Procedures involving phlebotomy are critical for obtaining diagnostic blood specimens and represent a well known and recognized problem, probablyamong the most important issues in laboratory medicine. The aim of this report is to show spurious hyperkalemia and hypocalcemia due toinadequate phlebotomy procedure. The diagnostic blood specimens were collected from a male outpatient 45 years old, with no clinical complaints.The tubes drawing order were as follows: i) clot activator and gel separator (serum vacuum tube), ii) K3EDTA, iii) a needleless blood gas dedicatedsyringewith 80 I.U. lithium heparin, directly connected to the vacuum tube holder system. The laboratory testing results from serum vacuum tubeand dedicated syringe were 4.8 and 8.5 mmol/L for potassium, 2.36 and 1.48 mmol/L for total calcium, respectively. Moreover 0.15 mmol/L of freecalcium was observed in dedicated syringe. A new blood collection was performed without K3EDTA tube. Diff erent results were found for potassium(4.7 and 4.5 mmol/L) and total calcium (2.37 and 2.38 mmol/L) from serum vacuum tube and dedicated syringe, respectively. Also free calciumshowed diff erent concentration (1.21 mmol/L) in this new sample when compared with the fi rst blood specimen. Based on this case we do not encouragethe laboratory managers training the phlebotomists to insert the dedicated syringes in needle-holder system at the end of all vacuum tubes.To avoid double vein puncture the dedicated syringe for free calcium determination should be inserted immediately after serum tubes before EDTAvacuum tubes.

Incorrect order of draw could be mitigate the patient safety: a phlebotomy management case report.

De Souza Lima Oliveira, Gabriel;LIPPI, Giuseppe;SALVAGNO, GIAN LUCA;MONTAGNANA, Martina;GUIDI, Giancesare
2013

Abstract

Procedures involving phlebotomy are critical for obtaining diagnostic blood specimens and represent a well known and recognized problem, probablyamong the most important issues in laboratory medicine. The aim of this report is to show spurious hyperkalemia and hypocalcemia due toinadequate phlebotomy procedure. The diagnostic blood specimens were collected from a male outpatient 45 years old, with no clinical complaints.The tubes drawing order were as follows: i) clot activator and gel separator (serum vacuum tube), ii) K3EDTA, iii) a needleless blood gas dedicatedsyringewith 80 I.U. lithium heparin, directly connected to the vacuum tube holder system. The laboratory testing results from serum vacuum tubeand dedicated syringe were 4.8 and 8.5 mmol/L for potassium, 2.36 and 1.48 mmol/L for total calcium, respectively. Moreover 0.15 mmol/L of freecalcium was observed in dedicated syringe. A new blood collection was performed without K3EDTA tube. Diff erent results were found for potassium(4.7 and 4.5 mmol/L) and total calcium (2.37 and 2.38 mmol/L) from serum vacuum tube and dedicated syringe, respectively. Also free calciumshowed diff erent concentration (1.21 mmol/L) in this new sample when compared with the fi rst blood specimen. Based on this case we do not encouragethe laboratory managers training the phlebotomists to insert the dedicated syringes in needle-holder system at the end of all vacuum tubes.To avoid double vein puncture the dedicated syringe for free calcium determination should be inserted immediately after serum tubes before EDTAvacuum tubes.
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Utilizza questo identificativo per citare o creare un link a questo documento: http://hdl.handle.net/11562/585152
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