|Year : 2016 | Volume
| Issue : 1 | Page : 20-26
Evaluation of request forms received in blood bank and biochemistry laboratory in a teaching hospital in North India: A comparative study of preanalytical errors
Sonam Kansay1, Minni Verma2
1 Department of Transfusion Medicine, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
2 Department of Biochemistry, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
|Date of Web Publication||4-Aug-2016|
H. No. 120, Sector 20A, Chandigarh - 160 020
Source of Support: None, Conflict of Interest: None
Background: Clinical laboratories usually focus their attention on quality control methods and quality assessment programs in dealing with the analytical aspects of testing. However, quality in clinical laboratories cannot be assumed by merely focusing on analytical aspects only. Preanalytical processes are equally important for ensuring quality services since most of the laboratory errors occur in this phase thus influencing patient outcomes and cost.
Objective: The aim of this study was to evaluate and compare the level of completion of request forms in blood bank (BB) and biochemistry (BC) laboratory of a teaching hospital in North India.
Materials and Methods: A total of 3532 requisitions were received in BB and 18,410 in BC laboratory between November 2014 and April 2015. The information regarding incomplete/inappropriate requisitions and samples in both departments were recorded, compared, and analyzed.
Results: The most common deficiency was the absence of clinical/provisional diagnosis among both the outpatient department (OPD) (50.7%) and inpatient department (IPD) (3.2%) request forms in BC. Doctor's name not mentioned in 1.1% of the OPD requisitions and platelet count not mentioned on 7.8% of platelet request forms in IPD requisitions were the most common deficiencies in BB. The only well-documented parameter was the patient's name. Maximum numbers of incomplete requests were received from medicine OPD's followed by Intensive Care Units, emergency and medicine wards.
Conclusions: As laboratory data play a significant role in medical diagnosis, incorrect/incomplete data provided to the laboratory significantly affects the comments and successful outcome of the treatment that patient receives. Therefore, clinicians and paramedical staff should be trained to adequately fill all the required information into the request forms and appreciate its importance to patient's management. Furthermore, feedback/interpretation of significant results by the laboratory physicians to the clinicians should be emphasized.
Keywords: Inpatient department, outpatient department, preanalytical error, quality control, request forms
|How to cite this article:|
Kansay S, Verma M. Evaluation of request forms received in blood bank and biochemistry laboratory in a teaching hospital in North India: A comparative study of preanalytical errors. J Nat Accred Board Hosp Healthcare Providers 2016;3:20-6
|How to cite this URL:|
Kansay S, Verma M. Evaluation of request forms received in blood bank and biochemistry laboratory in a teaching hospital in North India: A comparative study of preanalytical errors. J Nat Accred Board Hosp Healthcare Providers [serial online] 2016 [cited 2018 Jan 20];3:20-6. Available from: http://www.nabh.ind.in/text.asp?2016/3/1/20/187754
| Introduction|| |
The easiest and best way of communication between the clinician and laboratory physician is the request form. The clinician sending the request form should give relevant clinical details on the request form that will help the laboratory staff in correlating the results with the diagnosis which will further help the clinicians in confirming clinical diagnosis and patient management effectively. There should be closer interaction between clinicians and laboratory personnel to improve the quality of services. 
