Technical Staffing Ratios.

CONTEXT.­: Laboratory managers and medical directors are charged with staffing their clinical laboratories as efficiently as possible. OBJECTIVE.­: To report and analyze the results of 3 College of American Pathologists Q-Probes studies that surveyed the normative rates of laboratory technical staffing ratios. DESIGN.­: Participants in the College of American Pathologists Q-Probes program submitted data on the levels of staffing and test volumes performed in their laboratories in 2014, 2016, and 2019. From these data, we calculated departmental productivity ratios, defined as testing volume per full-time equivalent, and degrees of managerial oversight, defined as the ratio of nonmanagement to management full-time equivalents. Participants completed general questionnaires surveying their hospital and laboratory demographics and practices, the data from which we determined demographic and practice characteristics that were significantly associated with technical staffing ratios. RESULTS.­: Sixty-seven, 82, and 79 institutions submitted data for the years 2019, 2016, and 2014, respectively. Technical staffing ratios varied widely among the various laboratory departments within each institution and among different institutions participating in this study. With the exception of cytology departments, productivity and managerial oversight ratios did not significantly change between these 3 studies. In the 2019 study, greater testing volumes were associated with higher productivity ratios. Significant associations between managerial oversight ratios and practice characteristics were not consistent across the 3 studies. CONCLUSIONS.­: Technical staffing ratios varied widely among the various laboratory departments within each institution and among different institutions participating in this study.

Phlebotomy Staffing.

CONTEXT.­: Laboratory directors are tasked with staffing laboratories in a manner that provides adequate services and maintains economic sustainability. OBJECTIVE.­: To determine the national normative rates of phlebotomy staffing and the types of laboratory operational characteristics that may be associated with the magnitude of those staffing levels. DESIGN.­: Study participants provided data on inpatient and outpatient phlebotomy sites, including the numbers of patients receiving phlebotomy services, phlebotomy staff, and billable tests. From these data, we calculated performance indicators including the numbers of phlebotomies/phlebotomy full-time equivalent staff, outpatient phlebotomy visits/full-time equivalent staff, and average outpatient phlebotomy wait times. Participants also completed a survey of their laboratory phlebotomy practices. RESULTS.­: This study was conducted during the third quarter of 2017. Forty-two institutions participated in this study, providing eligible results for 40 selected inpatient sites and 70 selected outpatient sites. The ratios for all performance indicators spanned between 3.3- and 142-fold. The median average outpatient phlebotomy wait time was 8 minutes. None of the performance indicators were associated with the practice variables that we chose to test. CONCLUSIONS.­: The distribution of phlebotomy staffing performance indicators among the laboratories participating in this study varied widely, even among those groups performing similar volumes of tests.

Workflow Mapping-A Q-Probes Study of Preanalytic Testing Processes: A College of American Pathologists Q-Probes Study of 35 Clinical Laboratories.

CONTEXT.­: Workflow mapping is a tool used to characterize operational processes throughout most industries and to identify non-value-added activities. OBJECTIVE.­: To develop a set of workflow mapping tools to compare the sequence and timing of activities, including waiting steps, used by clinical laboratories to process specimens during the preanalytic testing phase. DESIGN.­: Laboratories enrolled in this College of American Pathologists Q-Probes study created workflow maps detailing the steps they used to process specimens from the time of sample arrival in the laboratory to the time of sample delivery to chemistry analyzers. Enrollees recorded the sequence and types of steps involved in specimen processing and the time needed to complete each step. RESULTS.­: Institution average total specimen processing times (SPTs) and the number of steps required to prepare samples varied widely among institutions. Waiting steps, that is, steps requiring specimens to wait before advancing to the next process step, and specimen centrifugation consumed the greatest amount of processing times for both routine and STAT testing. Routine and STAT testing SPTs were shorter at institutions that used rapid centrifuges to prepare samples. Specimen processes requiring more sample waiting steps and computer entry steps had longer aggregate total process times than those with fewer such steps. CONCLUSIONS.­: Aggregate specimen processing times may be shortened by reducing the number of steps involving sample waiting and computer entry activities. Rapid centrifugation is likely to reduce overall average institutional SPTs.

Laboratory Staff Turnover: A College of American Pathologists Q-Probes Study of 23 Clinical Laboratories.

