High Five for

venous blood
collection for
immunoassays
Preanalytical errors are said to be the reason for up
to 62 % of all errors in laboratory medicine [1]. Here are
some tips on how to avoid the most frequent errors.
1. Carraro P et al. Errors in a stat laboratory: Types and frequencies 10 years later. Clin Chem 2007; 53,7: 1338-42.
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This presentation tells you about the venous

blood collection process for immunoassays
Immunoassays are used to detect biomarkers that are generally
only present in small amounts in the blood; therefore correct
venous blood collection is pivotal for reliable, accurate test
results.
Radiometer provides immunoassays for cardiac markers,
infection, hemostasis and pregnancy on the AQT90 FLEX
analyzer platform.

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Quality results begin with a quality specimen

Agenda
Why the preanalytical phase is important
High Five for safe venous blood collection
Blood collection tubes

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The preanalytical phase of

venous blood collection
Preanalytical errors are said to be
the reason for up to 62 % of all
errors in laboratory medicine [1].

Error rate

The errors that can occur during

the collection and handling of blood
specimens are potentially
numerous, and the complications to
the patient potentially harmful.
Standards for venipuncture can
reduce or alleviate many of these
errors [2]
CLSI

Preanalytical phase

62 %

Analytical phase

15 %

Postanalytical phase

23 %

CLSI: Vision: To be the leader in

clinical and laboratory standards to
improve the quality of medical care. [3]

1. Carraro P et al. Errors in a stat laboratory: Types and frequencies 10 years later. Clin Chem 2007; 53,7: 1338-42.
2. CLSI. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard Sixth Edition. CLSI document GP41-A6. Wayne, PA: Clinical and Laboratory
Standards Institute; 2007.
3. www.clsi.org.
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High Five for

safe venous blood sampling:
Path of workflow:

This workflow is
based on CLSI
international
guidelines [1,2]

1. Patient preparation patient assessment and

correct data registration to maximize patient safety
2. Blood collection device greater sample integrity
and operator safety
3. Sample collection maximum safety
for patient and operator
4. Sample handling key steps for
greater sample integrity
5. Sample transport and storage minimum time
to patient results

1. CLSI. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard Sixth Edition. CLSI document GP41-A6. Wayne, PA: Clinical and Laboratory
Standards Institute; 2007.
2. CLSI. Tubes and Additives for Venous and Capillary Blood Specimen Collection; Approved Standard - Sixth Edition. CLSI document GP39-A6. Wayne, PA: Clinical and Laboratory
Standards Institute; 2010.
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1. Patient
preparation
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1. Patient preparation

Patient assessment and correct data

registration to maximize patient safety

Accurate patient identification is fundamental for

patient safety
Use at least 2 patient identifiers [1]

Proper specimen labeling

practices are critical
components of effective and
accurate patient identification
[2]

Proper sample labeling ensures the right result for

the right patient

Attach patient ID label to the sample tubes before you

leave the patient

Tips!
Carefully select a sampling site with optimal access
and blood flow

The preferred venipuncture site is the area of either arm

that is in front of and below the bend of the elbow with
a number of superficial large veins [3]
When the preferred veins are not acceptable or
available, veins on the back of the hand are also
acceptable [3]

Establish a dedicated
procedure for identifying
patient and sample.

1. Joint Commission: National Patient Safety Goals Effective January 1, 2014 (Hospital Accreditation Program, Goal 1).
2. Kahn S. Specimen mislabeling: A significant and costly cause of potentially serious medical errors. www.acutecaretesting.org Apr 2005.
3. CLSI. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard Sixth Edition. CLSI document GP41-A6. Wayne, PA: Clinical and Laboratory
Standards Institute; 2007.
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1. Patient preparation

Errors can be caused by:

Correct data registration to

maximize patient safety

Lack of patient identification and/or

sample labeling
Transcription errors due to manual
data entry
Lack of a dedicated procedure for
identifying patient and samples

Errors can lead to:

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Non-compliance
Misdiagnosis
Incorrect treatment
Resampling
Lost billing opportunities
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2. Blood collection
device
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2. Blood collection device

