Adolfo Romero

Detection and removal of fat particles from postoperative salvaged blood in orthopedic surgery

BACKGROUND: Although transfusion or return of salvaged shed blood has become popular in major orthopedic procedures, this blood‐saving method is still controversial because shed blood may be contaminated with chemical and tissular debris, such as fat particles, which may increase the risk of fat embolism after bone surgery.

Identification of preanalytical mistakes in the stat section of the clinical laboratory.

In the era of total quality management, detection and correction of mistakes at all stages of laboratory testing is of outstanding interest, although most attention has been directed towards detecting and correcting errors in the analytical portion of the testing process (1). One of the reasons for this, in addition to the lack of focus on the problem, is the practical difficulty in reporting and measuring the number of errors (1). This situation especially applies to the stat department of the laboratory, due to the huge pressure of demands for an almost immediate response, which may influence the quality (accuracy) of test results. However, as preanalytical mistakes may account for up to 80% of overall mistakes in laboratory testing (2, 3), their detection and prevention are key strategies to improve laboratory quality, and the greatest reduction in the number of laboratory errors is likely to result from improving the quality of specimen collection (4). The University Hospital ‘‘Virgen de la Victoria’’ is a 720-bed teaching hospital with specialised care units that serves an area with a population of 300,000 served by 19 community health centres attended by general practitioners. Some 4500 blood specimens from inpatients and outpatients are processed daily in the clinical laboratory, and approximately 30% of these are referred to the stat section. As an initial step towards the identification and prevention of preanalytical mistakes in the stat section of our clinical laboratory, we retrospectively assessed the number of

Length of sedimentation reaction in blood: a comparison of the test 1 ESR system with the ICSH reference method and the sedisystem 15.

Abstract The aim of this study was to compare the performance of the automatic TEST 1 ESR system, SIRE Analytical Systems (TEST 1), with that of the the Sedisystem 15, Becton Dickinson (SEDI), and the International Council for Standardization in Haematology reference method (Westergren) for measuring the length of sedimentation reaction in blood (LSRB). This reaction was measured in 418 paired blood samples drawn in K2-EDTA vacuum tubes and specific tubes from patients scheduled for routine LSRB measurement. The TEST 1 system uses micro-sedimentation and quantitative capillary photometry technology, whereas the SEDI uses a CCD camera. For Westergren, a 200 mm column with 3.0 mm internal diameter was used. Compared to Westergren, TEST 1 gives accurate values of LSRB in most of the samples (mean of differences: 0.99±10.4 mm; 95% CI, −0.807 to 2.78 mm; n =131). Similar results were obtained in the comparison with SEDI (mean of differences: −0.626±8 mm; 95% CI, −1.756 to 0.5 mm; n =195). Compared to those of fresh blood samples, LSRB values were significantly lower in 24 h stored samples, either at 4 °C (21.5±2.3 vs. 19.4±2.2 mm; ρ (Spearmans coefficient of correlation): 0.981; n = 44) or at room temperature (19.1±2.5 vs. 16.2±2.1 mm; ρ: 0.903; n = 46). In conclusion, TEST 1 is a rapid, reliable system for automatic measurement of LSRB in standard K2-EDTA blood samples. It has a very low imprecision and maintains a good performance in 24 h stored samples. In addition, due to its operational characteristics (60 samples/20 min) it is a suitable tool for clinical laboratories with a high work load as well as for emergency laboratories.

Role of training activities for the reduction of pre-analytical errors in laboratory samples from primary care.

BACKGROUND The presence of pre-analytical errors (PE) is a usual contingency in laboratories. The incidence may increase where it is difficult to control that period, as it is the case with samples sent from primary care (PC) to clinical reference laboratory. Detection of a large number of PE in PC samples in our Institution led to the development and implementation of preventive strategies. The first of these has been the realization of a cycle of educational sessions for PC nurses, followed by the evaluation of their impact on PE number. METHODS The incidence of PE was assessed in two periods, before (October-November 2007) and after (October-November, 2009) the implementation of educational sessions. Eleven PC centers in the urban area and 17 in the rural area participated. In the urban area, samples were withdrawn by any PC nurse; in the rural area, samples were obtained by the patients reference nurse. The types of analyzed PE included missed sample (MS), hemolyzed sample (HS), coagulated sample (CS), incorrect sample (ISV) and others (OPE), such as lipemic or icteric serum or plasma. RESULTS In the former period, we received 52,669 blood samples and 18,852 urine samples, detecting 3885 (7.5%) and 1567 (8.3%) PEs, respectively. After the educational intervention, there were 52,659 and 19,048 samples with 5057 (9.6%) and 1.256 (6.5%) PEs, respectively (p<0.001). According to the type of PE, the incidents compared before and after compared incidences were: MS, 4.8% vs. 3.8%, p<0.001; HS, 1.97% vs. 3.9%, p<0.001; CS, 0.54% vs. 0.25%, p<0.001; ISV, 0.15% vs. 0.19% p=0.08; and OPE, 0.3% vs. 0.42%, p<0.001. CONCLUSIONS Surprisingly the PE incidence increased after the educational intervention, although it should be noted that it was primarily due to the increase of HS, as the other EP incidence decreased (MS and CS) or remained unchanged (ISV). This seems to indicate the need for a comprehensive approach to reduce the incidence of errors in the pre-analytical period, as one stage interventions do not seem to be effective enough.

