Supply chain disruptions due to the SARS‐CoV‐2 pandemic lead to an unusual preanalytical error in measuring hemoglobin concentration in a large medical center

Abstract

Preanalytical errors are defined as those that occur prior to the testing process (e.g., test request, patient and specimen identification, specimen collection, transport, accessioning and processing) and represent 46-68% of all analytical errors in clinical pathology labs [1,2]. We present an unusual preanalytical error at our Institution caused by the SARS-CoV-2 pandemic. The sequence of events leading to this error in our Hospital is described chronologically as follows. A series of variable Hemoglobin (Hg) levels was communicated to the Hematology Core Lab at Johns Hopkins Hospital, using a reporting system called HERO. HERO is an acronym for "Hopkins Event Reporting Online," an online portal for any Johns Hopkins Health System employee to report potential or observed situations, which have, or may in the future, caused harm to patients or staff. HERO tickets are infrequent and the Hematology Core lab receives on average 0-2 HERO(es) per month.However, on April of 2022, a marked increase in notifications were noted totaling 18 (Figure 1A). The HERO descriptions had, in common, variable Hg levels from blood collected from the same patients in relatively short intervals, often within 24 hrs. The values fluctuated randomly upwards or downwards, with no predictable periodicity.Figure 1B and C shows illustrative cases of variable Hg values from two patients. During this process, there was no harm to any of the patients.Every HERO ticket requires a complete investigation by the Core lab staff to determine the cause(s) triggering them. An initial assessment rapidly revealed that the discrepant values were not explainable by bleeding, transfusion, hemolysis, or use of novel medications. However, further investigation identified that all specimens were from the Oncology Service located in one specific floor/ward of the Hospital.Moreover, all specimens were collected from central venous catheters ("central lines") for administration of chemotherapy, which are useful for patients with malignancies.