The team brainstormed the collection of samples, as well as the types of errors causing specimen rejection and a slowdown in the workflow process.
- Negligence in labeling periodically occurred by one staff member
- In some instances, samples clotted due to inadequate mixing (sodium citrate, EDTA, heparin)
- Occasionally, the wrong medical record number caused investigative time to correct
- In rare instances, samples hemolyzed due to difficulty in drawing a patient
- In several instances, samples were collected in an incorrect tube, but mostly by one staff member
- Incorrect quantity or insufficient samples sometimes occurred due to difficulty in collection
After doing the Five Whys for each problem the team determined that negligence in labeling and the wrong medical record problems could be corrected by a modern laboratory information system (LIS) integrated with the hospital medical information system. For the clotting issue, the team recommended a protocol that required the phlebotomist to gently mix the blood sample tube after collection and put it on a tube rocker. Improved training and retraining of phlebotomists on technique as well as better blood collection devices was recommended for reducing the number of hemolyzed samples and for making sure sufficient quantities of blood were collected.
