Original Article | Iran J Pathol.

2018; 13(2): 173-178

Iranian Journal of Pathology | ISSN: 2345-3656

The Evaluation of Error Types and Turnaround Time of Preanalytical Phase in

Biochemistry and Hematology Laboratories

Gokhan Cakirca

Dept. of Biochemistry, Sanliurfa Mehmet Akif Inan Training and Research Hospital, Sanliurfa, Turkey

KEYWORDS ABSTRACT

Preanalytical Error; Background & objective: Each laboratory should determine the type of errors and
Specimen Rejection;
turnaround time (TAT), especially in the preanalytical phase to report quality and
Quality;
Specimen Transportation; timeliness of the test results. The current study aimed at investigating the common
Turnaround Time causes of preanalytical errors in biochemistry and hematology laboratories and evalu-
ating the preanalytical TAT for outpatient samples.
Article Info
Methods: Data of rejected samples in the laboratory information system from Sep-
Received 16 Jan 2017; tember 2014 to September 2015 were retrospectively reviewed. Also, the preanalyti-
Accepted 05 April 2017; cal TAT of the outpatient samples was evaluated over the period of three months from
Published Online 17 July 2018;
June to August 2015. Preanalytical TAT was calculated from order entry to barcode
scanning in the autoanalyzer.
Results: With respect to the ratios of blood sample transfers, 1% of samples (2305
out of 225,563) in the hematology laboratory and 0.6% (1467 out of 255,943) in the
biochemistry laboratory were rejected. The most common cause of rejection in the
hematology and biochemistry laboratories was insufficient volume (48.8%) and he-
molyzed sample (74.1%), respectively. The average preanalytical TAT for the outpa-
tient samples was 62.3 minutes.The preanalytical TAT accounted for 10.8% (order
entry-sample collection), 49% (sample collection-sample receipt), and 40.2% (sample
receipt-barcode scanning in the autoanalyzer), respectively.
Conclusion: Of all the samples received in the biochemistry and hematology labora-
tories, the overall percentage of rejections were 0.6% and 1%, respectively. The main
target to improve preanalytical TAT was determined as the transportation (sample
collection-sample receipt) step.

Gokhan Cakirca, MD, Sanliurfa Mehmet Akif Inan Training and Research Hospital, Biochemistry Depart-
Corresponding information:
ment, Sanliurfa, Turkey. E-mail: cakirca.gokhan@gmail.com

Copyright © 2018, IRANIAN JOURNAL OF PATHOLOGY. This is an open-access article distributed under the terms of the Creative Commons Attribution-non-
commercial 4.0 International License which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

