Specimen Handling and Processing  Patient position

 Pre-analytical- prior to analysis  Prolonged tourniquet application

- all the steps taken before the actual  Underfilled tube
testing of the sample  Wrong collection time
 Specimen Handling is a critical phase in
obtaining quality results. During Specimen Transport
 Approximately 46% to 68% of all  Agitation-induced hemolysis
laboratory errors occur prior to analysis  Delay in transporting
 To ensure delivery of a quality specimen  Exposure to light
for analysis: follow established policies  Failure to follow temperature
and procedures requirements
 Transport method (e.g., hand vs.
Possible Sources of Preanalytical Errors pneumatic tube)
Before Collection
 Age of patient During Specimen Processing
 Altitude  Contamination (e.g., dust or glove
 Dehydrated patient powder)
 Duplicate test orders  Delay in processing or testing
 Exercise  Delay in fluid separation from cells
 Gender of patient  Evaporation
 Inadequate fast  Failure to centrifuge specimen according
 Incomplete requisition to test requirements
 Medications  Failure to separate fluid from cells
 Patient stress  Incomplete centrifugation
 Pregnancy  Mislabeled aliquot
 Smoking  Multiple centrifugations
 Strenuous exercise  Rimming of clots
 Treatments (e.g., intravenous
medications, radioisotopes) During Specimen Storage
 Wrong test ordered  Exposure to light
 Temperature change outside defined
At Time of Collection limits
 Misidentified patient
 Antiseptic not dry Routine Handling
 Expired tube Mixing Tubes by Inversion
 Failure to invert additive tubes properly  Additive tubes require 3 to 10 gentle
 Faulty technique inversions depending on the type of tube
 Improper vein selection and the manufacturer’s instructions as
soon as they are drawn
 Inadequate volume of blood
- to distribute the additive evenly
 Inappropriate use of plasma separator
while minimizing the chance of
tube (PST) or serum separator tube hemolysis
(SST)
 Incorrect collection tube
 Incorrect needle position
 Incorrect needle size  Vigorous mixing: hemolysis.
 Mislabeled tube o Tests that cannot be performed
 Mixing tubes too vigorously on hemolyzed specimens:
 Nonsterile site preparation  Potassium
  Magnesium  Specimens that require separation of the
 Most enzyme tests serum or plasma from the cells-
 Inadequate mixing of: centrifuged within 1 hour of arrival in
o anticoagulant tubes: microclot the lab
formation- cause erroneous test  CLSI guideline H18-A3: maximum time
results, especially for limit for separating serum and plasma
hematology studies from the cells at 2 hours from time of
o gel separation tubes: prevent the collection
additive from functioning  Prompt delivery and separation
properly; clotting may be minimize the effects of metabolic
incomplete processes
 Nonadditive tubes do not require o Glycolysis- can prevented by an
mixing. additive: sodium fluoride

Transporting Specimen Time Limit Exceptions

 Rough handling and agitation can  STAT or medical emergency
hemolyze specimens, activate platelets, - priority over all other specimens;
affect coagulation tests as well as break transported, processed, and tested
tubes immediately
 Tubes should be transported stopper up  EDTA specimens
- reduce agitation, aid clot formation - within 1 hour of collection: preserve
(serum tubes), and prevent contact the integrity of the blood cells and
of the tube contents with the tube prevent artifact formation
stopper.  EDTA specimens for CBCs should be
o Blood in contact with tube - analyzed within 6 hours; generally
specimen contamination and stable for 24 hours at room
can contribute to aerosol (a fine temperature.
mist of the specimen) formation  CBC specimens in microcollection
during stopper removal. - within 4 hours.
 They should also be placed in a plastic  EDTA specimens for erythrocyte
bag with a biohazard logo, a liquid-tight sedimentation rate (ESR) determinations
closure, and a slip pocket for paperwork - within 4 hours (room temperature)
- CLSI AND OSHA guidelines or within 12 hours (refrigerated)
 Nonblood specimens- leak-proof  EDTA specimens for reticulocyte counts
containers with adequately secured lids - stable up to 6 hours at room
 Specimens transported through temperature and up to 72 hours if
pneumatic tube systems should be refrigerated
protected from shock; sealed in zipper-  Glucose test specimens (in sodium
type plastic bags to contain spills fluoride tubes)
 Department of Transportation (DOT) - stable for 24 hours at room temp and
and the Federal Aviation Administration up to 48 hours when refrigerated (2o
(FAA)- for specimens sent to off-site C to 8oC)
locations by courier or mail systems  Prothrombin time (PT) results
Delivery Time Limits - 24 hours after collection
 All specimens should be transported to (unrefrigerated and uncentrifuged)
the laboratory without delay  Partial thromboplastin time (PTT) test
 Routine blood specimens- should be at specimens
the laboratory within 45 minutes of - within 4 hours of collection
collection regardless of storage conditions
Special Handling - where specimens are centrifuged
 Body temperature: 36.4oC–37.6oC(37oC and separated from the cells to
average) protect analyte stability
 Room temperature: 15oC–30oC - specimens are identified,
 Refrigerated temperature: 2oC–10oC logged/accessioned, sorted by
 Frozen temperature: −20oC or lower department and type of processing
(some specimens require −70oC or required, and evaluated for
lower) suitability for testing

