Order of blood draw: Opinion Paper by the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE)

Abstract

It has been well reported over recent years that most errors within the total testing process occur in the pre-analytical phase (46%-68.2%), an area that is usually outside of the direct control of the laboratory and which includes sample collection (phlebotomy). National and international (WHO, CLSI) guidelines recommend that the order of draw of blood during phlebotomy should be blood culture/sterile tubes, then plain tubes/gel tubes, then tubes containing additives. This prevents contamination of sample tubes with additives from previous tubes that could cause erroneous results. There have been a number of studies recently looking at whether order of draw remains a problem with modern phlebotomy techniques and materials, or it is an outdated practice followed simply because of historical reasons. In the following article, the European Federation of Clinical Chemistry and Laboratory Medicine Working Group for the Preanalytical Phase (EFLM WG-PRE) provides an overview and summary of the literature with regards to order of draw in venous blood collection. Given the evidence presented in this article, the EFLM WG-PRE herein concludes that a significant frequency of sample contamination does occur if order of draw is not followed during blood collection and when performing venipuncture under less than ideal circumstances, thus putting patient safety at risk. Moreover, given that order of draw is not difficult to follow and knowing that ideal phlebotomy conditions and protocols are not always followed or possible, EFLM WG-PRE supports the continued recommendation of ensuring a correct order of draw for venous blood collection.

The EFLM strategy for harmonization of the preanalytical phase

“…In recent years, after development of high quality evacuated blood collection tubes, the risk of cross contamination of additives during a well-conducted venipuncture using straight needles has been convincingly ruled out when manufacturers recommendations are followed [27]. Nevertheless, in the belief that an ideal blood collection is sometimes unattainable, and also considering that following the order of draw is not a challenge for phlebotomists [28][29][30], the WG-PRE currently recommends that the order of draw should preferably be followed when drawing venous blood [31].…”

Harmonization in laboratory medicine: more than clinical chemistry?

“…The use of harmonized standard operating procedures (SOP), assuring multiple identifiers, as well as automated systems for patient/sample identification and information technology facilities, should obviate the risks of patient misidentification and "wrong blood in tube", true nightmares for any clinical laboratory [21]. Major advancements have been achieved in standardizing patient preparation, sample collection and handling procedures, thanks also to the efforts of working groups, in particular, the WG-PRE of the EFLM [22][23][24][25][26][27]. Finally, further work to optimize and standardize sample transportation procedures [28,29], and to harmonize criteria for evaluating the quality of biological samples and accepting/rejecting them has been largely promoted and reported, also by means of automated workstations and serum indexes [30,31].…”

Improving quality in the preanalytical phase through innovation, on behalf of the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE)

“…In keeping with these issues, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has established a specific Working Group for the Preanalytical Phase (WG-PRE), the aims of which are mainly aimed at mitigating the vulnerability of many preanalytical activities, releasing official documents, guidelines and recommendations, as well as providing continuous education for laboratory professionals and other healthcare operators. The WG has already published many documents on the harmonization and/or standardization of preanalytical activities [6][7][8][9][10][11][12][13], and has also been proactive in organizing many educational meetings across Europe. This collective article hence follows the previous three opinion papers that were published by the EFLM WG-PRE on the same topic, in concert with the first [14], second [15] and third [16] join EFLM-BD meetings which were held in Parma, Zagreb and Porto.…”