Vol.13 No.2 Spring 2018 IRANIAN JOURNAL OF PATHOLOGY

 Gokhan Cakirca .174

Introduction sample collection-sample receipt, and sample receipt-

Clinical laboratories play a key role in the diagnosis barcode scanning in the autoanalyzer) were calcu-
and treatment of patients since they provide data from lated. The “sample receipt-barcode scanning in the
the analysis of body fluids. Laboratory errors lead to autoanalyzer” step involves distribution of specimens
a number of clinical problems including delayed diag- to sections of the lab, centrifugation, and specimen
nosis, additional laboratory testing, and incorrect di- loading.
agnosis and treatment (1). Preanalytical phase errors In the outpatient clinics of the hospital, phlebotomy
account for approximately 60%-70% of laboratory is usually performed by experienced staff using a va-
errors. Major sources of preanalytical errors include cutainer system. However, in the inpatient services,
inappropriate test request, patient preparation, speci- phlebotomy is mostly performed by nurses and interns
men collection, specimen transportation, and speci- using syringes and needles. The blood specimens are
men preparation for testing (2). Reduction of error transported to the laboratory by the hospital person-
rates in preanalytical phase is essential to ensure cost nel. Then, the specimens are assessed by experienced
effectiveness, patient satisfaction, and quality labora- staff and either accepted or rejected depending on
tory service (3,4). the rejection criteria of the hospital laboratories. The
The turnaround time (TAT) used in hospitals to assay rejection criteria of the laboratory are clotted speci-
the performance of laboratory is defined as the time mens, insufficient volume, excess volume, specimens
taken from order entry to result reporting (5). Shorten�- with visible hemolysis, lipemic specimens, labelling
ing TAT is important for early diagnosis and treatment errors, inappropriate tube, empty tube, and damaged
that shortens patients` hospital stay and consequently specimens. The current study was approved by the
increases their satisfaction and safety (6,7). Local Ethics Committee of Mustafa Kemal Univer-
sity.
The current study aimed at investigating (I) the
causes and incidences of the specimens rejection in Statistical analysis was conducted with Microsoft
the preanalytical phase and (II) the preanalytical TAT Excel 2010 program. Calculations of rejected speci-
of outpatient samples for quality and timeliness of re- mens for hematology and biochemistry laboratories
porting the test results. were presented as number and percentage. Data of
preanalytical TAT were expressed as median (min-
Materials and Methods
max).
The current study was conducted at the hematology
Results
and biochemistry laboratories of the Mustafa Kemal
teaching Hospital. In the current study, the specimens Table 1 lists the distribution of hematology and bio-
rejected by the hematology and biochemistry labora- chemistry samples rejected in the current study. Out
tories from September 2014 to September 2015 were of 225,563 samples received in hematology labora-
reviewed. The data were obtained from the laboratory tory during the study period, 2305 samples (1%)
information system (LIS). Furthermore, the preana- were rejected. Out of 255,943 samples received in
lytical TAT of outpatient samples of chemistry, im- biochemistry laboratory during the study period,
munoassay, coagulation, and hematology test units 1467 samples (0.6%) were rejected. In the hematol-
were evaluated over a period of three months from ogy laboratory, the most common cause of rejection
June to August 2015. The preanalytical phase consists was insufficient volume (48.8% of total rejections)
of order entry, barcode printing, sample collection, followed by clotted specimens (45.6% of total rejec-
sample receipt, and barcode scanning in the autoana- tions). In the biochemistry laboratory, the most com-
lyzer steps automatically recorded in LIS as five time mon cause of rejection was hemolyzed specimens
points. The time intervals between the stages of pre- (74.1% of total rejections) followed by insufficient
analytical workflow (order entry-sample collection, volume (16.5% of total rejections). Of the specimens

Vol.13 No.2 Spring 2018 IRANIAN JOURNAL OF PATHOLOGY

175. The Evaluation of Error Types and ...

rejected due to hemolysis, 66% were collected from chemistry test units had a median of 62 minutes, im-
the hospital inpatient services and 34% from the hos- munoassay test units had a median of 73 minutes, co-
pital outpatient clinics. agulation test units had a median of 63 minutes, and
Table 2 shows the analysis of preanalytical TAT hematology test units had a median of 51 minutes.
of outpatient specimens. The preanalytical TAT for

Table 1. Rejection analysis for hematology and biochemistry specimens

Biochemistry specimen rejection, Hematology specimen rejection,
Rejection criteria
frequency; n (%) frequency; n (%)
Clotted samples 32 (2.2) 1052 (45.6)
Insufficient samples 242 (16.5) 1124 (48.8)
Excessive amount - 45 (2)
Hemolyzed samples 1087 (74.1) 24 (1)
Lipemic samples 46 (3.1) 3 (0.1)
Labelling errors 33 (2.2) 30 (1.3)
Any other reasons a
27 (1.8) 27 (1.2)
Total Rejection (n) 1467 2305
Total sample (n) 255, 943 225, 563
Total rejection rate (%)b 0.6 1
a: Inappropriate tube, empty tube and damaged specimens.
Percentages: (Number of rejected samples/Total number of rejected samples) x100.
b: (The total number of rejected samples/ total number of samples for each laboratory) x100.

Table 2. Analysis of preanalytical TAT of outpatient specimens

Laboratory test Order entry- Sample collection- Sample receipt- Preanalytical TAT
groups Sample collection Sample receipt Barcode scanning in (minutes)
the autoanalyzer
Chemistry
7 (1-335) 26 (4-276) 29 (11-505) 62
(n: 15,097)
Immunoassay
8 (1-224) 29 (4-236) 36 (11-382) 73
(n:7,248)
Coagulation
6 (1-233) 35 (4-213) 22 (11-299) 63
(n:3,094)
Hematology
6 (1-335) 32 (4-276) 13 (5-289) 51
(n:10,538)

Average 6.75 30.5 25 62.3

% of each stage 10.8% 49% 40.2% 100%

The data were expressed as median (min–max), n: Number of blood samples. Chemistry test units: 30 tests like metabolites, electro-
lytes, enzymes, lipid profile etc.; immunoassay test units: 27 tests like thyroid function tests, vitamins, fertility hormones, tumor mark-
ers etc.; coagulation test units: 5 tests like prothrombine time, partial thromboplastin time, fibrinogen, etc.; hematology test units: 22
tests like hemoglobin, hematocrit, red blood cell count, platelet count, white blood cell count etc.

