentration, they have low blood their collaborative team effort can ensure best patient care.
glucose levels due to small glycogen reserves. The serum creatinine
concentration rises from infancy to puberty depending on skeletal
References
muscle development [25]. The alkaline phosphatase activity is greater 1. Plebani M. Errors in clinical laboratories or errors in laboratory medicine?
in males than in females and vice versa when females reach over 50 Clin Chem Lab Med. 2006;44(6):750-9.
years of age [26]. Gender specific hormones are different and gender 2. Atay A, Demir L, Cuhadar S, Saglam G, Unal H, Aksun S, et al. Clinical
based differences are observed in albumin, calcium, magnesium and biochemistry laboratory rejection rates due to various types of preanalytical
hemoglobin levels (lower in females) whereas amino acids, urea, errors. Biochem Med. 2014;24(3):376-82.
uric acid, Creatinine, Reticulocyte count aspartate aminotransferase, 3. Lippi G, Bassi A, Brocco G, Montagnana M, Salvagno GL, Guidi GC.
alanine aminotransferase, alkaline phosphatase and creatine kinase Preanalytic error tracking in a laboratory medicine department: Results of
( higher in males) [24,27]. The plasma concentration of cholesterol, a1year experience. Clin Chem. 2006;52(7):1442-3.
total protein, albumin, fibrinogen, serum calcium-phosphate and 4. Li ppi G, Sal vagno GL, Mont agnana M, Franchini M, Guidi GC.
iron as well as female sex hormones are affected by menstrual Phlebotomy issues and quality improvement in results of laboratory
cycle and pregnancy which results in hemodilution. Diet charts are testing. Clin Lab. 2006;52(5-6):217-30.
maintained for in house patients in hospitals. They provide a ready
5. Bologna LJ, Lind C, Riggs RC. Reducing major identification errors within
reference to all solid and liquid intakes by patients. Any special a deployed phlebotomy process. Clin Leadersh Manag Rev. 2002;16(1):22-
requirement in diet that the patient is receiving should be mentioned 6.
in test requisition form by either the nursing staff or by the duty
6. Bologna LJ, Mutter M. Life after phlebotomy deployment: Reducing
doctor so that laboratory can interpret results in a meaningful
major patient and specimen identification errors. J Healthc Inf Manag.
manner. A high fat meal causes increase in serum concentration 2002;16(1):65-70.
of glucose, iron, lipids, alkaline phosphatase and triglycerides
7. Lippi G, Guidi GC. Risk management in the preanalytical phase of
whereas it reduces serum urate levels [28]. A higher protein diet
laboratory testing. Clin Chem Lab Med. 2007;45(6):720-7.
intake increases plasma urea, serum cholesterol and phosphate
concentration. Short term starvation (48 hours) leads to significant 8. Er nst DJ, Bal ance LO, Cal am RR, Rut h McCall, Smith SS, Szamosi
changes including increased organic acids like ketone bodies ( aceto DI, et al. Clinical Laboratory Standards Institute (CLSI). Procedures for
the collection of diagnostic blood specimens by venipuncture; approved
acetic acid, beta hydroxyl butyric acid) which causes metabolic
standard.
acidosis with a decrease of both PH and bicarbonates [29]. Long
term starvation leads to decreased concentration of blood proteins, 9. Kornstein MJ, Byrne SP. The Medicolegal Aspect of Error in Pathology:
cholesterol, triglycerides, apolipoproteins and urea [30]. Exercise and A Search of Jury Verdicts and Settlements. Archives of Pathology &
Laboratory Medicine; 2007;131(4):615-8.
physical activity causes changes in concentration of analyte due to
volume shifts between intravascular and interstitial compartments, 10. Procedures for the collection of diagnostic blood specimens by
loss of volume by sweating and changes in hormone concentration venipuncture; Approved Standard. 6th ed.
of epinephrine, norepinephrine, glucagon, somatotropin, cortsol, 11. College of american pathologists commission on laboratory accreditation.
ACTH (increased) and insulin (decreased) [31,32]. There are studies Laboratory Accreditation Program. Laboratory General Checklist. College
in literature that have demonstrated rise of creatine kinase four times, of American Pathologists. 2006.
pyruvate kinase 2.6 times, AST & bilirubin 1.4 times and urea 1.3 12. Kohn LT, Corrigan JM, Donaldson MS. To err is Human: Building a Safer
times in samples from individuals tested a day before and 45 minutes Health System. Washington, DC: National Academy Press; 2000.
after marathon race [33]. The intake of beverages like coffee, tea and
13. Tan MH, Wilmhurst EG, Gleason RE, Soeldner JS. Effect of posture on
soft drinks also affect analyte concentration due to caffeine content serum lipids. N Engl J Med. 1973;289(8):416-9.
which is found to inhibit phosphodiesterase and subsequently cyclic
AMP degradation. Cyclic AMP rises blood glucose concentration 14. Recommendations for improving cholesterol measurement: A report/
from the laboratory standardization panel of the national cholesterol
and plasma renin activity and catecholamine release [34]. Smoking
education program. Bethesda, Md: US Dept of Health and Human
entails changes in blood leukocytes and erythrocytes, vitamins, Services, Public Health Service, National Institutes of Health; 1990.90-146.
tumor markers and heavy metals [35]. Nursing staff needs to pay
extra attention to patient’s posture while drawing samples for 15. Renoe BW, McDonald JM, Ladenson JH. The efforts of stasis with and
without exercise on free calcium, various cations and related parameters.
catecholamines, aldosterone, rennin, angiotensin II and anti-diuretic
Clin Chim Acta. 1980;103:91-100.
hormone analysis [36], because supine position tends to reduce
effective filtration process causing volume shift from intravascular 16. National Committee for Clinical Laboratory Standards. Standard
compartment. In upright condition macromolecules with greater Procedures for the Collection of Diagnostic Blood Specimens by
Venipuncture. Approved standard. ASH-3. Villanova, Pa: National
than 4 nm diameter cannot pass through the membrane and follow
Committee for Clinical Laboratory Standards; 1977.
volume shift leading to increased concentration of measured analyte
by 5-15% in comparison to supine position. 17. Statland BE, Bokelund H, Winkel P. Factors contributing to intra-
individual variation of serum constituents: 4. effects of posture and
Conclusion tourniquet application on variation of serum constituents in healthy
subjects. Clin Chem. 1974;20(12):1513-19.
Diagnostic investigations are the back bone of patient care as
clinical decisions heavily rely on the performance and interpretation. 18. NCCLS-Tubes and Additives for Venous Blood Specimen Collection;
Approved Standard- 5th Edition. H1-A5 23(33);2003.
The advent of modern instruments in laboratory medicine has
made investigations more perfect but it is crucial to be aware of 19. BD Evacuated Blood Collection System Package Insert 6/2004.

