| The Joint Commission on Accreditation of Healthcare Organizations promotes improved patient safety through its programs and resources. True or false? | View Page |
| These statements describe things related to medical error prevention. | View Page |
| Root Cause Analysis Root causes are specific reasons that contribute to medical errors. They cause mistakes that lead to great patient harm (adverse events). Usually they can be identified. Examples: Using a wrong calculation factor Neglecting to use directions for complicated tests Reporting the wrong test result Using outdated reagents Testing clotted or partially-filled samples Diluting a test sample incorrectlyIn most cases, management has the authority and means to resolve root causes. Root Cause Analysis also recommends actions to prevent reoccurrence of an adverse event. | View Page |
| Study The Internet provides extensive, current resources for studying ways to prevent errors. Performing word searches for Medical Errors or Patient Safety or Laboratory Errors identifies a wealth of Internet resources.
A Patient Safety search lists more than 93 million items. | View Page |
| New Joint Commission Standards The healthcare community uses RCA to reduce medical errors, but it is reactive in nature. For this reason, Joint Commission collaborates with recognized patient safety experts to develop and implement additional patient safety standards. These new standards charge healthcare organization leaders to create cultures of patient safety. They emphasize the need for teamwork and effective communication. They are based on well-known experiences of the aviation industry and they reflect findings from Joint Commission's Sentinel Event Database. They identify communication breakdowns as the most common underlying factor in all types of Sentinel Events. | View Page |
| Joint Commission Patient Safety Goals Joint Commission adopted national patient safety goals for healthcare organizations, including specific goals for laboratories. 2009 Laboratory Services National Patient Safety Goals These goals are directly quoted. | View Page |
| Choose the organization(s) that strive to improve patient safety. | View Page |
| Improving Patient Safety
Many other organizations strive to improve patient safety. These dedicated groups promote current information about their goals, projects, progress, publications, tools, and educational offerings in their Internet Websites. | View Page |
| American Society for Clinical Pathology
The American Society for Clinical Pathology, ASCP, promotes medical error prevention through its projects, programs, and activities. It includes this important topic in its many 400 workshops, symposia, teleconferences, and self-study programs.
ASCP also promotes error prevention in the medical textbooks, reference manuals, slide atlases, audiovisual materials, and computer software it publishes. Its membership newsletters and The American Journal of Clinical Pathology and LabMedicine journal frequently address error prevention and patient safety. | View Page |
| American Society for Clinical Laboratory ScienceThe American Society for Clinical Laboratory Science, ASCLS, joins the leadership effort to prevent medical errors and increase patient safety. | View Page |
| Public Responsibility for Safety People can help prevent errors in their medical care by understanding their treatment, keeping organized health records, and asking questions. They should feel comfortable talking with medical professionals when things do not seem right.
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| Factors that Contribute to Medical Errors | View Page |
| Employer Responsibility Your employer has a responsibility to educate you about chemical hazards, and safety procedures. | View Page |
| Your Responsibility Read the manufacturers' labels and MSDS sheets and follow the instructions and warnings. Access pertinent safety information through your supervisor. If you detect any potential hazards either in the facility or in your work procedures, contact your supervisor as soon as possible. | View Page |
| Handling and Storage Data Information concerning the eye, skin, and respiratory protection required while using the chemical. Safety goggles are the minimum eye protection and rubber or nitrile gloves must be worn when handling any chemical. Any special ventilation that might be needed. | View Page |
| General Laboratory Precautions Laboratory safety includes a number of precautions designed to protect you and your coworkers. Remember that: eating drinking smoking applying cosmetics or lip balm are forbidden in areas where chemicals are present. | View Page |
| Personal Protective Equipment Personal protective equipment is an essential way to protect yourself from the dangers of chemicals. You'll find on the label or MSDS exactly what kinds of clothing, gloves, and coverings you'll need to keep yourself safe. Also, the laboratory's chemical hygiene plan will include information about necessary personal protective equipment and engineering controls that will reduce your exposure to hazardous chemicals. At a minimum, safety goggles and rubber or nitrile gloves (not necessarily utility gloves) are necessary parts of your personal protective equipment. | View Page |
| Monitoring Certain chemicals in use in the laboratory, such as formaldehyde, are hazardous if your exposure to them is too prolonged. The amount of the chemical to which you can be exposed before possible danger is called the threshold limit value. Monitoring badges are used from time to time to measure your exposure. These are worn in the "breathing zone" for a certain period of time--often eight hours (for long-term exposure) or fifteen minutes (for short-term exposure). Based on the results of this monitoring, additional personal safety measures, such as ventilation or face-fitted masks, may be implemented for your protection. | View Page |