The rate of analytical errors in clinical laboratories have decreased significantly over the last few decades, and currently available evidence demonstrates that the pre- and post-analytical steps of the total testing process are more error-prone than the analytical phase.  In recent years, there has been an increasing interest in quality improvement and patient safety activities in healthcare. Accreditation agencies are expecting the laboratories to go beyond analytical quality and take responsibility for the pre- and post-analytical phases where most errors arise.  Clinical laboratories have long focused their attention on quality control (QC) methods and quality assessment programs in dealing with the analytical aspects of testing, but quality in clinical laboratories cannot be assumed by merely focusing on analytical aspects only. Pre- and post-analytical processes are equally important for ensuring quality laboratory services.  Process analysis has revealed that laboratory errors occur primarily in the preanalytical phase, influencing patient outcomes and cost. ,
Audit is defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Laboratory-based audits evaluate components of laboratory services; providing feedback to staff and users about the laboratory functions and efficiency.  There are three components involved in laboratory auditing namely: preanalytical phase, analytical phase, and postanalytical phase. Preanalytical phase definition by International Organization for Standardization (ISO 15189:2007): Steps starting, in chronological order, from the clinicians request including the examination, requisition, preparation of the patient, collection of the primary sample and transportation to and within the laboratory and ending when the analytical examination begins.  Mistakes in the preanalytical phase alone can account up to 50% of the mistakes in the testing cycle.  This phase includes procedures which are not under the direct control of laboratory personnel and are mostly performed outside the laboratory. Inadequate or incomplete information on the request form takes away much of the time of the laboratory physician in imagining the clinical condition of the patient, making interpretative comments difficult and may delay communications with the requesting physician, more so in patients with life-threatening medical conditions. , In India, there is paucity of data for monitoring laboratory medicine which therefore calls for auditing of laboratory practices among clinicians and laboratory personnel.
| Materials and Methods|| |
The study was conducted over a period of 6 months, i.e., from November 2014 to April 2015 in blood bank (BB) and biochemistry (BC) laboratory of a 626 bedded educational and charitable hospital dealing with a huge population of Punjab and adjoining areas. It is a multispecialty teaching hospital (includes medical college, nursing college, physiotherapy, and dental college), and currently has major Clinical Departments like Surgery (subunits: General Surgery, Gastroenterology, Urology, and Neurosurgery), Internal Medicine, Chest and Tuberculosis, Pediatrics, Gynecology and Obstetrics, Ophthalmology, Orthopedics, Oncology, Emergency, Psychiatry, Dialysis, Dermatology, ENT (Ear, Nose, and Throat) and Dental Surgery as well as Intensive Care Units (ICUs): Neonatal ICU, Surgical ICU, Intensive and Critical Care Unit. It has adequate faculty and residents as per the Medical Council of India norms. On an average, daily BB and BC laboratory receive 20 and 100 request forms with required samples, respectively. This descriptive study dealt with the preanalytical stage of laboratory investigations and compared the clinical practices at two different laboratories of the same hospital.
Specimens along with filled laboratory request forms were received in the laboratory reception room for registration before being processed. Request forms from the clinicians and containers with specimen from the patients were checked at reception for the adequacy and appropriateness. Request forms were verified manually to see if they were completed correctly and contained the required information. Practices of phlebotomists in processing specimens were verified by examining if adequate volume and type of specimens were taken in the correct vial (e.g., blood sample for sugar estimation should be taken in oxalate vial while for renal and liver function tests it should be in plain vial) and whether they were completely labeled. Same protocols were applied in both BB and BC laboratory.
Entries of all the properly filled request forms with appropriate samples received were recorded and maintained in the sample receiving register while entries of incompletely filled request forms and inappropriate samples were recorded on the preanalytical error reporting register in both the departments. Junior doctors/technician on duty screened the request forms daily and noted down the deficiency which was verified by the concerned laboratory physician. Recorded data were compiled, analyzed, and tabulated in form of tables and figures [Table 1], [Table 2], [Table 3], [Table 4] and [Table 5] and [Figure 1], [Figure 2]. Data from both the departments were compared so that practices of the clinicians with regard to both the departments could be inferred. Inappropriate or inadequate samples/incomplete request forms were not received, and they were asked for fresh request form and sample before further testing to prevent any kind of error.
