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Received: 21-07-2020 | Accepted: 10-09-2020 | Published: 19-09-2020                                     Pages: 24-26                                                                                                                                                                                            

Clinical Medicine Insights Page 24 

 

Aquaintance of sample collection -Must for patient care 

Kaorey Nivedita N  

 

Introduction:  

Pre-analytical procedures are a common source of error in laboratory diagnoses that arise 

during patient preparation, sample collection, sample transfer, and sample storage. Although 

it has been reported that the pre-analytical phase is error-prone, it has recently been shown 

that a lot of errors occur in the „pre-analytical phase‟ where the initial procedures of the 

testing process are performed by health care professionals in outside the direct control of a 

clinical laboratory that is a phlebotomist who collects blood from patients. 

In the current scenario the continuity of quality in laboratory medicine is their emphasis on 

the performance and effectiveness of the analysis processes [1]. Although recent evidence 

suggests that many errors are actually found outside the analytical stage which is the forward 

and post-analytical stage. These stages are found to be more subtle than the risk of error [2]. 

Therefore our learning needs to be updated for all pre-analytic variables.  

Commonly reported types of pre-analytical error are missing sample or test request, incorrect 

or missing identification, infusion contamination, hemolyzed samples, saturated and 

inadequate containers, unsuitable containers, unsuitable blood rate for anticoagulant and 

unstable carcass condition. and storage [3] The new update of CLSI guidelines for venous 

specimen collection focuses on further details of patient identification, specimen labeling, 

patient posture, collection from mastectomy patients, managerial use, adverse reactions, 

needle transplantation, anterior venous and anterior presentation. prevention of iatrogenic 

anemia. 

Preffered venipuncture sites  include the antecubital fossa and the back of the hand. 

Prioritization for the antecubital veins are as follows A. Veins in the median aspect center of 

the arm B. Veins in the lateral aspect outer thumb side that is  cephalic vein C. Veins in the 

medial aspect inner little finger side that is  basilic vein. Tourniquet application must not 

exceed one minute before accessing the vein to prevent hemoconcentration . Because of the 

prevalence of Methicillin resistant staphylococcus aureus and other pathogens on previously 

used tourniquets, single-use tourniquets are recommended to prevent the spread of 

healthcare-acquire infections.While 70% isopropyl alcohol is still the recommended 

antiseptic of choice, the procedure that has to follow is  “cleanse the site with friction” not 

using concentric circles from inside to outside. Studies suggest that the friction scrub with 

movement back and forth is superior to concentric circular cleaning. The site must  be 

allowed to air dry before performing the venipuncture. Once the site is cleaned, if it is 

necessary to repalpate the site, the gloved finger must also be cleaned with alcohol in order 

to not contaminate the site. The needle insertion is the site one  inches below, not above the 

insertion site to reduce the risk of an accidental needlestick. The order of draw is to be 



Aquaintance of sample collection -Must for patient care 

Clinical Medicine Insights Page 25 

maintained  whether the specimens are collected by evacuated tube method or by syringe and 

is also the same for plastic or glass tubes.  

Order of draw  is recommended due to the carryover from one tube to another. A. Blood 

culture tube (yellow with SPS) or blood culture bottles B. Sodium citrate tubes (light blue) 

C. Serum tubes  non additive and additive tubes and gels (red,SST) D. Heparin tubes  with or 

without gel (light green or dark green) E. EDTA tubes  with or without gel (lavender, pearl 

white or pink) F. Sodium fluoride or potassium oxalate with antiglycolytic inhibitor (gray). 

Only blood cultures, glass non additive tubes or plastic tubes without clot activator may be 

collected before the coagulation tube light blue  .Syringes must not be used for trace element 

collections that include testing for cobalt and chromium because the plunger tip contributes 

such elements to the specimen 

Blood collection devices and their  components  like tube stoppers,  tube walls, surfactants, 

clot activators, and separator gels may interfere with the endogenous analytes,  extraneous 

materials, or bind blood components result in erroneous  measurements of the elements[4]. 

