11/10/2014

Q.A. vs. Q.C

Review on:
Specimen Collection, Handling and
Storage with
Quality Assurance and Quality
Control

Quality Assurance
Over all program or system that ensures that the
final results generated by the laboratory has
achieved and maintained a specified quality.

Quality Control
reliability of laboratory results in terms of accuracy
and precision:
Machine
Reagents
techniques

Phases in the Performance of

Laboratory Tests
Patients Preparation
Pre-analytical Phase
Analytical Phase
Post-analytical phase

Fasting
Diet
Exercise
Smoking
Alcohol ingestion
Drugs
Circadian rhythm

WHICH OF THE FOLLOWING IS INCREASD AFTER A

STRENOUS ACTIVITY?

WHICH OF THE FOLLOWING IS INCREASD AFTER A

STRENOUS ACTIVITY?

1.AST
2. TESTOSTERONE

3. AMMONIA
4. LDH

5. CPK

1.AST
2. TESTOSTERONE

3. AMMONIA
4. LDH

5. CPK

A. 1,2 AND 3
B. 2 AND 4

C. 2, 3 AND 4
D. 1,3 AND 5

E.1,2,3,4 AND 5

A. 1,2 AND 3
B. 2 AND 4

C. 2, 3 AND 4
D. 1,3 AND 5

E.1,2,3,4 AND 5

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TRAVELLING ACROSS SEVERAL TIME ZONES

AFFECTS CIRCADIAM RHYTHM, HOW MANY
DAYS ARE REQUIRED TO ESTABLISH A STABLE
DIURNAL VARIATION?

5 DAYS

Specimen Collection

Public Relations and Client Interaction

Phlebotomy Related Vascular Anatomy
Blood specimens
Venipuncture Equipment
Tube Additives
Venipuncture Procedure
Syringe Method
Evacuated Tube System

Public Relations

Phlebotomy
Related Vascular
Anatomy

Professionalism
Appearance
Attitude

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Integrity and honesty

Compassion
Motivation
Dependability and work ethics
Diplomacy
Ethical conformity

The major veins

for venipuncture
are in the
antecubital fossa

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H-pattern

M-Pattern
Median Vein

MCV
At the center of antecubital fossa
First choice for venipuncture

Located at the very

center
First choice in Mpattern
Safe to puncture

Cephalic vein

Lateral
Second-choice in H-pattern
Often hard to palpate
Obese patients

Median Cephalic
Median Basilic

Basilic vein
Medial of antecubital fossa
Not well anchored,rolls easily
Accidentaly puncture the brachial artery
and the median cutaneous nerve branch
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Types of Blood specimens

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Venipuncture Equipment

Arterial, venous, capillary

55% fluid, 45% blood cells

Tourniquet
Restricts venous blood
flow
Distends the vein,
making them prominent
Not more than 1 minute

Whole blood
Plasma
Anticoagulated blood, Clear to slightly hazy, pale yellow
With fibrinogen

Serum
Pale yellow, Separated from cells after clotting
Usually used in blood chem
No fibrinogen

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Venipuncture Equipment

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Syringe System

Needles
Sterile, disposable
Sized by length and gauge
(the # that relates to the
needle diameter)
Gauge inversely related to
diameter
If too large= damage the vein
If too small= hemolyze the
rbc
Gauge 21-23

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Evacuated Tubes

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VENIPUNCTURE
Deoxygenated blood;
Dark red
antecubital fossa, dorsal (hand), Wrist, ankle
Pointers:
Tourniquet application
60mmHg pressure
Alcohol must not remain on the skin
15 to 30-degree angle
Drawing of blood with IV line

IMPORTANT REMINDERS

VENIPUNCTURE TECHNIQUE-ETS

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Order of Draw

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Complications

STEPS IN DOING VENIPUNCTURE

WHAT IS THE MOST

IMPORTANT STEP IN
DRAWING BLOOD?

IDENTIFYING THE IN-PATIENTS

Must be two (2) identifiers

IDENTIFYING THE OUT-PATIENTS

Must be at least two (2) identifiers

Ask the patients full name

Ask the patients date of birth

Ask the patients full name

Ask the patients date of birth
Ask the patients address

STEPS IN DOING
VENIPUNCTURE

STEPS IN DOING
VENIPUNCTURE

NEVER DRAW IF THERE IS A

DISCREPANCY!

