Center Releases "Errors & Impacts" Poster
by Dennis Ernst
Do those who work with you and for you scoff at the many details you know are critical for every venipuncture? Do you need something that reinforces the importance of every step to your students and new hires? We thought so.
That's why the Center for Phlebotomy Education just released a new poster that connects the dots between preanalytical errors and patient outcomes. Blood Collection Errors and Their Impact on Patients is a 20 x 28-inch laminated chart listing over 40 errors that can be committed during the collection, transport, and handling of blood samples. A corresponding column lists the impact each error can have on the test result and patient. Examples include:
ERROR: Delay in transporting/testing coagulation specimens - POTENTIAL IMPACT: Stroke, thrombophlebitis, and pulmonary embolism caused by unwarranted modification to blood thinner dosage based on inaccurate aPTT result.
- ERROR: improper mixing
- POTENTIAL IMPACT: Patient mismanagement due to delays when anticoagulated tubes contain clots and must be recollected.
- ERROR: patient misidentification
- POTENTIAL IMPACT: Transfusion- or medication-related death. Misdiagnosis, medication error, and general patient mismanagement due to being treated according to the results of another patient.
- ERROR: filling tubes in the wrong order
- POTENTIAL IMPACT: Seizure and death from potassium carrying over from EDTA into tube to be tested for K+. Medication errors when additives carry over into coag tubes, falsely lengthening coagulation times and leading to unwarranted and life-threatening medication adjustments. Unnecessary antibiotic administration and prolonged hospitalization due to contaminated blood cultures.
- ERROR: pouring blood from one tube into another
- POTENTIAL IMPACT: Patient mismanagement/misdiagnosis & medication errors based on altered results, especially potassium. Stroke/hemorrhage due to unwarranted modification to blood thinner dosage.
- ERROR: underfilling heparin tubes
- POTENTIAL IMPACT: Patient mismanagement and/or /misdiagnosis from altered potassium, sodium, ALT, AST, amylase, and lipase results.
This is a posterized version of one of the Center's SmartChartsTM, a series desktop reference materials in pdf format available for downloading at www.phlebotomy.com and free to all Phlebotomy Central members. Posting the Errors/Impacts poster in prominent areas provides poignant evidence to the entire staff of the importance of every step of blood collection, handling, and transportation.