title: Incorrect order of draw could be mitigate the patient safety: a phlebotomy management case report.
abstract: Procedures involving phlebotomy are critical for obtaining diagnostic blood specimens and represent a well known and recognized problem, probably among the most important issues in laboratory medicine. The aim of this report is to show spurious hyperkalemia and hypocalcemia due to inadequate 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) K,EDTA, iii) a needleless blood gas dedicated-syringe with 80 I.U. lithium heparin, directly connected to the vacuum tube holder system. The laboratory testing results from serum vacuum tube and 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 free calcium was observed in dedicated syringe. A new blood collection was performed without K3EDTA tube. Different 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 calcium showed different concentration (1.21 mmol/L) in this new sample when compared with the first blood specimen. Based on this case we do not encourage the 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 EDTA vacuum tubes.
authors.affiliation: Laboratory of Clinical Biochemistry, Department of Life and Reproduction Sciences, University of Verona, Verona, Italy. dr.g.lima.oliveira@gmail.com
authors.forename: Gabriel
authors.initials: G
authors.lastname: Lima-Oliveira
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Lippi
authors.forename: Gian Luca
authors.initials: GL
authors.lastname: Salvagno
authors.forename: Martina
authors.initials: M
authors.lastname: Montagnana
authors.forename: Geraldo
authors.initials: G
authors.lastname: Picheth
authors.forename: Gian Cesare
authors.initials: GC
authors.lastname: Guidi
mesh_terms: D006801:Humans; D008297:Male; D008875:Middle Aged; D061214:Patient Safety; D018962:Phlebotomy / Q000592:standards*; D013048:Specimen Handling
references.citation: Arch Pathol Lab Med. 2006 Sep;130(9):1260-1
references.pmid: 16948506
references.citation: MLO Med Lab Obs. 1993 Mar;25(3):22-7
references.pmid: 10171391
references.citation: Clin Chem Lab Med. 2010 Oct;48(10):1447-54
references.pmid: 20716012
references.citation: Clin Biochem. 2012 Jun;45(9):683-7
references.pmid: 22440459
references.citation: Scand J Clin Lab Invest. 2004;64(3):175-84
references.pmid: 15222627
references.citation: South Med J. 2002 Oct;95(10):1218-20
references.pmid: 12425515
references.citation: Biochem Med (Zagreb). 2011;21(2):152-9
references.pmid: 22135855
references.citation: Biochem Med (Zagreb). 2012;22(2):180-6
references.pmid: 22838184
references.citation: Br J Biomed Sci. 2012;69(3):136-8
references.pmid: 23057163
references.citation: Br J Biomed Sci. 2013;70(1):6-9
references.pmid: 23617091
references.citation: Int J Lab Hematol. 2011 Oct;33(5):457-62
references.pmid: 21414180
references.citation: Ann Clin Biochem. 2008 Nov;45(Pt 6):601-3
references.pmid: 18768536
references.citation: J Clin Pathol. 2011 Nov;64(11):1019-20
references.pmid: 21778299
references.citation: Blood Coagul Fibrinolysis. 2013 Apr;24(3):252-5
references.pmid: 23160241
references.citation: Clin Chim Acta. 2011 Jul 15;412(15-16):1482-4
references.pmid: 21510927
references.citation: Biochem Med (Zagreb). 2012;22(2):145-9
references.pmid: 22838180
references.citation: Arch Pathol Lab Med. 1993 Sep;117(9):890-6
references.pmid: 8368900
references.citation: Semin Thromb Hemost. 2012 Sep;38(6):565-75
references.pmid: 22669757
references.citation: Ann Clin Biochem. 2010 Sep;47(Pt 5):485-6
references.pmid: 20595407
references.citation: Clin Chem. 1982 Jun;28(6):1399
references.pmid: 7074955
references.citation: Scand J Clin Lab Invest. 1999 Nov;59(7):491-500
references.pmid: 10667686
references.citation: Biochem Med (Zagreb). 2012;22(3):342-51
references.pmid: 23092065
references.citation: ISRN Hematol. 2012;2012:875357
references.pmid: 22888448