STEPS IN DOING
VENIPUNCTURE

Identify yourself
Who you are
Where you are from
What you are going to do

STEPS IN DOING
VENIPUNCTURE

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VERIFY fasting states

Have you had anything to eat or drink?
When was the last time you had
anything to eat or drink?

VERIFY diet restrictions

STEPS IN DOING
VENIPUNCTURE

Sanitize hands
Put on gloves
Recommended:
Do not touch the patient without
gloves on.

STEPS IN DOING
VENIPUNCTURE

GLASS TUBES are strongly

recommended for medication levels
PLASTIC/GLASS Serum tubes should
NEVER be used before coagulation
tubes

STEPS IN DOING
VENIPUNCTURE

Check latex sensitivity

Check for allergies

STEPS IN DOING
VENIPUNCTURE

CLSI statesNEVER combine

Tubes
Holders
Needles
from different manufacturers

STEPS IN DOING
VENIPUNCTURE

Tubes MUST be:

Durable over its shelf life and during
centrifugation
Plastic syringes should be avoided

STEPS IN DOING
VENIPUNCTURE

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Apply tourniquet:
Used to increase intravascular pressure (single use only)
Helps
Palpating the vein and filling of the tubes

Within 20 seconds, analytes begin to change

Suggested time: 1 min.
Retying a tourniquet, must wait two (2) min.
Tourniquet location???

STEPS IN DOING
VENIPUNCTURE

BP cuff
40mmHg
Pump hand one to two times

STEPS IN DOING
VENIPUNCTURE

Cleansing venipuncture sites

Concentric motion
Air-dry at least 30s

DO NOT HAVE PATIENT PUMP

HAND! (except when using BP cuffs)

STEPS IN DOING
VENIPUNCTURE

Do not use the following veins

Underside wrist
Lower extremities
Feet
Ankles
STEPS
IN DOING
On the side
of the mastectomy arm

VENIPUNCTURE

Difficult veins
If you MUST re-touch, then you
MUST re-CLEAN

STEPS IN DOING
VENIPUNCTURE

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Invert tubes immediately

CA 5x
Na Citrate 3-4x
Heparin 8x
EDTA 8x
Na Fluoride 8x

STEPS IN DOING
VENIPUNCTURE

STEPS IN DOING VENIPUNCTURE

Check the venipuncture site (after 3-5 min.)

Bandage for 15 min. to one (1) hr.
Patients should NOT bend the arm up
If bleeding lasts more that one minute, notify
nurse or supervisor

SPECIAL HANDLING
Examples of tests that require chilling of
specimen
Gastrin
Ammonia
Lactic acid
Catecholamines
Pyruvate
PTH

STEPS IN DOING VENIPUNCTURE

Place gauze over the site. (NO cotton balls!)
Remove needles and dispose immediately
A non-additive tube may be drawn before
coagulation tubes when using a multi-draw
needle
No CA or additive tube (except SPS) should be
drawn before coagulation studies

STEPS IN DOING VENIPUNCTURE

Labeling:
Patients last and first name
ID#
Date, time, initials of phlebotomist
Time when TDM samples are collected

SPECIAL HANDLING
Examples of tests requiring transport of
specimens at 37 deg C.
Cold agglutinins
Cryofibrinogen
Cryoglobulins

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SPECIAL HANDLING
Tests requiring protection from light:
Bilirubin
All Vitamin levels
Beta carotene
Porphyrins
Both from sunlight and artificial light (with UVL)

SPECIAL HANDLING
Serum
Specimens should be clooted before
centrifugation
30-60 min for complete clotting at 20-25 deg C
NOTE: The use of wooding applicator stick for
rimming the sides of the tube is NOT
RECOMMENDED!.
Clotting time of sample is prolonged if:
Sample is chilled
Patient is in AC therapy

SPECIAL HANDLING

SPECIAL HANDLING

Plasma
Use the appropriate collection tube
Centrifuge immediately after collection

FAILURE OF BLOOD TO ENTER THE NEEDLE

ARE CAUSED BY THE FOLLOWING:

Criteria for rejection

Under the following conditions, blood specimens
may not be acceptable for testing purposes:
Inappropriate specimen containers
Discrepancies in Patient ID
Inadequate volume of blood
Hemolyzed serum/plasma
Improper storage/transport conditions

Notes on Venipuncture:
Complete Order of
draw
Stop, light red, stay
put, green light, go

Multiple
venipuncture
attempts
Try again below the
first site, other arm,
hand or wrist veins
Ask someone else
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Notes on Venipuncture