|Figure 1: Comparison of incomplete request forms and samples received from different departments in the outpatient department. Requisitions were received from following outpatient departments (OPD's): Medicine, Surgery, Gynecology and Obstetrics (G and O), Pediatrics (Paed.), Orthopedics (Ortho.), Dermatology (Derma.), Ophthalmology (Ophtha.), Chest and Tuberculosis (CTB) and Psychiatry (psychi.)|
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|Figure 2: Comparison of incomplete request forms and samples received from different departments in inpatient department. Requisitions were received from following inpatient departments (IPD's): Intensive Care Units (ICU), Emergency (Emg.), Medicine wards (MW), Surgery wards (SW), Gynecology and Obstetrics (G and O), Pediatrics (Paed.), Orthopedics (Ortho.), Dermatology (Derma.), Chest and Tuberculosis (CTB), Psychiatry (psychi.), Oncology (Onco.), Operation Theatre complex (OT), and Private wards (Pvt. W)|
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|Table 1: Total number of incomplete/inappropriate patient request forms and samples|
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|Table 2: Frequency and percentage of incomplete/ inappropriate patient request forms and samples from outpatient department and inpatient department|
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|Table 3: Different type of deficiencies in outpatient department patient request forms and samples|
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|Table 4: Different type of deficiencies in inpatient department patient request forms and samples|
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|Table 5: Comparison of results of present study with other studies from the literature|
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| Results|| |
Type of deficiencies varied among both the outpatient department (OPD) and inpatient department (IPD) requisitions. Mainly three different deficiencies were observed in OPD requisitions namely absent or incomplete treating doctor's name, absent provisional diagnosis, or missing/wrong date. Request form that contained more than one type of deficiency was considered as request form with multiple deficiencies. Therefore, the total number of deficiencies outnumbers the total deficient requests in both the departments as many of the requisitions have multiple deficiencies.
A total of 3532 requisitions were received in BB including both OPD and IPD. One hundred and eight (3%) of these requisitions were incomplete or inappropriate. Deficiencies in request forms/samples were more in IPD (3.9%) compared to OPD (1.2%) requests. There were 20 (0.6%) requisitions with multiple deficiencies [Table 1] and [Table 2]. Doctor's name absent in the request form was the most common deficiency in OPD requests (1.1%) [Table 3]. Out of total 2440 IPD request forms; packed red blood cell (PRBC), platelet and fresh frozen plasma (FFP) requests were 1,685,115, and 640, respectively. Fourteen different types of deficiencies were observed in IPD requests forms. Most common deficiency observed in IPD requisitions was platelet count not mentioned on platelet request forms (7.8%) followed by prothrombin time/activated partial thromboplastin time not mentioned on FFP request forms (3.3%) and hemoglobin levels not mentioned on PRBC request forms (1.4%) [Table 4]. Maximum numbers of deficient/inappropriate requisitions or samples were received from medicine OPD [Figure 1]. Among different IPD's maximum number of deficient/inappropriate requisitions or samples were received from ICUs (n = 30) followed by hospital emergency (n = 21) [Figure 2].
A total of 18410 requisitions were received in BC laboratory from OPD and IPD. Out of which, 4316 (23.4%) were deficient/inappropriate. Deficiencies were more among OPD (58.9%) than IPD (3.6%) requests. Numbers of requisitions with multiple deficiencies were exceedingly high in BC laboratory, i.e., n = 932 (5.1%) [Table 1] and [Table 2]. Absent provisional diagnosis (50.7%) was the most common deficiency in OPD requests [Table 3]. Among IPD requests, most common deficiency detected was a lack of diagnosis/clinical details (3.2%) followed by lack of doctor's name (1.7%) on the requisition forms [Table 4]. Maximum numbers of deficient/inappropriate requisitions or samples were received from medicine OPD followed by Ophthalmology and Gynecology and Obstetrics Department [Figure 1]. Among different IPD's maximum deficient requisitions/samples were received from medicine ward (MW) (n = 122) followed by ICU's (n = 98) [Figure 2].