Table 3. Types of preanalytical errors in the previous studies*

Guimaraes et al. (9) Sinici Lay et al. (10) Goswami et al. (11) Jacobsz et al. (12) Bhat et al. (13)
Clotted Clotted Hemolyzed Clotted Clotted
Insufficient Insufficient Insufficient Insufficient Labeling errors
Hemolyzed Inappropriate tube/container Illegible hand writing Labelling errors hemolyzed
*Types of preanalytical errors are written in order of frequency.

Vol.13 No.2 Spring 2018 IRANIAN JOURNAL OF PATHOLOGY

 Gokhan Cakirca .176

Discussion tly several times (18). It is believed that paying no

The reported incidence of the specimens rejected attention to this procedure increases the incidence of
by biochemistry and hematology laboratories ranged clotted specimens.
0.3% to 2.7% (8-10). Similarly, in the current study, Goswami et al., reported that hemolyzed specimens
the incidence of the specimens rejected by the bio- (81% of total rejections) was the most common cause
chemistry and hematology laboratories were 0.6% leading to specimen rejection (11). In the current
and 1%, respectively. Table 3 summarizes compara- study, similarly, hemolyzed specimen was the most
tive data regarding types of preanalytical errors in the common cause of rejection in the biochemistry labo-
previous studies (9-13). ratory (74.1%). Hemolysis may be caused by a num-
In the current study, insufficient volume (48.8%) ber of conditions including forceful evacuation of a
was the most common factor leading to specimen syringe into a tube, prolonged tourniquet application,
rejection in the hematology laboratory and the sec- vigorous mixing of the blood collected into the tube,
ond common factor in the biochemistry laboratory and the use of inappropriate needles (19). Dorotic et
(45.6%). Similarly, this factor was the second com- al., found in a questionnaire study that nurses had
mon cause of specimen rejection in several studies (9- insufficient knowledge about the reasons of hemo-
12). Literature shows that the incidence of insufficient lysis (20). The frequency of hemolysis was more in
volume is remarkably high in pediatric, neonatal, and inpatient services than outpatient clinics, similar to
oncology wards, in which peripheral vascular access the results of the study by Chawla et al. (16). A higher
is difficult (14,15). Chawla et al., found that the num�- incidence of hemolysis in inpatient services may be
ber of specimens with insufficient volume was higher due to incorrect phlebotomy techniques and not us-
in the outpatient clinics than inpatient services. The ing vacutainer system for blood collection. Samples
authors suggested that this difference could be attrib- in the inpatient services are mostly collected using
uted to the fact that the phlebotomists working in the syringes and needles. One study reported that the
blood collection areas perform incorrect phlebotomy phlebotomy technique used for blood collection had a
practices due to a heavy workload (16). High rates significant effect on the incidence of hemolysis (21).
of insufficient volume in the current study could be Another study reported that the incidence of preana-
attributed to the fact that phlebotomy is mostly per- lytical errors decreased from 61% to 48% after using
formed with syringes and needles in the inpatient ser- vacutainer system (22).
vices of the hospital. This can be due to the point that It is important to reduce turnaround time for early
appropriate and sufficient amount of blood cannot be diagnosis and treatment by providing the safety and
transferred to specimen collection tubes via syringes pleasure of patients. In the current study, preana-
and needles, particularly to tubes with anticoagulants. lytical TAT of outpatient samples was 62.3 minutes
Clotted specimen was the second most common and increased preanalytical TAT was primarily due
factor leading to specimen rejection in the hematol- to delayed transportion of samples to the laboratory.
ogy laboratory (45.6%). In some studies, this factor Similarly, Kaur et al., found the TAT of preanalyti-
is the most common factor with an incidence rang- cal phase as 50.4±11.9 minutes in outpatient depart-
ing 43.8% to 55.8% (9,10,13). Inappropriate handling ment and promotion of sample transportation resulted
and pretreatment of blood samples after collection (e in prolonged preanalytic TAT (23). In another study,
g, poor mixing, keeping at horizontal position) is the the time taken to preanalytical phase for outpatient
main reason of the aforesaid clotting problem (17). chemistry specimens was 29.7±6.9 minutes and that
In accordance with Clinical Laboratory Standards In- was 68.1% of overall TAT. Additionally, lagging in
stitute (CLSI) guidelines, it is advised that all blood phlebotomy was the main factor of extended preana-
samples collected in vacuum tubes be mixed gen- lytical stage (24). Delays in transport may result from