PREANALYTIC CONSIDERATIONS: Venipuncture

Burns, scars, tattoos
Damaged veins-sclerosed (hardened) or
thrombosed (clotted) occluded
Edema
Hematoma
Mastectomy
IV lines

Pediatric venipuncture
Superficial veins of the
antecubital fossa, never
deep, hard-to-find veins.
Wrap in blanket or ask to
sit on parents lap to
immobilize
Use 23 G (butterfly,
syringe needle)

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Procedural Errors

PREANALYTIC CONSIDERATIONS: Venipuncture

Hematoma
Iatrogenic anemia (10% of
blood volume)

Inadvertent arterial
puncture
Infection of the site
Nerve injury

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CAPILLARY PUNCTURE
Indications for skin puncture

CAPILLARY PUNCTURE

No accessible veins
Fragile veins
Thrombotic veins/ those with clot-forming
tendencies
POCT samples
Newborns and infants

Lateral plantar heel surface

Lateral plantar surface of big toe
Lateral palmar surface of fingers
Earlobes

Arterialized Capillary Puncture

May be obtained for blood gas analysis

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PUNCTURES SHOULD NOT BE MADE

MORE THAN 2 mm DEEP FOR
INFANTS; FOR ADULTS 2-3 mm DEEP

SPECIMEN HANDLING AND STORAGE

Centrifugation

Purposes of rapid separation of blood:

Minimize changes
To prevent continuous metabolism
To prevent electrolytes shift
Prevent hemolysis
Complete clotting: 30-60 minutes
Premature separation must be avoided
Separation is done within a maximum of 2 hours

Unacceptable Specimen

SPECIMEN HANDLING AND STORAGE

Factors that affect the integrity of specimen:
Temperature
Evaporation
Exposure to light

Saved samples and pathologic samples

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SPECIMEN HANDLING AND STORAGE

GIVE THE CAUSES
OF THIS KIND OF
SAMPLE.
(specific answer)

Temperature:
Room temp.
Refrigeration temp.
Ice packs

Freezing temp.
Solid CO2
Nitrogen gas

Anaerobic condition
ABG
Ionized and non-ionized calcium
ACP

ARTERIAL PUNCTURE IS PERFORMED

BY WHOM?

MD AND RT

5 SITES FOR
ARTERIAL
PUNCTURE

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5 SITES FOR
ARTERIAL
PUNCTURE

BEVEL
ACCIDENTALLY
COMES OUT
NEEDLE IS
PULLED OUT
BEFORE
RELEASING
THE
TOURNIQUET

TUBE HOLDER

Radial artery
Brachial artery
Femoral artery
Scalp artery
Umbilical artery

IDENTIFY
WHAT IS
WRONG IN
THIS
PICTURE?

IDENTIFY THE
ENCIRCLED PART

BASILIC VEIN

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CEPHALIC VEIN

WHAT SHOULD YOU DO IF YOU HAVE

DIFFICULTY LOCATING THE VEINS OF
YOUR PATIENT?

QUALITY CONTROL SYSTEM

Check the other arm
Enhance the vein prominence
Use an alternative site

Detect, reduce and correct deficiencies in the

laboratorys analytical process
Precisionand accuracyof laboratory tests

Objective:
Check reagents
Monitor stability of machine
Monitor personnel errors

Types of Quality Control

Internal QC
precision of laboratory tests
Based on the results of control specimens/
patients specimens

External QC
Accuracy of laboratory tests
Proficiency testing
interlaboratoryperformance

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QC materials:
Statistical Quality Control system

Standards
sample of known quantity
Specific analyte is present
Used to establish units

Controls
Sample of known quantity
Several analytes are present

Types of Variations

Mean, Mode Median

Standard deviation
Variance
Coefficient of Variation

Stages:
Establish statistical limits
Use these limits to evaluate the quality control data
Taking remedial action when indicated

Levey-Jennings Chart

RANDOM ERRORS
Present in all measurements
Due to chance
Influenced by personnel and environment
Dispersed data

SYSTEMATIC ERRORS
Control values consistently in one direction
Trend or shift data

WESTGARD CONTROL RULES

WESTGARD CONTROL RULES

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WESTGARD CONTROL RULES

WESTGARD CONTROL RULES

WESTGARD CONTROL RULES

WESTGARD CONTROL RULES

WESTGARD CONTROL RULES

End of Lecture

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