Should blood collection tubes be labeled before or after filling? What seems like a simple question with a simple answer has been the subject of a raging international debate between two of the industry's most respected authorities and their respective camps. Recently, the debate was moderated in print and online by the editor of Annals of Blood.

Taking the pre-collection labeling side are Dr.s Giuseppe Lippi and Mario Plebani, two of the most prolific researchers in the world of preanalytics, both based in Italy and members of the International Federation of Clinical Chemistry and Laboratory Medicine's Working Group on Laboratory Errors and Patient Safety (WG-LEPS). 

Arguing for post-collection labeling only are three equally prolific authors: international lecturer and Director of the Center for Phlebotomy Education Dennis J. Ernst MT(ASCP), NCPT(NCCT), George Fritsma, MS, MLS, purveyor of the Fritsma Factor, Your Interactive Hemostasis Resource, and David McGlasson MS, MLS(ASCP), a clinical research scientist for the United States Air Force.

In the November, 2017 issue of the Annals of Blood, the Lippi team's position was strongly stated, primarily because automated tube-labeling equipment now exists that can only label empty tubes. They also describe automated systems as being effective in reducing blood collection errors. Such devices, they claim, can print the order of draw to be followed on each label, the minimal draw volume for the tests requested, and the appropriate transport temperature. The list three organizations that advocate precollection labeling, the World Health Organization, The Italian Society of Clinical Biochemistry and Clinical Molecular Biology, and the European Federation of Clinical Chemistry and Laboratory Medicine. [Editor's note: read my column for further insight.]

In the February 2018 issue, Ernst et al made their case for post-collection labeling. The major objection for the authors is the potential for a tube to be labeled, but not used. Should the phlebotomist fail to complete the draw due to a fainting patient, withdrawal of consent, or difficult draw, the only thing preventing the tube from being used on another patient is for the phlebotomist to remember to throw it away. The authors argue strongly against adding another error point to an already error-prone procedure. They also hold firmly that when technology is developed that defies the prevailing standard, such as prelabeling instrumentation, the standards are not obligated to change so that the technology can prevail, especially when it introduces threats to patient safety. 

Annals of Blood editor, Dr. Emmanuel Favaloro discussed both positions in the April issue, stating he has no strong feelings one way or the other. He highlights the fact that no study has found either to be more effective in reducing labeling errors, and calls for a double-blind study to assess the respective error rates of each process. However, he observes such a study would be difficult since those involved in each study group would know which process they are participating in by the timing of the label's application to the tube. \

This issue  is likely to remain contested for the foreseeable future. Those who work where CLSI standards dictate the protocol will continue labeling only after the tubes are filled. To do otherwise, and who mislabel a sample, would have a difficult time explaining why the prevailing standard was violated. Likewise for those who work where the protocol is to label before collection. Regardless of the prevailing standard, any discussion on the right or wrong way is irrelevant whenever the tube is labeled correctly.

[Editor's note: read my column, "From the Editor's Desk,"  for further insight into this ongoing debate.]