Vol.13 No.2 Spring 2018 IRANIAN JOURNAL OF PATHOLOGY

177. The Evaluation of Error Types and ...

insufficient personnel and the lack of awareness PMID:18392122 PMCID:PMC2282400

among the hospital staff about the problems arising 6. Holland LL, Smith LL, Blick KE. Reducing
from delayed transportation. Fernandes et al., re- laboratory turnaround time outliers can re-
ported that using pneumatic tube system to transport duce emergency department patient length of
blood specimens may shorten the TAT (25). In addi�- stay: an 11-hospital study. Am J Clin Pathol.
tion, preanalytical phase of turnaround time can be 2005;124(5):672-4. https://doi.org/10.1309/

shortened with taking some measurements such as us- E9QPVQ6G2FBVMJ3B PMID:16203280

ing automatic sample tube barcoding device, choos- 7. Gelrud J, Burroughs H, Koterwas J. Emergen-
cy care center turnaround time--an improve-
ing appropriate tube, providing sufficient personnel,
ment story. J Healthc Qual. 2008;30(1):31-7.
and educating phlebotomists periodically.
PMID: 18257455
Conclusion 8. Dale JC, Novis DA. Outpatient phlebotomy
In the current study, the most frequent causes of success and reasons for specimen rejection.
Arch Pathol Lab Med. 2002;126(4):416-9.
specimen rejections were hemolyzed specimen and
PMID: 11900564
insufficient volume for biochemistry laboratory. For
9. Guimaraes AC, Wolfart M, Brisolara ML,
the hematology laboratory these included clotted
Dani C. Causes of rejection of blood samples
specimen and insufficient volume. Also, lagging in
handled in the clinical laboratory of a Univer-
transportation was the main factor of prolonged pre- sity Hospital in Porto Alegre. Clin Biochem.
analytic TAT. Hence, continuous training should be 2012;45(1-2):123-6. https://doi.org/10.1016/j.
planned for hospital staff on sample collection tech- clinbiochem.2011.10.009 PMID:22040813
niques (correct techniques for venepuncture, choos- 10. Sinici Lay I, Pinar A, Akbiyik F. Classification
ing appropriate tube, etc.) and transport time of the of reasons for rejection of biological specimens
specimens. based on pre-preanalytical processes to iden-
tify quality indicators at a university hospital
Conflict of interest clinical laboratory in Turkey. Clin Biochem.
Authors declared no conflict of interest. 2014;47(12):1002-5. https://doi.org/10.1016/j.
clinbiochem.2014.04.024 PMID:24794787
References
11. Goswami B, Singh B, Chawla R, Mallika
1. Howanitz PJ. Errors in laboratory medicine:
V. Evaluation of errors in a clinical labora-
practical lessons to improve patient safety.
tory: a one-year experience. Clin Chem Lab
Arch Pathol Lab Med. 2005;129(10):1252-61.
Med. 2010;48(1):63-6. https://doi.org/10.1515/
PMID: 16196513
CCLM.2010.006 PMID:20047530
2. Lippi G, Chance JJ, Church S, Dazzi P, Fontana
R, Giavarina D, et al. Preanalytical quality im- 12. Jacobsz LA, Zemlin AE, Roos MJ, Erasmus
provement: from dream to reality. Clin Chem RT. Chemistry and haematology sample re-
jection and clinical impact in a tertiary labo-
Lab Med. 2011;49(7):1113-26. https://doi.
ratory in Cape Town. Clin Chem Lab Med.
org/10.1515/CCLM.2011.600 PMID:21517699
2011;49(12):2047-50. https://doi.org/10.1515/
3. Sciacovelli L, Plebani M. The IFCC Working
CCLM.2011.743 PMID:21995606
Group on laboratory errors and patient safety.
13. Bhat V, Tiwari M, Chavan P, Kelkar R. Analysis
Clin Chim Acta. 2009;404(1):79-85. https://doi.
of laboratory sample rejections in the pre-ana-
org/10.1016/j.cca.2009.03.025 PMID:19328194 lytical stage at an oncology center. Clin Chim
4. Plebani M. Quality indicators to detect pre-an- Acta. 2012;413(15-16):1203-6. https://doi.
alytical errors in laboratory testing. Clin Chim
org/10.1016/j.cca.2012.03.024 PMID:22507083
Acta. 2012;33(3):85-8.
14. Detaille T, Pirotte T, Veyckemans F. Vascu-
5. Hawkins RC. Laboratory Turnaround Time.
lar access in the neonate. Best Pract Res Clin
Clin Biochem Rev. 2007;28(4):179-94.