Greater sample integrity and operator safety

Dedicated collection tube

ensures greater sample integrity
Select a self-filling vacuum tube prefilled with an
anticoagulant
If pre-evacuation by the end user is required, evacuate
the tubes immediately before use
Choose an anticoagulant that is compatible with the
specific assay(s) to be used

All blood collection equipment (tube,

adaptor, needle) should come from the
same manufacturer to ensure
compatibility

Anticoagulants and assay compatibility for

the AQT90 FLEX analyzer
EDTA
TnI, TnT, CKMB, Myo, NT-proBNP, D-dimer,
hCG, CRP

Lithium heparin
TnI, TnT, CKMB, Myo, NT-proBNP, D-dimer,
hCG, CRP

Citrate 3.2 %
D-dimer

Do NOT use tubes that contain a gel

Do NOT use serum tubes
1. Ball J et al. Needlestick injury in 2008. Results from a survey of RCN members. Royal College of Nursing 2008.
2. Sharps safety. RCN guidance to support implementation of the EU Directive 2010/32/EU on the prevention of sharps injuries in the health care sector. Royal College of Nursing 2011.
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2. Blood collection device

Greater sample integrity and patient safety with

the AQT90 FLEX analyzer

Do NOT use gel tubes

Blood collection tube gels are thixotropic
polymers.
A thixotropic gel is semi-solid under
static conditions it becomes fluid when
stirred or shaken and returns to the
semi-solid state upon standing.

Risk of wrong results

Whole-blood samples in gel tubes
If a tube with a gel is placed on the AQT90
FLEX analyzer and mixed by the inlet
wheel, we risk that part of the gel is mixed
with the blood when the sample is
aspirated
1. Unpublished data performed on the AQT90 FLEX.
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Plasma samples from gel tubes

If the aspirated sample contains gel droplets,
then the actual volume of sample will be too
low and the result will of course be affected
Highly increased imprecision has been seen
when plasma from gel tubes were used [1]
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3. Sample
collection
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3. Sample collection

Maximum safety for patient

Be sure to follow local procedures
and guidelines for sample
collection

Stop infusion
A sample from a limb receiving infusion:
Always stop infusion for a period of at least 2 minutes before you
start to collect a sample [1]

Using a tourniquet
Tourniquet application should not exceed 1 minute [1]
Indwelling lines sample collection procedure
Removing sufficient flush solution prevents sample
contamination.
Note: Without complete, thorough, and documented training,
phlebotomists should not collect blood from indwelling lines [1].

Mix with anticoagulant

Immediately after the sample is collected, gently invert
the tube according to recommendations to mix the
anticoagulant with the blood.

1. CLSI. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard Sixth Edition. CLSI document GP41-A6. Wayne, PA: Clinical and Laboratory
Standards Institute; 2007.
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3. Sample collection

Maximum safety for patient and operator

Sample contamination can be

caused by:

Operator safety can be

compromised by:

Diluting the sample with flush solution

if an insufficient amount of flush
solution has been removed

Lack of dedicated procedure for

operator safety

This can lead to:

Contaminating the sample with flush
solution will alter the sample result so
that it no longer represents the
patient status
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This can lead to:

Needle stick injury
Operator concern over own safety
Infection by blood-borne pathogens

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4. Sample
handling
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4. Sample handling

Key steps for greater sample integrity

Proper mixing of the sample immediately after

collection for a clot-free sample
Mix to dissolve the anticoagulant to prevent clots to form
Invert EDTA and lithium-heparin tubes at least 5-10
times unless otherwise specified by the tube
manufacturer [1]
Invert citrate tubes 3-4 times [1]

Note: An inversion is one complete turn of the

wrist, back and forth.