| Case Julie Smith, a newly certified phlebotomist at Northlake Hospital, entered a patient’s room on the third floor for a routine blood draw. The patient was an elderly woman who had very small fragile veins. Julie therefore decided to use a safety butterfly needle attached to a Vacutainer tube in order to draw the blood. When Julie was finished with the venipuncture, she detached the butterfly needle from the Vacutainer, and approached the Biohazard needle disposal box. She noticed that the disposal box was full , but decided to try to fit the butterfly into the box anyway. Holding the butterfly by the tubing, she tried to push the butterfly into the box. The needle suddenly recoiled and stuck Julie’s finger. Julie left the patient’s room in a panic and headed back to the lab to report the needle stick injury. | View Page |
| What should Julie have done to prevent the needle stick? | View Page |
| Discussion All biohazard needle disposal containers are marked with a “full” line at about ¾ of the box’s volume. Therefore, needles should never be sticking out of the top of the container. Julie should never have attempted to put the needle into an overly full container. The needlestick safety and prevention act requires the use of butterflies with built in safety devices. However, they are only effective if properly activated. When disposing of a butterfly needle, hold its “wings” with one hand, and the hub at the opposite end of the tubing with your other hand to prevent the needle from recoiling. Butterflies should be used with extra caution since they are the number one cause of needle stick injuries.Relevant topics:Needle disposal, Sharps disposal containers, Butterfly needles with safety 1, Butterfly needles with safety 2, Needle-stick injuries, Built-in safety features, Angel Wing™ safety butterfly, Punctur-Guard™ safety butterfly | View Page |
| Case A phlebotomist at Memorial Hills Hospital entered the room of a 6 year old patient. The only test ordered was a CBC, so the phlebotomist decided to do a finger stick. After gathering proper supplies for the finger stick, the phlebotomist began the procedure by putting on gloves and wiping the tip and side of the patient’s ring finger with alcohol. He positioned the safety lancet between the ball and the side of the finger and made a small incision. The child cried as the blood was collected.
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| Butterfly needles with built-in safety features continued Two examples of butterfly needles with built-in safety devices are shown.The Punctur-Guard™ (Bioplexus), shown above, uses an internal blunt needle which is activated after blood is drawn. The activated device showing the blunt internal needle is shown in the inset on the upper right.
The Angel Wing ™ (Monoject), is activated by sliding a safety shield over the needle after venipuncture.
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| Needle holders with built-in protection devices You will be required to use appropriate safety devices with your needle holder. Various options are available.
The Needle-Pro™ Needle protection device (Sims Portex) shown here is an example of a needle holder with a built-in safety device.
It is activated after venipuncture by pressing the orange protection device against any flat surface so as to engage the sheath firmly on the needle.
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| Multiple draw needles with built-in safety features. You will be required to use multiple draw needles with built-in Safety features.
One example is the Puncture-Guard™ (BioPlexus) needle, which uses an internal blunt needle (detail above) that is activated with forward pressure on the final blood tube prior to withdrawal of the needle from the vein.
Refer to your institution’s and the manufacturer’s procedure manuals before using these devices.
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| Needle holders, built-in protection devices contd When the orange safety sheath is engaged, as shown on the right, it protects the user from needlestick injury, until the device is properly disposed of in an approved sharps container.
Refer to the manufacturer’s instructions, and your procedure manual for detailed instructions prior to use. | View Page |
| Syringes with built-in safety devices Syringes are used for injections, as well as to collect blood.
There a various syringes with built-in safety features.One example is the Monoject™ (Sherwood Services AG), Safety Syringe, shown here. | View Page |
| Syringes with built-in safety devices contd. After use, a safety shield is slid over the needle, and locked into place.
The safety syringe with the shield locked in place is shown here. | View Page |
| Needles with built-in safety devices You will be using needles and/or needle holders with built-in safety devices.
Various such needles are on the market.
Remember that you must still activate the safety device to get the protection offered.
So careful attention to what you are doing is still one of the best ways to protect yourself against needlestick injury.
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| Butterflies with built-in safety features You will be using butterfly needles with built in safety features.
Butterfly needles are the number-one cause of needlestick injuries, so proper use of their safety devices is critical.
Their use is described in greater detail in the section on butterfly needle blood collection.