Vol.13 No.2 Spring 2018 IRANIAN JOURNAL OF PATHOLOGY

 Gokhan Cakirca .178

Anaesthesiol. 2010;24(3):403-18. https://doi. Nedić, Andjelo Beletić. Hemolysis from a nurs-

org/10.1016/j.bpa.2010.02.017 PMID:21033016 es’ standpoint – survey from four Croatian hos-
15. Gallieni M, Pittiruti M, Biffi R. Vascular ac- pitals. Biochem Med (Zagreb). 2015;25(3):393-
cess in oncology patients. CA Cancer J Clin. 400. https://doi.org/10.11613/BM.2015.039
2008;58(6):323-46. https://doi.org/10.3322/ PMID:26525069 PMCID:PMC4622201
CA.2008.0015 PMID:18971486 21. Berg JE, Ahee P, Berg JD. Variation in phle-
16. Chawla R, Goswami B, Tayal D, Mallika V. botomy techniques in emergency medicine
Identification of the types of preanalytical er- and the incidence of haemolysed samples. Ann
rors in the clinical chemistry laboratory: 1-year Clin Biochem. 2011;48(Pt 6):562-5. https://doi.
study at GB Pant Hospital. Laboratory Medi- org/10.1258/acb.2011.011099 PMID:21948490
cine. 2010;41(2):89-92. https://doi.org/10.1309/ 22. Singla P, Parkash AA, Bhattacharjee J. Preana-
LM9JXZBMLSVJT9RK lytical error occurrence rate in clinical chemis-
17. Dikmen ZG, Pinar A, Akbiyik F. Specimen try laboratory of a public hospital in India. Clin
rejection in laboratory medicine: Neces- Lab. 2011;57(9-10):749-52. PMID:22029191
sary for patient safety? Biochem Med (Za- 23. Vaneet Kaur KS, Minni Verma, Brinder Chopra.
greb). 2015;25(3):377-85. PMID:26527231 Monitoring of Turnaround time (TAT) in Bio-
PMCID:PMC4622196 chemistry Laboratory of a tertiary care hospital
18. Wayne P. Clinical Laboratory Standards Insti- in Punjab. IOSR Journal of Dental and Medical
tute. Collection, Transport, and Processing of Sciences. 2015;14(10):9-12.
Blood Specimens for Testing Plasma-Based 24. Chung HJ, Lee W, Chun S, Park HI, Min WK.
Coagulation Assays and Molecular Hemosta- Analysis of turnaround time by subdividing
sis Assays. CLSI H21-A5 document. Clinical three phases for outpatient chemistry speci-
Laboratory Standards Institute. 2008. mens. Ann Clin Lab Sci. 2009;39(2):144-9.
19. Lippi G, Plebani M, Di Somma S, Cervellin G. PMID: 19429800
Hemolyzed specimens: a major challenge for 25. Fernandes CM, Worster A, Eva K, Hill S, Mc-
emergency departments and clinical laborato- Callum C. Pneumatic tube delivery system for
ries. Crit Rev Clin Lab Sci. 2011;48(3):143- blood samples reduces turnaround times with-
53. https://doi.org/10.3109/10408363.2011.600228 out affecting sample quality. J Emerg Nurs.
PMID:21875312 2006;32(2):139-43. https://doi.org/10.1016/j.
20. Adrijana Dorotić DA, Vanja Radišić Biljak, Dara jen.2005.11.013 PMID:16580476

How to Cite This Article

Cakirca G. The Evaluation of Error Types and Turnaround Time of Preanalytical Phase in Biochemis-
try and Hematology Laboratories. Iranian Journal of Pathology, 2018; 13(2): 173-178.

Vol.13 No.2 Spring 2018 IRANIAN JOURNAL OF PATHOLOGY