1180 / Systematic monitoring of the hemolysis prevalence in laboratory samples

SPAIN
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Implementation of Patient Safety initiatives / Activities
Surveillance of Patient Safety There is no specified text here
Topic of the reported practice
Quality indicators
Aim and the benefit of the Patient Safety Practice
 
Hemolytic samples are the most prevalent cause of erroneous results in emergency laboratories at hospitals and continues to be a safety concern for patients (1). The hemolysis detected in samples interferes on several laboratory tests, leading to inaccurate results rejected by the lab, and in consequence, new interventions and delay in patient care. Even worse, if hemolysis is not detected on sample, these errors can trigger wrong medical decisions.
The main cause of erroneous results on hemolytic samples is the interference due to the outflow of intracellular components. The main laboratory tests affected by hemolysis are routine biochemical tests (potassium, LD, AST, total protein, magnesium, phosphorus, iron, triglycerides, insulin, enolase or troponin). The magnitude of the error depends on the degree of hemolysis, being considered significant an inaccuracy exceeding 10%.
The reported prevalence of hemolysis from literature or proficiency testing schemes ranges between 1 and 8% (2). The main causes of hemolysis in the samples are the blood drawing, transportation and processing methods. Differences in blood drawing procedures between health systems accounts for the high variability in the incidence of hemolyzed samples observed in laboratory.

In 2012, Hemolyzed specimens represented a 8% of samples in La Paz Hospital Emergency Laboratory, so a Global strategy was proposed to reduce this prevalence.


1.- Lippi G, Plebani M Di Somma S, Cervellin G. hemolyzed specimens: a major challenge for Emergency Departments and clinical laboratories Crit Rev Clin Lab Sci 2011 May-Jun; 48 (3):143-53)
2.- Plebani M, Sciacovelli L, M Marinova, Marcuccitti J, Chiozza ML Quality indicators in laboratory medicine: a key tool for patient safety and quality Clin Biochem 2013 Sep; 46 (13-14): 1170-4)
Description of the Patient Safety Practice
 
Methodology and implementation

”Reduction in prevalence of hemolyzed samples” strategy in Hospital La Paz from 2012 to the present, include several actions:

1- Systematic investigation of hemolysis on samples and reporting of specific comments in the affected tests pointing to the possible error due to hemolysis, and the need to confirm these results in a new blood sample.
The laboratory uses an automated detection system of hemolysis, incorporated in its biochemistry autoanalyzer. This system, called "serum Indexes" allows systematically investigation and quantify the presence of hemolysis in all samples. A warning comment on the laboratory report about the expected degree of inaccuracy in the result is automatically generated.
From the information stored in the laboratory information system described above, we construct a solid indicator of the prevalence of hemolysis, disaggregated by clinical units. Thus a quarterly indicator helps to know which are the units with the highest prevalence, where security strategy will be prioritized This indicator serves as a benchmark to evaluate the effectiveness of the corrective actions
The prevalence of hemolyzed samples is calculated as; (Number of hemolyzed samples in the quarter for the unit / total number of requests ordered by the unit) * 100.

2- In a regular manner, the results of the indicator, prevalence of hemolysis per hospitalization wards and in the emergency wards, is disseminated by Safety Nursing leaders.


3- Promote Root Cause Analysis (RCA) in high prevalence Units.
In the Emergency Service, a Focus Group was created to investigate the causes of hemolysis. The Group was composed of members of the Emergency Unit, Clinical Laboratory Service and the Patient´s Safety Committee. RCA indícated blood drawing procedures as major cause of hemolysis. An observational study was carried out. During a period of one month, 6 nurses scored their blood drawing procedures in all patients. Hemolysis was investigated in the laboratory by “Serum index” in all these samples.
A clear relationship between the method used in blood drawing and occurrence of hemolysis was observed. Blood drawing using catheter or syringe and later transfer to the vacuum tubes multiplies the risk of hemolysis in the samples by 3.7 (95% CI: ). This form of extraction accounted for 65% of hemolized samples, so it is concluded that to avoid the high prevalence of hemolysis in the Emergency Service would be necessary to decrease the use of catheter for blood drawing (1). This conclusion is consistent with the literature reviewed (2).

4. Dissemination of information about the causes of hemolysis production and recommended procedures to avoid it.
The Safety Nursing leaders, along with the Patient´s Safety Committee, started a training scheme for reference persons in any Hospital Unit, including workshops and information for dissemination ( poster on Figure 1)

Evaluation
Global prevalence of hemolysis in the Hospital decreased from 8% to 5.5% between January 2012 and June 2015 (Figure 2). In the Emergency Unit prevalence decreased from 20% to 7.5% (Figure 3)


1.- Prieto N, Gomez-Rioja R , Alcaide MJ, Beard MR, Fernandez-Calle P, Torres A. Risk of hemolysis in the Emergency Department Depend on phlebotomy practices Biochemia Medica 2013; 23 (1). A32
2.-Heyer NJ, Derzon JH, Winges L, Shaw C, D Mass, SR Snyder, Epner P, JH Nichols, Gayken JA, Ernst D, Liebow EB. Effectiveness of practices to reduce blood sample hemolysis in EDs: a laboratory medicine best practices systematic review and meta-analysis Clin Biochem 2012 Sep; 45 (13-14):.. 1012-1032).
Attachment of relevant written information and/or photos, as appropriate
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, partly
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Quantitative
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
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Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Yes
Specification of implementation in another health care setting(s)
Primary care
Successful implementation's level  of this Patient Safety Practice across settings
Yes, across multiple specialities within the same setting
Involved health care staff
 
Physicians
Nurses
Clinical manager
Quality manager
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
No
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
There is no specified text here
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users' level of involvement
There is no specified text here
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Not known
List of sources where public information is accessible
There is no specified text here
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Regular data feed back to involved staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
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Contact information
 
Name: Rubén Gómez Rioja
Country: SPAIN
Organisation: Hospital La Paz, Madrid
E-mail: rgrioja@salud.madrid.org
Phone: There is no specified text here
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