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| Activation of safety device Activate the safety device in use at your institution.Be sure to follow your institution’s procedure for activating this device to protect yourself from needlestick exposure. | View Page |
| Butterfly needle - Angel WingTM safety butterfly The Angel Wing™ (Monoject), is activated by sliding a stainless steel safety shield over the needle after withdrawal from the vein.The Angel Wing™ (Monoject), is activated by sliding a stainless steel safety shield over the needle after withdrawal from the vein. | View Page |
| Butterfly needle - Butterfly needles with built-in safety features You will be using butterfly needles with built-in safety device. The safety device must be activated upon completion of the blood collection.You will be using butterfly needles with built-in safety device. The safety device must be activated upon completion of the blood collection.The Angel Wing™ (Monoject) safety butterfly is shown here.
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| Finger stick - Finger stick collections A finger-stick collection is performed by piercing the fingertip with a safety Lancet, which controls the depth of incision, and collecting capillary blood. The BD Microtainer™ Brand Safety Flow Lancet is shown here.Finger-sticks should not be performed on children under one year of age.
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| Finger stick - puncture Select a safety lancet appropriate for the size of the patient’s finger.You may warm the finger prior to puncture to increase blood flow.Make the puncture perpendicular, rather than parallel, to the finger print. | View Page |
| Syringe - Transferring blood to collection tubes After collecting the blood specimen into a syringe, properly activate the appropriate safety device, and dispose of the needle in a sharps container.Attach the syringe to a blood transfer device by twisting the needle tip into the hub of the device.Push a vacuum blood collection tube into the holder of the transfer device, and let the tube fill to the appropriate level.
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| Butterfly needle - Punctur-GuardTM safety butterfly Another type of safety butterfly needle is shown to the right.The Punctur-Guard™ (Bioplexus) uses an internal blunt needle (arrow) that is activated by manually locking a small lever on the butterfly.
Please refer to your facility’s and the manufacturer’s procedure manuals for detailed instructions.
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| Activate needle safety device After collecting the blood, activate the needle safety device according to manufacturer’s instructions, and place it in a sharps disposal container.
If blood was collected into a syringe, insert the syringe tip into the hub of a blood transfer device, and rotate the syringe clockwise to secure it to the device.
Push the blood culture bottle into the holder of the transfer device, and draw the appropriate volume of blood into the blood culture bottles. | View Page |
| Needlestick safety and prevention act continued Please keep the following in mind:
These devices must be used properly and conscientiously to prevent injury.
Carefully follow your institution’s policies and procedures to prevent needlestick injury.
Most devices require you to activate their safety features. Often, the device lets you know it is properly activated by a click or a snap.
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| OSHA bloodborne pathogens standard The Occupational Health and Safety Administration (OSHA), of the federal government has mandated bloodborne pathogen training for all US workers who are at risk of exposure.
The next few slides cover a few highlights of this training. You will receive complete OSHA bloodborne pathogens training before you begin work.
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| Needlestick safety and prevention act The Needlestick Safety and Prevention Act was passed by Congress in November 2000.
This law modifies the OSHA Bloodborne Pathogens Standard to require that health-care institutions use only needles and other sharps which have engineering controls and design features to help prevent accidental sharps injury.
Health care institutions must update their exposure control plans to reflect these changes.
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| Needlestick safety and prevention act continued There are many different types of needle safety devices on the market.
As you go through this program, we will introduce you to some of them | View Page |
| Needlestick safety and prevention act continued The law requires that each institution gets input from employees actually involved in blood collection.
So the actual safety devices you are required to use will vary depending on where you work.