The results of the present study were compared with the results of other studies [Table 5], and it was observed that incomplete requests were significantly less in both the departments of our hospital which was an appreciable finding (BB [3%] than BC [23.4%]).
| Discussion|| |
To reduce the number of errors in the preanalytical phase and achieve the standards of high quality, special attention must be devoted to this phase. The preanalytical phase includes requesting an investigation by the clinician, specimen collection, handling, and processing of the test sample before complete distribution to multiple workstations. , It is the responsibility of the health care providers to give the complete information about the presumptive or confirmed diagnosis, in a clear and legible handwriting, avoiding the abbreviations as far as possible.  They should ensure the accuracy and authenticity of the details of the patient identification with utmost vigilance making it least error prone. The term "laboratory error" is defined in ISO 22367 as "failure of planned action to be completed as intended, or use a wrong plan to achieve an aim, occurring at any part of the laboratory cycle, from ordering investigations to reporting results and appropriately interpreting and reacting to them."  The most common causes of errors in the total testing process as compiled by Plebani were in preanalytical (46-68%) phase.  Errors occur when working processes do not take into consideration every possible event. Poor coordination and inefficient communication systems; lack of proper guidelines and their implementation and inadequate maintenance of equipment increases the frequency of errors.  Similar problems were also faced by Depasquale and Crockford while auditing the radiology request forms indicating that the patient can get the best possible services if a multidisciplinary approach is adopted by all the teams involved in their management. 
In this study, 3% requisitions received in BB and 23.4% received in BC were incomplete or inappropriate. Burnett et al. and Makubi et al. in their study had shown that 43% and 100% of request forms lacked complete information. , Incomplete and inappropriate requests for investigations/transfusions results in unnecessary repeat sampling, wastage of resources and even wastage of time in bringing fresh request forms and samples to prevent any possible source of errors. Inappropriate choice of laboratory tests are the most frequently reported preanalytical errors in Bonini et al. study.  Reasons for the excessive ordering of tests by doctors include defensive behavior, fear or uncertainty, lack of experience, lack of protocols and guidelines, inadequate educational feedback, and clinician's unawareness about the cost of investigations. 
Makubi et al. study found that labeling of specimens was poorly done by phlebotomists/clinicians in as many as 82.2% of the specimens.  This finding was extremely high in contrast to present study where patient identification details on the sample were deficient only on 0.3% of BB and 0.3% of BC samples while inappropriate samples were sent in 0.2% of BB and 0.02% of BC requests. The lower frequency of labeling and sampling errors in the present study was probably because in our hospital, OPD phlebotomy was managed by the department of BC itself.
Lack of a specific request form for blood transfusion leads to inappropriate blood request. Guidelines for indication of different blood components are important to reduce the unnecessary use of blood and blood products thus reducing the risk of transfusion-associated infections to patient's who did not necessarily need blood. Makubi et al. study revealed that in their blood transfusion laboratory section, there was no specific laboratory request form for ordering blood; there were no guidelines for indication of blood transfusion in the wards/clinic, they were not participating in external quality assessment, and their Hospital Transfusion Committee was not in operation.  In contrast to it, in the present study, there was a specific request form for ordering blood and its components, guidelines for indication of blood components were present in wards and clinics. Moreover, a functional Hospital Transfusion Committee was there. These were the probable reasons for the low deficient/inappropriate request forms and samples in BB as compared to other studies. However, BC laboratory and BB both participated in external QC, but it was limited to the analytical aspect only.
In this study, maximum numbers of deficient/inappropriate requisitions or samples were received from ICU's, emergency ward and MWs, which was probably due to the heavy workload, stressful environment, and frequent changing of staff due to shift duties in these wards.