Remedy Publications LLC. 4 2018 | Volume 1 | Issue 1 | Article 1004

Rateesh Sareen, et al., Annals of Nursing and Primary Care

20. Touitou Y, Haus E. Biologic rhythms in clinical and laboratory medicine. 29. Lamers KJ, Doesburg WH, Gabreëls FJ, Lemmens WA, Romsom AC,
Berlin, Heidelberg, New York: Springer Verlag. 1992. Wevers RA, et al. The concentration of blood components related to
fuel metabolism during prolonged fasting in children. Clin Chim Acta.
21. Dasgupta A, Dean R, Saldana S, Kinnaman G, Mclawhon RW. Absorption
1985;152(1-2):155-63.
of therapeutic drugs by barrier gels in serum separator blood collection
tubes. Volume-and time-dependent reduction in total and free drug 30. Ditschuneit H, Wechsler J. Probleme der ambulanten nulldiätbehandlung.
concentrations. Am J Clin Pathol. 1994;101(4):456-61. Dtsch Arztebl. 1979;76(13):871-80.
22. Mole L, Margolis D, Carroll R, Todd J, Holodniy M. Stabilities of 31. Alexander S. Physiologic and biochemical effects of exercise. Clin Biochem.
quantitative plasma culture for human immunodeficiency virus, RNA, and 1984;17(2):126-31.
p24 antigen from samples collected in VACUTAINER CPT and standard
32. Cumming DC. Hormones and athletic performance. In: Felig P, Baxter JD,
VACUTAINER tubes. J Clin Microbiol. 1994;32(9):2212-5.
Frohman LA, eds. 12 Endocrinology and metabolism. New York, Toronto:
23. Young DS. Effects of preanalytical variables on clinical laboratory tests. McGraw- Hill, 1995:1837-85.
Washington, DC: AACC Press. 2nd ed. 1997.
33. Stansbie D, Begley JP. Biochemical consequence of exercise. J IFCC
24. Young DS, Bermes EW. Specimen collection and processing: sources 1991;3:87- 91.
of biological variation. In: Tietz NW, ed. 3rd ed. Textbook of clinical
34. Robertson D, Frölich JC, Carr RK, Watson JT, Hollifield JW, Shand DG, et
chemistry. Philadelphia: WB Saunders Company; 1987:58-101.
al. Effects of caffeine on plasma renin activity, catecholamines and blood
25. Calam RR. Samples from Patients to Laboratories. Walter Guder, pressure. N Engl J Med. 1978;298(4):181-6.
Sheshadri Narayanan, Hermann Wisser, Bernd Zawta. Darmstadt: Git
35. Young DS. Effects of preanalytical variables on clinical laboratory tests.
Verlag. Clinical Chemistry. 1996;43(8):1470a-1.
Washington, DC: AACC Press; 1993.
26. Schiele F, Henny J, Hitz J, Petitclerc C, Gueguen R, Siest G. Total bone and
36. Felding P, Tryding N, Petersen PH, Horder M. Effects of posture
liver alkaline phosphatases in plasma: biological variations and reference
on concentrations of blood constituents in healthy adults: practical
limits. Clin Chem. 1983;29(4):634-41.
application of blood specimen collection procedures recommended by the
27. Tarallo P, Humbert JC, Mahassen P, Fournier B, Henny J. Reticulocytes: Scandinavian Committee on Reference Values. Scand J Clin Lab Invest.
Biological variations and reference limits. Eur J Haematol. 1994;53:11-5. 1980;40(7):615-21.
28. Rifai N, Merrill JR, Holly RG. Postprandial effect of a high fat meal on
plasma lipid, lipoprotein, cholesterol and apolipoprotein measurement.
Ann Clin Biochem. 1990;27:489-93.

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