CONTEXT.­: Knowledge of laboratory staff turnover rates are important to laboratory medical directors and hospital administrators who are responsible for ensuring adequate staffing of their clinical laboratories. The current turnover rates for laboratory employees are unknown. OBJECTIVE.­: To determine the 3-year average employee turnover rates for clinical laboratory staff and to survey the types of institutional human resource practices that may be associated with lower turnover rates. DESIGN.­: We collected data from participating laboratories spanning a 3-year period of 2015-2017, which included the number of full-time equivalent (FTE) staff members that their laboratories employed in several personnel and departmental categories, and the number of laboratory staff FTEs who vacated each of those categories that institutions intended to refill. We calculated the 3-year average turnover rates for all laboratory employees, for several personnel categories, and for major laboratory departmental categories, and assessed the potential associations between 3-year average all laboratory staff turnover rates with institutional human resource practices. RESULTS.­: A total of 23 (20 US and 3 international) participating institutions were included in the analysis. Among the 21 participants providing adequate turnover data, the median of the 3-year average turnover rate for all laboratory staff was 16.2%. Among personnel categories, ancillary staff had the lowest median (11.1% among 21 institutions) and phlebotomist staff had the highest median (24.9% among 20 institutions) of the 3-year average turnover rates. Among laboratory departments, microbiology had the lowest median (7.8% among 18 institutions) and anatomic pathology had the highest median (14.3% among 14 institutions) of the 3-year average turnover rates. Laboratories that developed and communicated clear career paths to their employees and that funded external laboratory continuing education activities had significantly lower 3-year average turnover rates than laboratories that did not implement these strategies. CONCLUSIONS.­: Laboratory staff turnover rates among institutions varied widely. Two human resource practices were associated with lower laboratory staff turnover rates.

Blood Bank Specimen Mislabeling: A College of American Pathologists Q-Probes Study of 41 333 Blood Bank Specimens in 30 Institutions.

CONTEXT: -Incorrectly labeled patient blood specimens create opportunities for laboratory testing personnel to mistake one patient's specimen for a specimen from a different patient. Transfusion of blood that is typed on specimens that are mislabeled can result in acute hemolytic transfusion reactions. OBJECTIVE: -To assess the rates of blood bank ABO typing specimens that are mislabeled and/or contain blood belonging to another patient (so-called wrong blood in tube [WBIT]), and to compare these rates with those determined in a similar study performed in 2007. DESIGN: -Participants enrolled in this College of American Pathologists Q-Probes study for the first quarter of 2015 tallied the number of mislabeled and WBIT ABO blood typing specimens. Outcome measurements were the number of mislabeled and WBIT instances per 1000 specimens. We also evaluated the effects of various practice characteristics, in particular the use of bar coding, on the outcome measurements. RESULTS: -A total of 30 institutions submitting data on 41 333 ABO blood typing specimens recorded aggregate rates of 7.4 instances of mislabeling (306 specimens) and 0.43 instances of WBIT (10 of 23 234) per 1000 specimens submitted. Mislabeling rates were lower in institutions requiring that specimens be labeled with patients' birth dates than those that did not. The rates of specimen mislabeling and WBIT were otherwise unassociated with any of the other practice variables evaluated. CONCLUSIONS: -The rates of ABO blood typing specimen mislabeling and WBIT are not statistically different from those determined in a similar study performed in 2007 (P = .94 and P = .10). The use of bar coding was not associated with lower mislabeling (P = .80) or WBIT rates (P = .79).

The Pathologist Workforce in the United States: II. An Interactive Modeling Tool for Analyzing Future Qualitative and Quantitative Staffing Demands for Services.

CONTEXT: Pathologists are physicians who make diagnoses based on interpretation of tissue and cellular specimens (surgical/cytopathology, molecular/genomic pathology, autopsy), provide medical leadership and consultation for laboratory medicine, and are integral members of their institutions' interdisciplinary patient care teams. OBJECTIVE: To develop a dynamic modeling tool to examine how individual factors and practice variables can forecast demand for pathologist services. DESIGN: Build and test a computer-based software model populated with data from surveys and best estimates about current and new pathologist efforts. RESULTS: Most pathologists' efforts focus on anatomic (52%), laboratory (14%), and other direct services (8%) for individual patients. Population-focused services (12%) (eg, laboratory medical direction) and other professional responsibilities (14%) (eg, teaching, research, and hospital committees) consume the rest of their time. Modeling scenarios were used to assess the need to increase or decrease efforts related globally to the Affordable Care Act, and specifically, to genomic medicine, laboratory consolidation, laboratory medical direction, and new areas where pathologists' expertise can add value. CONCLUSIONS: Our modeling tool allows pathologists, educators, and policy experts to assess how various factors may affect demand for pathologists' services. These factors include an aging population, advances in biomedical technology, and changing roles in capitated, value-based, and team-based medical care systems. In the future, pathologists will likely have to assume new roles, develop new expertise, and become more efficient in practicing medicine to accommodate new value-based delivery models.

Laboratory productivity and the rate of manual peripheral blood smear review: a College of American Pathologists Q-Probes study of 95,141 complete blood count determinations performed in 263 institutions.