The patient's demographic data help in specimen identification and interpretation of results. Whenever, samples from different subjects have the same or similar names; information such as the location of the subject, age, and gender helps in identifying the subject and their samples. Furthermore, reference ranges for some tests vary with age and gender. The location/ward of the patient enables results to be immediately communicated to the clinician. Errors in personal data and lack of clinical information can be causes of errors since the attribution and processing of units depend on the accuracy of the information, supplied in the request for blood components.  Therefore, the request for blood components must be controlled at arrival, to detect any errors or omissions. Reject Request Form philosophy should be implemented as per acceptable norms and standards.  Laboratories can develop their own sample acceptance and rejection criteria, but a more proactive approach extending back to the point of collection is required for their successful implementation. The laboratory's procedures regarding unlabeled or mislabeled specimens should be clear, and sample labeling only by the phlebotomist should be strictly implemented. Collection procedure, container, transport temperature/time/safety criteria should be stipulated and monitored.
[Table 5] shows the comparison of findings of various other studies with this study and observed that the incomplete/inappropriate requests in the present study were quite low. ,,,,,,, It indicates that the clinicians and paramedical staff were more aware and sensitized regarding protocols for sending investigations/transfusion requests and their samples. It was also observed that incomplete requests were even less in BB (3%) than BC (23.4%) which might be because errors in BB results in very serious consequences and therefore, clinicians deal with the requests for BB more attentively while applying a casual approach for BC requests. Moreover, laboratory personnel (even if they are postgraduate doctors) are least bothered to give feedback/results and their interpretation to their clinical counterparts and it is one of the significant reason that clinicians do not bother and never ask for any expert opinions to the laboratory physicians thinking that in laboratory all are just technicians nor doctors. Providing immediate feedback for significant findings/results to the concerned clinician on a regular basis could probably result in an efficient coordination between the laboratory physician and clinician, and it would significantly improve the compliance of clinicians and paramedical staff.
Missing doctors' name was one of the major deficiencies in request forms of both the departments (1.1% vs. 0.7% in BB OPD vs. IPD; 3.9% vs. 1.7% in BC OPD vs. IPD) in the present study. It was 43% in Burnett et al. study which declined to 2% when they issued the requesting doctors with self-inking stamps personalized with their name and a unique provider number with an immediate and sustained improvement in compliance.  The implementation of the recommendations suggested in the summary report of Australian Department of Health, and Ageing Medical Benefits Division can reduce the preanalytical errors. Developing a periodical education program for laboratory staff, medical staff, and clinicians that target the most important errors or omissions on request forms and shifting to electronic request forms which will allow the implementation of mandatory fields are the few initiatives suggested by them that can reduce the incomplete requests forms and errors.  The use of barcode patient identification improves sample labeling, and the reduces the bedside errors. Murphy and Kay and Dzik used Barcode patient identification system for blood sample collection, compatibility testing and administration of blood and they found that it was easy to operate and also prevented their staff from becoming distracted and interrupted during the process of transfusion therapy. ,
The limitation of this study was that the preanalytical variables such as patient preparation, patient drug intake, diet, and timing of sampling and application of tourniquet have not been included as samples were received from patients attending OPD and IPD. Therefore, only those preanalytical variables pertaining to samples and request forms were considered which were under the supervision of laboratory personnel. However, the hospital follows good laboratory practices and has well-defined standard operating procedures for sample collection in the form of sample collection manual which deals with all the preanalytical variables such as usage of the right sample collection tube, proper quantity of sample, nonhemolyzed, and nonlipemic sample.
| Conclusions|| |
There is a need to encourage the clinicians and paramedical staff to complete and adequately fill all the required information into the request forms and appreciate its importance to patient's management. This can be achieved by increasing their awareness through repeated education, training programs, discussions, and receiving their feedback with special focus on the most important errors or omissions on request forms. At the same time, laboratory physicians should develop a routine for providing feedback and interpretations for significant results to the concerned clinicians on a regular basis which would significantly improve the compliance of clinicians and paramedical staff. Implementation of electronic request forms with mandatory fields and barcode patient identification system are few methods that can reduce the frequency of incomplete requests and incidence of errors.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]