Staying ahead with excellence in sample collection

Someone once said that nothing happens forever, and then everything happens at once. Partly due to technology, and partly due to an increasingly complex healthcare environment, this is arguably an apt description of the evolution of sample collection by phlebotomists in the last ten to twelve years. You might apply the “80:20 rule”: Back then, 80 percent of health systems used a manual process, and 20 percent had some sort of collection device. Today, the reverse is true.

Progress—and challenges

And yet, despite this obvious increase in efficiency, the collection process has become more and more difficult. For example, the lab has little to no margin for error, given more stringent turnaround time targets to meet SLAs, so phlebotomists are tasked with more stringent targets (for example, twelve routine collections per hour instead of six or seven). Given the shift away from inpatient bed stays, orders are also arriving from an increasingly large outpatient environment, and managing larger phlebotomy groups and their devices is crucial. Phlebotomists are more commonly working alongside nursing teams, and the ability to interact responsibly to avoid re-sticks (or no sticks at all) is vital. And, while an iPhone or Android device both bring wonderful user experience, they also require training and set-up and present security challenges, as more of the underlying technology is available across networks that must be kept secure and safely beyond the reach of any potential privacy violations.

In 2011, Dr. Robert Hawkins wrote that the clinical lab industry’s focus on quality has resulted in an error rate of 4-5 Sigma (on a par with the Sigma estimate for baggage handling, at 4 Sigma, and way ahead of healthcare generally, placed at around 1-2 Sigma),1 but the pre-analytical phase still represents over half of all errors in published studies. Not that a reminder of the importance of getting this right is needed, but it is still the highest risk area.2

So, how can we effectively work within the confines of these shifting trends while maintaining as high a level as possible of error free labeling reliability? The three obvious areas of staff training, leveraging technology, and partnerships within and outside the organization remain key, but each now require new considerations when planning for success.

Training and technology

The benefits of effective training for end users can never be overstated, as the complexity of what is expected at the patient’s side has increased. Users must be aware of the correct order of draw of samples (usually well-known by phlebotomists but less known among nurse collectors), when to appropriately reschedule or credit a test, and the best way to embed the National Patient Safety Goals of using two patient identifiers and labeling in the presence of the patient into the workflow. Fortunately, technology can do a lot of the heavy lifting here, but what it cannot do is ensure that the staff are well versed in ensuring privacy rules are not breached.

In its 2017 Data Breach Investigation Report, Verizon analyzed 1,368 security incidents across 27 countries, and concluded that the greatest threat was from insiders, with 58 percent of protected health information (PHI) data breaches coming from internal staff at healthcare organizations.3 And according to a recent Accenture study, a lack of training could open an organization up to security weakness through employees not only inadvertently (or, alas, sometimes deliberately) compromising data.4 Training on how to properly use devices and applications is a given; but training on repercussions if something is compromised is often neglected—be it patient information on a smartphone or on a piece of paper.

With regard to technology, over the past five to seven years smartphone and tablet use have quickly increased. They are now standard in many healthcare institutions for physicians, nurses, and phlebotomists. While security can be addressed to fend off the risks of theft or inappropriate use, there are still important nuances to consider prior to deployment. For example, how will a user interact with a touchscreen device if it is not optimized to avoid “fat fingering” buttons in a busy hospital hallway while wearing protective gloves and trying to determine the supplies required for the next isolation patient? And, if a user chooses an iOS pathway, what is the best way to scan a wrist bracelet and ruggedize the device? After all, these were designed for consumers and have no built-in scanners or protective sleeves to prevent destruction from wipes or dropping on the unit floor.

If users can solve the ruggedization problem, could they use the camera to scan? Perhaps the Android route may be preferable, but since the operating system and the device manufacturer are not one and the same, what security or other compromises might they be trading off? While one size does not fit all, a clear assessment plan that leverages the experiences from institutions that have solved these issues is an excellent way to pre-empt poor adoption.

The value of partnerships

Finally, partnerships among the laboratory, informatics, and nursing teams and patient safety officers can go a long way toward ensuring that nothing—whether it is a process or a specimen—falls through the cracks. Beyond that, it is also much easier now to partner with third-party vendors to create the best solution possible for the specific needs of the institution. The majority of technology partners have a well-established application for sample collection. That typically means they will be able to engage more deeply to understand, for example, how draw responsibility needs to be moved between phlebotomists and nursing, how to create a worklist that enables staff to claim patients on the list and alert others to avoid any unnecessary patient visits, or how to configure a system to not only scan the patient at the beginning of a workflow, but also to scan the labels after they have been affixed on the tubes. Configuration for such workflows is key, and the more lab leaders are able to influence those options when an application is being built, the better for their institution.

While there has been a steep evolution in a few short years in this area, excellence in phlebotomy and improved patient safety can be easily achieved through careful planning around training, technology and partnerships—as long as the complexities of a deceptively simple workflow are not taken for granted.


  1. Hawkins R. Managing the pre- and post-analytical phases of the total testing process. 2012;32(1)5-16.
  2. See, for example, Astion ML, Shojania KG, Hamill TR, Kim S, Ng VL. Classifying laboratory incident reports to identify problems that jeopardize patient safety. Am J Clin Pathol. 2003;120:18-26; Kalra J. Medical errors: overcoming the challenges. Clin Biochem.2004; 37:1063-71; Rattan A and Lippi G. Frequency and type of preanalytical errors in a laboratory medicine department in India. Clin Chem Lab Med. 2008;46:1657-1659.
  3. Cyberespionage and ransomware attacks are on the increase warns the Verizon 2017 Data Breach Investigations Report. April 27, 2017.
  4. One in Five Health Employees Willing to Sell Confidential Data to Unauthorized Parties, Accenture Survey Finds. March 1, 2018.