Preanalytical mistakes in samples from primary care patients

Abstract Background: Preanalytical mistakes (PAMs) in samples usually led to rejection upon arrival to the clinical laboratory. However, PAMs might not always be detected and result in clinical problems. Thus, PAMs should be minimized. We detected PAMs in samples from Primary Health Care Centres (PHCC) served by our central laboratory. Thus, the goal of this study was to describe the number and types of PAMs, and to suggest some strategies for improvement. Methods: The presence of PAMs, as sample rejection criteria, in samples submitted from PHCC to our laboratory during October and November 2007 was retrospectively analysed. Results: Overall, 3885 PAMs (7.4%) were detected from 52,669 samples for blood analyses. This included missed samples (n=1763; 45.4% of all PAMs, 3.3% of all samples), haemolysed samples (n=1408; 36.2% and 2.7%, respectively), coagulated samples (n=391; 10% and 0.7%, respectively), incorrect sample volume (n=110; 2.8% and 0.2%, respectively), and others (n=213; 5.5% and 0.4%, respectively). For urine samples (n=18,852), 1567 of the samples were missing (8.3%). Conclusions: We found the proportion of PAMs in blood and urine samples to be 3-fold higher than that reported in the literature. Therefore, strategies for improvement directed towards the staff involved, as well as an exhaustive audit of preanalytical process are needed. To attain this goal, we first implemented a continued education programme, financed by our Regional Health Service and focused in Primary Care Nurses. Clin Chem Lab Med 2009;47:1549–52.

Preanalytical errors: a preliminary approach to the point of view of primary health care givers.

Abstract Background: The presence of errors in the preanalytical phase is a widely studied topic. However, information regarding the perspective of those professionals involved is rather scant. Methods: Two focus groups of professionals from Primary Care involved in the preanalytical phase (general practitioners [GP], community nurses [CN], and other auxiliary health workers, including administrative personnel [AHW]) were convened. A qualitative analysis with a phenomenological approach was performed by using the structure of SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis as a guide, and results were categorized by grouping the resultant dimensions according to this structure. Results: Overall, 12 professionals (3 GP, 6 CN, and 3 AHW) were distributed in two groups. Age and gender distribution were similar between groups. The most commented strengths were organizational capability and teamwork. The main weakness was the workload increase (compared to the short time spent on sample collection). Opportunities were related to workload optimization through on-line analytical requests. Threats were related to the long time elapsed between sample drawing at Primary Care and delivery to the Central Laboratory. Conclusions: The phenomenological approach allows revealing those aspects that cannot be entirely elucidated by objective data measurement. Attitudes considered as positive can be exploited by the institution, whereas those considered as negative alert us to possible future problems. Primary Care professionals offered a different point of view to laboratory staff, but both recognized high workload as the main threat and on-line analytical request as the best opportunity. These perspectives may help to improve detection and decrease the number of errors.

Preanalytical errors: the professionals’ perspective

This study was partially supported by project Fondo de Investigaciones Sanitarias (FIS) grant PIFIS 1099/12 from “Instituto de Salud Carlos III” Ministerio de Sanidad y Politica Social. Gobierno de Espana. (Health Ministry, Spanish Government).

Integrating Research Techniques to Improve Quality and Safety in the Preanalytical Phase

Background Reducing errors in the preanalytical phase is difficult, which suggests the issue may be multidimensional. As such, qualitative research may be truly innovative in this context. Method We carried out a descriptive study using a qualitative method incorporating 4 focus groups. Data analysis followed the principles of Grounded Theory. Results We queried in each of the 4 focus groups collectively to identify weaknesses in the system. Those weaknesses that were most cited were logistics, coupled with uneven compliance with regulations. Conclusion All 4 focus groups mapped out directives for future work, so that regulatory aspects, process management, communication and resources could be identified as key areas where error reduction is critical.

Multidisciplinary training activities for decreasing preanalytical mistakes in samples from primary care

Abstract Background: The presence of preanalytical mistakes (PM) in samples from primary care centres (PCC) is a widely studied topic. Different correcting strategies have been proposed, with variable success. We planned a series of multidisciplinary sessions for clinical update, with the aim to decrease PM rates in samples from PCC. Methods: The incidence of PM in samples from PCC processed at the laboratories of University Hospital Virgen de la Victoria (LAB1) and University Hospital Juan Ramon Jimenez (LAB2) was assessed during two time periods (October to November 2013 and January to May 2014). Clinical update sessions were conducted between periods (2014). Differences in PM rates between observation periods were evaluated. Results: With respect to 2014, we observed a significant reduction of PM rates in blood samples processed at LAB1 during 2015, whereas those in LAB2 were slightly increased. The most common PMs were haemolysed sample at LAB1 and missed sample at LAB2. Conclusions: Although the presence of PM remains slightly high, there was a significant reduction after the clinical update sessions in LAB1, where the most frequent PM was haemolysed sample. In contrast, the PM rates were slightly increased at LAB2, and the main source was missed sample. This might be explained, at least in part, by different problems associated with sample transportation, and by the delay in transferring acquired knowledge into clinical practice. Implementation of regular programme of update sessions and improvements in sample transportation might help to reduce the PM presence in our area.