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| What is a Hidden Error? Hidden errors are those that cannot be detected or corrected by the laboratory analyst prior to testing. Most often these errors can be prevented by the phlebotomist following correct venipuncture procedure for every procedure, every time.Hidden errors include hemoconcentration, incorrect order of draw, and (the most serious of all errors) misidentification of patient or specimens. Because these errors often are unknown, the analyst may inadvertently report erroneous patient results which could be harmful to the safety and well-being of the patient. Condition What is it? How does it happen? What is the Result? Hemoconcentration Blood pools at site of venipuncture Tourniquet is applied for a prolonged period of time Test results may be inaccurate because blood components move between blood and tissues Pouring Blood between tubes Mixing contents of two or more tubes Removing top of tube to combine contents of one tube with another Inaccurate test results due to over or under dilution or incorrect anticoagulant Clots form due to lack of mixing Patient may have to be redrawn Incorrect patient identification and incorrect specimen labeling Using the wrong name to label a specimen Failure to positively identify EVERY patient using 2 unique identifiers BEFORE beginning venipuncture Failure to label EVERY specimen in the presence of the patient Failure to concentrate fully on the task Results reported to caregiver for wrong patient Compromises patient care; may be life-threatening | View Page |
| Protect Yourself The safety of both the phlebotomist and patient is of utmost concern at all times. In the unfortunate event of an accidental needlestick or if you get blood or other potentially infectious materials in your eyes, nose, mouth, or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. Report this immediately to your employer and seek immediate medical attention. It is imperative that the phlebotomist follow facility protocol for reporting the incident. This ensures prompt treatment for the injury. The facility procedure must be followed whether the accidental puncture was from a clean or contaminated needle.The single most important element to prevent an accidental needlestick is for the phlebotomist to fully concentrate during every procedure. Keeping your mind on the task at hand contributes to a successful and safe result. | View Page |
| References Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays; Approved Guideline. Fourth ed. CLSI document H21-A4. NCCLS. Wayne, PA: 2003.Clinical and Laboratory Standards Institute (CLSI). Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard. Sixth ed. CLSI document H3-A6. NCCLS. Wayne, PA: 2007.Clinical and Laboratory Standards Institute (CLSI). Procedures for the Handling and Processing of Blood Specimens; Approved Guideline. Third Edition. CLSI document H18-A3. NCCLS. Wayne, PA: 2004.Ernst DJ. Applied Phlebotomy. Baltimore, MD: Lippincott Williams & Wilkins: 2005.Lowe B. Reinforcing safety sticklers. Advance for Medical Laboratory Professionals. May 2004; 16:2A-3A.The Joint Commission. Patient Safety-2009 National Patient Safety Goals. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/. Accessed July 18, 2009. | View Page |
| Needles and Patient Safety All needles are single use. That is, every needle is immediately discarded in a sharps container after one insertion. If you suspect that you inadvertently touched anything with the needle prior to inserting the needle into the patient's vein, the needle cannot be used; the safety device must be activated and the needle discarded.NEVER remove a needle from a patient and reinsert into another vein; this could put the patient at risk for infection. | View Page |
| Blood Collection Systems and Devices The phlebotomist has a choice of several blood collection systems. Three that are commonly used are discussed on the following pages. Evacuated Tube SystemThe primary choice for a routine venipuncture that will be performed on an adult or an older child is a blood collection system that consists of a holder (or adapter), a needle that is pointed on both ends, and evacuated blood collection tubes. One end of the needle will pierce the vein and the other end will pierce the stopper of the evacuated tube so that blood will flow into the tube to fill the vacuum. A safety device is required on either the holder or the needle to comply with current standards for needle safety. Two examples of needle holders equipped with safety devices are shown on this page. | View Page |
| Winged Device The winged device is another popular choice for the phlebotomist. This may be chosen for pediatric venipuncture, small delicate veins on adults (particularly geriatric patients), or hand veins. The device can be used with a needle holder and evacuated tube or a syringe. A needle safety device is incorporated into the design of the winged device to prevent needlestick injury. | View Page |
| Venipuncture Procedure At a Glance Required Step Description Step #1 Wash your hands. Clean your hands with soap and water or gel cleanser. Step #2 Positively identify patient using unique identifiers. Ask the patient to state his/her first and last name; if the patient is unable to give you this information, ask the patient's caregiver to confirm the patient's name. A second unique identifier must also be used. Step #3 Special test requirements Determine if the test to be obtained has any special requirements. For example, should the patient be fasting? Is this a timed test? If any requirements are not met, consult with the caregiver to determine a course of action. Step #4 Prepare the patient Explain the procedure to the patient and obtain cooperation. Usually the patient will extend an arm. (This is a form of implied consent.) Position the arm for venipuncture; support the arm on a firm surface; the arm should be in a downward position. Step #5 Site determination The patient can make a fist, but should not pump the hand open and closed. Apply tourniquet Palpate the vein. Release the tourniquet and assemble appropriate equipment. Step #6 Aseptic technique Wear gloves that have not been altered in any way. Cleanse site with approved disinfectant. Allow the disinfectant to air-dry to avoid hemolysis of the