 Body Temperature Specimens Specimen Sustainability

- will precipitate or agglutinate if  Hemolysis- most frequently cited
allowed to cool below body reason for rejection of chemistry
temperature  (followed by) insufficient amount of
- transport at or near normal body specimen, or QNS (quantity not
temp sufficient)
- collected in tubes that are  Hematology: clotting- most frequent
prewarmed to 37o C reason for rejection of hematology
specimens is clotting
 Chilled specimens  Rejected specimens are not discarded
- completely immersed in a slurry of until the ordering physician or nursing
crushed ice and water and unit has been notified.
- tested immediately or refrigerated
upon arrival in the laboratory EXAMPLES OF SPECIMEN REJECTION
o Potassium levels increase if CRITERIA
chilled  Inadequate, inaccurate, or missing
 Light-Sensitive Specimen specimen identification (e.g., a urine
o Bilirubin- can decrease by up to specimen that is not labeled)
50% after 1 hour of light  Additive tubes containing an inadequate
exposure volume of blood (e.g., a partially filled
 Wrap blood specimens in aluminum foil, coagulation tube)
use amber-colored containers or use  Hemolysis (e.g., a hemolyzed specimen
light-blocking secondary specimen intended for potassium determination)
transport containers  Wrong tube (e.g., a CBC specimen
collected in a red top tube)
 Outdated tube (e.g., a CBC specimen
collected in a tube that expired the week
before)
 Improper handling (e.g., a lavender top
tube with a CBC specimen that has clots
in it due to improper mixing)
 Contaminated specimen (e.g., a urine
specimen for culture and sensitivity in
an unsterile container)
 Insufficient specimen, referred to as
Specimen Processing “quantity not sufficient” (QNS) for the
 Central processing or triage test ordered (e.g., a specimen for an
- screening and prioritizing area erythrocyte sedimentation rate submitted
- where specimens are received and in a microtainer)
prepared for testing  Wrong collection time (e.g., a specimen
for therapeutic drug monitoring (TDM)
 collected before the drug has been - equal-size tubes with equal volumes
given) of specimen must be placed opposite
 Exposure to light (e.g., bilirubin results one another
can be 50% lower after 1 hour of
exposure to light) Centrifuging Plasma and Serum Specimens
 Delay in testing (e.g., a specimen for a  Tests on plasma (tubes with
sedimentation rate in an EDTA tube is anticoagulants) may be centrifuged
stable only for 4 hours at room without delay
temperature, and 12 hours if o Prothrombin time (pro- time or
refrigerated, and sodium citrate PT) specimen collected in a
specimens older than 4 hours will give light-blue top sodium citrate
incorrect PTT results) tube
 Delay or error in processing. Serum o StatSpin Express 2 centrifuge
tubes that have not been spun within 2  Chemistry tests- performed on serum;
hours or refrigeration of serum tubes STAT chemistry tests are collected in
before centrifugation will increase some green top (heparin) tubes
analytes, such as potassium, creatinine,  Some laboratories use heparinized
phosphorus, LDH, and decrease plasma instead of serum to reduce
analytes, such as glucose, ionized turnaround time (TAT)
calcium, and CO2  Serum specimens that must clot first
o Not complete clotting: fibrin
Centrifugation formation
 Non- additive and gel-barrier serum o Complete clotting: 30-60 mins
tubes(SSTs)- completely clotted before at room temp
centrifugation
 Heparin gel-barrier tubes (PSTs)-can be Aliquot Preparation
centrifuged right away  Aliquot- portion of a specimen used for
 Hematology test specimens drawn in testing
(EDTA) tubes and specimens for tests - for multiple tests on a single
performed on whole blood- never specimen
centrifuge - for tests performed on different
 Centrifuge- spins blood and other instruments or in different areas of
specimens at a high number of the testing department
revolutions per minute (rpm)  Aliquots are prepared by transferring a
o Centrifugal force: separate the portion of the specimen into one or more
cells and plasma or serum in tubes labeled with the same ID
blood specimens to separated information as the specimen tube.
 Specimens for tests that require serum or  OSHA: “All procedures involving blood
plasma samples must be centrifuged or potentially infectious materials shall
be performed in such a manner as to
Tubes Awaiting Centrifugation minimize splashing, spraying,
 Stoppers should remain on tubes splattering, and generation of droplets of
o To avoid loss of CO2 and an these substances.”
increase of pH - disposable transfer pipettes (for
o To avoid evaporation and serum and plasma)
contamination  Serum and plasma: indistinguishable
Centrifuge Operation when transferred into the aliquot tubes
 Tubes should be “balanced” in a  Pouring the serum or plasma into aliquot
centrifuge tubes is not recommended because it
increases the possibility of aerosol
formation or splashing.