Differences in posture standing, sitting, supine cause changes in plasma volume resulting in 

hemoconcentration from supine to sitting to standing, thereby increased analyte levels [5]. 

Using a too-thin needle may result in hemolysis, distorting results for hematological cell 

counts and potassium concentrations [6]. Prolonged use of a tourniquet results in 

hemoconcentration and changes in analyte concentrations [7]. Although mixing is 

recommended by manufacturers of collection tubes, a recent study showed that lack of 

mixing did not lead to clinically significant differences in analytes compared to mixing [8]. 

Hemolysis, icterus, and lipemia may result in spurious test results [9]. Inadequate filling will 

decrease blood to additive ratio, which may lead to inaccurate results [10]. Thus with  

awareness and the introduction of strategies to recognize preanalytical errors the goal of 

achieving total laboratory quality is finally within our grasp. 

Hence laboratory physician and all laboratory personnel should be aware that spurious 

interferences may be present and that each laboratory is ultimately responsible for evaluating 

equipment and developing normal reference ranges. Careful evaluation of how specimens are 

collected, centrifuged, stored, and transported should be considered. Further, open 

communication between laboratory staff, laboratory physician,clinician  should be pursued to 

ensure best patient outcomes, minimize unnecessary costs, limit the need to redraw patients, 

improve laboratory productivity, and decrease testing turnaround time. 

REFERENCES- 

1. Barth JH. Clinical quality indicators in laboratory medicine. Ann Clin 

Biochem. 2012;49:9–16. [PubMed] 

2. Plebani M. The detection and prevention of errors in laboratory medicine. Ann Clin 

Biochem. 2010;47:101–10. [PubMed] 

3. Carraro P, Plebani M. Errors in a stat laboratory: types and frequency 10 years later. Clin 

Chem. 2007;53:1338–42. [PubMed] 

4. Bowen RA, Remaley AT. Interferences from blood collection tube components on 

clinical chemistry assays. Biochem Med (Zagreb) 2014;24:31-44. 

https://www.ncbi.nlm.nih.gov/pubmed/22042979
https://www.ncbi.nlm.nih.gov/pubmed/19952034
https://www.ncbi.nlm.nih.gov/pubmed/17525103


Aquaintance of sample collection -Must for patient care 

Clinical Medicine Insights Page 26 

5. Lippi G, Salvagno GL, Lima-Oliveira G, Brocco G, Danese E, Guidi GC Postural change 

during venous blood collection is a major source of bias in clinical chemistry testing. Clin 

Chim Acta 2014;440:164–8.  

6. Lippi G, Salvagno GL, Montagnana M, Brocco G, Cesare GG. Influence of the needle 

bore size used for collecting venous blood samples on routine clinical chemistry 

testing. Clin Chem Lab Med 2006;44:1009-14 

7. Lippi G, Salvagno GLMontagnana M, Lima-Oliveira G Guidi GC, Favaloro EJ Quality 

standards for sample collection in coagulation testing. Semin Thromb 

Hemost 2012;38:565–75 

8. Lima-Oliveira G.Lippi G, Salvagno GL, Brocco G, Gaino S, Dima F, et al.Processing of 

diagnostic blood specimens: is it really necessary to mix primary blood tubes after 

collection with evacuated tube system? Biopreserv Biobank2014;12:53–9. 

9. Lippi G, Plebani M, Favaloro EJ. Interference in coagulation testing: focus on spurious 

hemolysis, icterus, and lipemia. Semin Thromb Hemost 2013;39:258–66. 

10. CLSI. Collection, transport, and processing of blood specimens for coagulation testing 

and general performance of coagulation assays: approved guideline. Wayne 

(PA): CLSI; 2008. CLSI document H21–A5. 

 

 

 

 

 

 

 

 