specimen and discomfort to the patient. Step #7 Specimen collection Re-apply tourniquet about 3-4 inches above puncture site, insert needle, bevel-side up, at about a 30° angle, and collect specimens. Remove needle and immediately activate the safety device. Mix specimens by gentle inversion 5-10 times. Step #8 Patient care Apply direct pressure to stop bleeding at puncture site; do not have patient bend arm as this may cause a hematoma to form. After about 2 minutes, check the puncture site to verify that bleeding has stopped. Apply bandage if appropriate. Thank the patient for his/her cooperation. Step #9 Specimen labeling Label specimen(s) in the presence of the patient including all the information that is required by your facility. Check the labeled tubes a second time against the patient's wristband to verify labeling accuracy. A professional phlebotomist follows the procedure in the same way for every venipuncture. This ensures that none of the vital steps are omitted. The phlebotomist who is consistent in performance and who concentrates fully to obtain a quality specimen is an indispensable part of the healthcare team. | View Page |
| Don't Get Stuck Without It Current practice mandates the use of safety devices on all needles. These devices are designed for ease of use and disposal. Tampering or disabling any safety mechanism is forbidden and unprofessional. If the safety mechanism has been compromised, you are putting yourself, the patient and your coworkers at risk of injury. | View Page |
| Do It Right the First Time All sharps, including needles with safety devices activated, must be immediately placed into an approved biohazard sharps container. Containers with rigid sides must be puncture proof and leak proof. The container must be tightly closed and discarded when 3/4 full. Biohazard waste other than sharps should be properly disposed of in clearly marked biohazard bags or containers according to site protocol. | View Page |
| Don't Compromise Your Safety An important element of safety is personal protective equipment (PPE). This must be provided to phlebotomists by their facility and may include gloves, lab coats and protective eyewear. An N95 respirator (shown in the lower image) or other respiratory protection may be required to protect the phlebotomist from Mycobacterium tuberculosis or other airborne infectious agents. Phlebotomists and other healthcare workers must be medically cleared and fit-tested to wear N95 respirators. For the phlebotomist, gloves are required during every procedure. The gloves must remain totally intact. The gloves cannot be altered in any way as to expose the hand or fingers to potential bloodborne pathogens. Never remove all or part of the finger tip of the glove while performing venipuncture. | View Page |
| Antibody identification checklist To improve the quality of conclusions when identifying antibodies, a checklist is a simple quality control tool to increase transfusion safety. If a specific antibody pattern cannot be identified with acceptable confidence, or if significant serologic or non-serologic data are inconsistent and cannot be rationalized, further testing will be required.Before concluding that the investigation is complete, unless not applicable, mentally reply to each question in the checklist. If any answer is no, has it been resolved? Antibody Identification Checklist Yes/No/NA 1. For a single antibody, does the reaction pattern fit only one antibody specificity? 2. Is antibody specificity consistent with the results of the initial antibody screen? 3. Are reaction phases consistent with antibody specificity? 4. If multiple antibodies are present, can all reactions be explained by the antibody combination? 5. If the autocontrol is negative, are patient red cells negative for the corresponding antigen(s)? 6. Have additional possible antibodies been excluded by selected red cells? 7. Can all variable reaction strengths be explained? 8. If tested, are antigen-negative donor cells compatible by antiglobulin crossmatch? 9. If there are data that do not fit antibody specificity or if there are results that are improbable, are they explainable? 10. Have all results and conclusions been systematically evaluated for consistency? | View Page |
| Literature and online resources Literature Dutton RP, Shih D, Edelman BB, Hess J, Scalea TM. Safety of uncrossmatched type-O red cells for resuscitation from hemorrhagic shock. J Trauma. 2005 Dec;59(6):1445-9. Johnson ST, Rudmann SV,Wilson, SM. Serologic problem solving strategies:a systematic approach. Bethesda, MD: AABB, 1996.Online resourcesThe following are online examples of good practice. The information should not be used as a substitute for technical and clinical judgment. Medical and technical information becomes obsolete quickly and current sources relevant to the user's location should always be consulted. Urgent requirements for blood (Calgary Laboratory Services, Calgary,Alberta, Canada) Online resource for laboratory's clients Why is there never enough O Rh negative blood? (American Red Cross) Advice for physicians on how to help prevent shortages of O Rh negative blood Transfusion reactions: Transfusion complications (Canadian Blood Services) Education website for CBS's hospital customers REACT (Sunnybrook HSC, Toronto, ON, Canada) Pocket reference card for nurses on signs and symptoms of transfusion reactions Quick cals (online calculator of p values for Fisher's exact test) Use a one-tailed test (since we would expect an antibody to react with red cells that are positive for the corresponding antigen) | View Page |
| The antibody screen is positive but the transfusion of the O Rh-negative RBCs is already in progress. What are the transfusion service (TS) laboratory's priorities in this case?Place the following procedures that will be followed by the TS in the appropriate order of priority. | View Page |
| Signs and symptoms - Job Aids Some blood safety standards require that a list of common signs and symptoms of suspected adverse reactions be included in both nursing and transfusion service manuals. Several organizations have developed job aids to help clinical staff recognize the signs and symptoms of various suspected transfusion reactions and to suggest appropriate actions (e.g., see REACT in Online Resources). | View Page |