With up to 75% of laboratory errors occurring during the pre-analytical phase of testing,1 according to Dennis Ernst, director of the Center for Phlebotomy Education, a frequently overlooked area is patient or non-phlebotomist collections (e.g., clinicians’ staff, home health nurses, patients). Talk about collection of body fluids often is when patients stop listening and look as if they are thinking, “You want me to do what with what?” Taking time to connect with patients and other healthcare providers will help guarantee better samples for testing. Says Frank E. Young, MD, PhD, “The basic and most common cause of non-compliance is the patient who does not understand what is expected.”
We said it, but did they get it?
A patient receives the containers and verbal instructions for an Ova & Parasite, Clostridium difficile toxin, and a stool culture collection. Two days later, the patient returns with a cup of stool at room temperature and the PVA lid on the Cary Blair vial — and the lab staff wonders, “Why?” First and foremost, talk to patients one on one — without distraction. Is the space in which instructions are given private, or are they given to the patient standing in the lobby area in front of others? The lower the patient’s satisfaction with the interaction, the greater the likelihood of non-adherence. Were his instructions given to him as he was on his way out the door? Were written instructions provided? Was the patient asked if he understood after the instructions were given? Use clear language in non-medical terms that the patient can understand.2 Then ask the patient to repeat or explain the information he was just given. Throughout the instructions, use gentle probes: “What will you do to collect the sample?” and — if appropriate — “Show me.” Redundancy is key. Tell patients what they are going to be told, then tell them, and, finally, review what they were told.
Laboratorians, no doubt, understand the value of the read-back policy, which ensures the information was heard and transcribed correctly, and which offers the opportunity to correct immediately any mistakes. When teaching patients, asking them to repeat their instructions is designed to make certain they heard what was said. For example, state, “I want to be sure I did not leave anything out, so please tell me what you are to do?” This step gives immediate feedback about what the patient understands. Explain that to get the most benefit from tests ordered for them, the results depend on proper collection and handling of the specimen.2
Common errors
Be aware of several common mistakes that are made in collecting samples such as
- assuming the patient knows what a “clean catch mid-stream” is.
- receiving specimens that are at an incorrect temperature. To assist patients, containers should be labeled with the correct storage temperature.
- specimens received unlabeled or not labeled to CLSI standards with two identifiers (e.g., patient’s full name and date of birth).
- date or time of collection are not indicated.
Be a better educator
Is it the fault of the patient for returning incorrectly collected specimens, unlabeled specimens, or specimens maintained at the incorrect storage temperature? No, the educator is responsible for teaching the patient. Educators need to remember to slow down, and focus on the patient and the instructions; be thorough; use multiple modalities — verbal, written, and visual aids (e.g., sample containers, illustrations) — when giving instructions; give patients the lab’s phone number in case they have questions regarding collections; and give patients the correct tools to do the job.
Communicating with a wide variety of patients can present a challenge. In healthcare settings, many different languages, cultures, and ages will be encountered.3 The U.S. Census Bureau states that by 2012, 10,000 people will turn 65 every day.4 To be successful in communicating with older patients or those with limited language skills, follow these tips:
- Allow extra time and minimize distractions.
- Use short, simple words and sentences.
- Do not use medical jargon or technical terms.
- Frequently summarize the important points.
- Give patients the opportunity to ask questions.
- Assess patients’ understanding of the instructions given.
Teach other healthcare professionals
Make sure all healthcare professionals understand specimen integrity, order of draw, and handling requirements. If a nurse is upset that the specimen she delivered was deemed quantity not sufficient, or QNS, was she taught that when drawing with a butterfly, she must draw a discard tube first? If the emergency department staff has been upset because its specimens are hemolyzed, resulting in delays because the lab needs to recollect, make sure that department been taught that drawing lab specimens from an IV start does not necessarily save the patient a poke. Does the provider’s office staff (which refrigerates SSTs and spins them at day’s end) not know serum specimens must clot for 30 minutes and be spun down within two hours? These situations demand phlebotomist educators to teach other healthcare professionals and patients in order to guarantee they deliver the best specimens possible.
Stephanie Ponti (CPT 1) is a phlebotomy instructor at Cuesta College, San Luis Obispo, CA.
References
- Bersch C. Quoting Dennis Ernst. 2011: A giant leap. MLO. 2011; 43:(1):4.
- Bowman S. You said it but did they get it? How to check for understanding, http://www.bowperson.com/BOWPERSON/CheckforUnderstanding.pdf. Accessed July 5, 2011.
- Allegra Learning Solutions. Cultural Competence in Healthcare. http://www.corexcel.com/courses4/Cultural_Competence_in_Healthcare_Course_Handout.pdf. Accessed July 5, 2011.
- Robinson T, White G, Houchins J. Improving communication with older patients: Tips from the literature. Fam Pract Manag. 2006;13(8):73-78. http://www.aafp.org/fpm/2006/0900/p73.html. Accessed July 6, 2011.
MLO‘s “Tips from the clinical experts” column provides practical, up-to-date solutions to readers’ technical and clinical issues from experts in various fields.
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