What Should We Do?: Fixing the mixing

Question: Our NICU performs all of their lab draws. We're receiving more than clotted specimens than from other units. They are convinced the lab is clotting the specimen when we receive it. What should we do?

Our response: It's always the lab's fault, isn't it? Everyone knows labs hemolyze samples, add clots to tubes with anticoagulants upon arrival, and contaminate blood cultures. Those rascals!

When people engage in the blame game, it points to a much greater problem than just tubes that aren't properly mixed upon collection. A mixing problem is easy to fix; ending the blame game is not. We suspect the nursed know deep down the lab isn't purposely corrupting samples just so they don't have to test them. But why they would make that their defense? It's hard to tell for sure, but it's likely felt they were being blamed for purposefully allowing tubes to clot. They reacted by simply firing back with the same accusation. 

What needs to happen here is the nurses have to know that you don't feel they are the problem, but that the process is the problem. Which sounds more accusatory: "Your nurses aren't mixing the tubes" (blaming the person), or "there's something about how the tubes are being mixed that needs attention" (blaming the process).

Focusing on the process rather than the person (or department) is far more likely to rally everyone toward a solution. Regardless of who is being blamed, a clotted tube still has to be recollected. Go back to the unit and have a frank conversation with the nurse in charge. The conversation should start something like this: "I'm sorry if I gave you the impression that I felt your nurses were the problem with the clotted samples. I certainly don't believe anyone's doing it on purpose. The problem isn't your staff, it's more likely they were never given the information they needed to prevent clotting. That's not their fault." 

Then explain the lab doesn't want tubes clotted any more than they do. Make sure she knows that a clotted tube makes extra work for everyone involved, delays test results, and, worst of all, the poor child has to get stuck twice. If it's the microcapillary tubes that you're having to recollect, explain how they are one of the more susceptible tubes for clotting, and how mixing has to be conducted even during collection sometimes. If the tubes have a scoop design, tapping it on a hard surface every now and then during the collection might help. If it's a closed system that uses a straw or capillary tube, gently flicking the bottom of the tube once in a while can start the mixing process. Regardless of the device, mixing after the draw has to be immediate, gently, and purposeful. 

Suggest a quick inservice, one you can conduct or the nurse supervisor. It should only take a few minutes per group. Working it into a regular staff meeting might be the most effective. That would also be the perfect opportunity to show everyone you're focused on the process, not the person.

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