The Phlebotomist and Front End Error

As laboratories focus more time and more energy on quality improvement and error reduction, one thing seems clear to me; the phlebotomist does not have a chance. What appears on the surface as a simple task is  one of the most complex in the whole of the laboratory process.

A person has to greet the patient, check their identity (which includes catching the errors of the people before), check the list of tests, select the appropriate tubes, put them in the right order, check the arm for accessible veins, prepare the vacuum tube apparatus, put on the tourniquet, puncture the skin, draw the blood keeping in mind that too little is a problem, as is too much. Then they have to mix the tubes with additives, not too much and not too little, at the same time as changing tubes. Keeping the tourniquet on too long is a problem.

When the needle comes out, make sure they don’t puncture themselves, or the patient, and the apply pressure to try and avoid a haematoma.

Then check the requisition to make sure again that the right tubes were collected in the right order for the right tests. And then they have to get the labels right.

All this is happening in the milieu of elderly people with small and weak veins, athletes with thick skin, children who are nervous and often crying and pulling away, and drug users who have shot their veins, and mom being distracted by the kids crying or running around.

And then they have to go through it again, time after time, 40-50-60 times a day.

And if a patient decides to complain because they felt rushed, or some discomfort, then we stack on more tension.

And then we have the ICU and the Emergency Department situations with all their own inherant complications, distractions, and tensions.

No wonder we have front end error as the greater proportion of significant laboratory error (40%) reported in most series around the world. 
James Reason would call most of the problems that occur in phlebotomy either as uncogntive slips, or maybe training issues. But I disagree. I don’t think that more training can help here. This is an interesting task that combines a highly complex series of steps that need to be done with mind numbing repetition and speed, in a distracting environment, with the constant reminder of zero tolerance for error. I think that the reality is that it is a near impossible expectation.

There is a site called IVteam.com which had a very short article a year ago (September 9, 2009) that discussed the development of a phlebotomy performing robot under development at Department of Mechanical Engineering at Imperial College London. (http://www.ivteam.com/phlebotomy-robot).
Now I know, as do you that machines are not ever perfect and there will be many arms that don’t work with the robot as well. But a robot is less likely to pick up the wrong tube, or get them in the wrong order, or under-mix or over-mix, or get the labels wrong. So for the laboratories that can afford it, we might one day see a mix of skilled phlebotomists and robots. For most places and most situations, we will continue to see phlebotomists sans machine.
I think that Quality folks should be really up on this and follow along. Other than doubling or trebling the phlebotomy staff (like that is ever going to happen!) this is likely going to be the only way to really address pre-examination error.



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