1. CLSI. Procedures for the Handling and Processing of Blood Specimens for Common Laboratory Tests; Approved GuidelineFourth Edition. CLSI document GP44-A4. Wayne, PA:
Clinical and Laboratory Standards Institute; 2010.
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4. Sample handling

Key steps for greater sample integrity

Microclots can be formed if

the sample is not mixed
properly immediately after its
collection.
Clots in the sample
can lead to:
Wrong results
Analyzer downtime due to
blocked sample fluid
pathway

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5. Sample transport
and storage
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5. Sample transport and storage

Minimum time to patient results with the AQT90

FLEX analyzer

Analyze sample immediately for optimal

sample integrity and short TAT
If samples cannot be analyzed immediately, separate
plasma immediately after sample collection
Store plasma at 2-8 C[1]
Analyze plasma within 24 hours of collection time

The ability to run tests directly on whole-blood

samples in capped tubes minimizes sample
handling time and thereby the time to patient
results.

NOTE:
Analyze TnI whole-blood
samples within 2 hours after
sample collection
Analyze other whole-blood
samples within 3 hours after
sample collection

Tips!
Note time of sample collection.
Stay within the specified time range.

1. Sample stability claims validated by internal testing.

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5. Sample transport and storage

Minimum time to patient results

Prolonged storage time can lead to:

Prolonged storage time can alter the
sample result so that it no longer
matches the patients disease state
Incorrect results

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Incorrect storage temperature can

lead to:
Incorrect storage temperature can alter
the sample result so that it no longer
matches the patients disease state
Incorrect results
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High Five for

safe venous blood sampling:
Path of workflow:
1. Patient preparation patient assessment and
correct data registration to maximize patient safety
2. Blood collection device greater sample integrity
and operator safety
3. Sample collection maximum safety
for patient and operator
4. Sample handling key steps for
greater sample integrity
5. Sample transport and storage minimum time
to patient results

1. CLSI. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard Sixth Edition. CLSI document GP41-A6. Wayne, PA: Clinical and Laboratory
Standards Institute; 2007.
2. CLSI. Tubes and Additives for Venous and Capillary Blood Specimen Collection; Approved Standard - Sixth Edition. CLSI document GP39-A6. Wayne, PA: Clinical and Laboratory
Standards Institute; 2010.
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Blood collection tubes for the

AQT90 FLEX analyzer
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Venous blood collection tubes

Tube manufacturers providing tubes

supported by the AQT90 FLEX analyzer

Becton Dickinson (BD)

Greiner International
Terumo
Sarstedt

All the manufacturers have tubes using the American/

international color codes for caps.
NOTE: In addition, Sarstedt also has tubes using the
European color codes for caps.
There are minor deviations from the international color
codes for citrate tubes in the Japanese market.
Sample tubes with one of three anticoagulants are used:
EDTA
Lithium heparin
Citrate 3.2 %

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Venous blood collection tubes

Venous blood collection tubes supported by

the AQT90 FLEX analyzer
Tube manufacturers specifications to sample tubes
Becton
Dickinson

Greiner Int.

Terumo

Sarstedt

Tube size:
13 mm 75 mm

Tube size:
13 mm 75 mm

Tube size:
13 mm 75 mm

Cap types:
Conventional
Hemoguard

Cap types:
Safety cap

Cap type:
Venosafe

Tube size:
13 mm 65 mm
11 mm 66 mm

Anticoagulants:
EDTA
Li-heparin
Citrate 3.2 %

Anticoagulants:
EDTA
Li-heparin
Citrate 3.2 %

Draw volume:
>2 mL

Draw volume:
>1.8* mL

Anticoagulants:
EDTA
Li-heparin
Citrate 3.2 %
Draw volume:
>1.8* mL

Cap type:
Monovette
Anticoagulants:
EDTA
Li-heparin
Citrate 3.2 %
Draw volume:
>2.6 mL

*1.8 mL for citrate tube containing 0.2 mL of citrate so that final volume is 2.0 mL
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Venous blood collection tubes

The AQT90 FLEX analyzer helps prevent the

user from choosing the wrong tube for a
specific test
After installation of an AQT90 FLEX
analyzer, the user sets up the analyzer to
fit local preferences.

NOTE:
The tube type is defined as
tube cap color and a name
that lets users easily and
correctly identify the tube

Tube setup is a vital part of analysis setup.

A tube type is defined for each type of
sample tube approved for use on the
analyzer, and used locally.
For each tube type it is defined which tests
can be done with the tube.
A test cannot be run on a tube if the test is
not defined for that tube type

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