CONTEXT: Automated laboratory hematology analyzers are capable of performing differential counts on peripheral blood smears with greater precision and more accurate detection of distributional and morphologic abnormalities than those performed by manual examinations of blood smears. Manual determinations of blood morphology and leukocyte differential counts are time-consuming, expensive, and may not always be necessary. The frequency with which hematology laboratory workers perform manual screens despite the availability of labor-saving features of automated analyzers is unknown. OBJECTIVE: To determine the normative rates with which manual peripheral blood smears were performed in clinical laboratories, to examine laboratory practices associated with higher or lower manual review rates, and to measure the effects of manual smear review on the efficiency of generating complete blood count (CBC) determinations. DESIGN: From each of 3 traditional shifts per day, participants were asked to select serially, 10 automated CBC specimens, and to indicate whether manual scans and/or reviews with complete differential counts were performed on blood smears prepared from those specimens. Sampling continued until a total of 60 peripheral smears were reviewed manually. For each specimen on which a manual review was performed, participants indicated the patient's age, hemoglobin value, white blood cell count, platelet count, and the primary reason why the manual review was performed. Participants also submitted data concerning their institutions' demographic profiles and their laboratories' staffing, work volume, and practices regarding CBC determinations. The rates of manual reviews and estimations of efficiency in performing CBC determinations were obtained from the data. SETTING: A total of 263 hospitals and independent laboratories, predominantly located in the United States, participating in the College of American Pathologists Q-Probes Program. RESULTS: There were 95,141 CBC determinations examined in this study; participants reviewed 15,423 (16.2%) peripheral blood smears manually. In the median institution (50th percentile), manual reviews of peripheral smears were performed on 26.7% of specimens. Manual differential count review rates were inversely associated with the magnitude of platelet counts that were required by laboratory policy to trigger smear reviews and with the efficiency of generating CBC reports. Lower manual differential count review rates were associated with laboratory policies that allowed manual reviews solely on the basis of abnormal automated red cell parameters and that precluded performing repeat manual reviews within designated time intervals. The manual scan rate elevated with increased number of hospital beds. In more than one third (35.7%) of the peripheral smears reviewed manually, participants claimed to have learned additional information beyond what was available on automated hematology analyzer printouts alone. CONCLUSION: By adopting certain laboratory practices, it may be possible to reduce the rates of manual reviews of peripheral blood smears and increase the efficiency of generating CBC results.

Detecting and preventing the occurrence of errors in the practices of laboratory medicine and anatomic pathology: 15 years' experience with the College of American Pathologists' Q-PROBES and Q-TRACKS programs.

This review extracts those studies from the CAP Q-PROBES and Q-TRACKS programs that have benchmarked and monitored the occurrence of errors in the practices of laboratory medicine and anatomic pathology. The outcomes of these studies represent in aggregate the analysis of millions of data points collected in thousands of hospitals throughout the United States. Also presented in this review are hospital and laboratory practices associated with improved performance (ie, fewer errors). Only those associations that were shown to be statistically significant are presented. They represent only a small fraction of the practices examined in these studies. The reader is encouraged to peruse the Q-PROBES studies cited in the reference list to learn about the wide range of practices investigated. The institution of some of these practices for which the associated error reductions were not statistically significant might nonetheless improve performance in some environments. There is no way of knowing whether some better-performing institutions compensated for not employing presumably beneficial practices by applying other practices about which the studies' authors neglected to inquire. Nor is there any way of knowing whether institutions in which performance was poor employed presumably beneficial practices, but possessed operational flaws about which the studies' authors neglected to inquire. Certainly, hospitals operating in the bottom 10% of benchmarked performances would do well to investigate the possibility that some of these practices might reduce the incidence of errors in their institutions. From the results of these studies, there emerge two complementary strategies that appear to be associated with reduction of errors. Obviously, the first strategy involves doing what is necessary to prevent the occurrence of errors in the first place. Several tactics may accomplish this goal. Healthcare workers responsible for specific tasks must be properly educated and motivated to perform those tasks with as few errors as possible. There must be written policies and protocols detailing responsibilities and providing contingencies when those responsibilities are not met. The successful completion of required tasks must be documented, especially those tasks that are performed as requisite to others. In other words, it should be impossible to move on to subsequent operations in testing processes before documenting the successful completion of previous requisite operations. Finally, the opportunities for making errors must be reduced. Specifically, the number of steps in which specimens are delivered to laboratories, tests are performed, and results are disseminated to those who use them must be reduced as much as possible. The second strategy involves the assumption that despite our best efforts to prevent them, errors will occur. No matter how smart we are, no matter how careful we try to be, we will make mistakes. It is essential that systems designed to eliminate errors include elements of redundancy to catch those mistakes. Work must be checked and verified before therapeutic decisions are finalized. This is especially true when those decisions are irrevocable and the potential damage caused by errors cannot be undone. Ideally, systems that use redundancy should include provisions to shut down the testing process altogether when the successful execution of previous steps cannot be verified. Once error detection systems are established, service providers can gauge their performance by employing tools of continuous monitoring to assess the degree to which health care workers comply with required procedures, and with which services achieve their intended outcomes.

Continuous monitoring of stat and routine outlier turnaround times: two College of American Pathologists Q-Tracks monitors in 291 hospitals.

CONTEXT: The laboratory test turnaround times (TATs) that exceed the expectations of clinicians who order those tests, the so-called outlier test reporting rates, may be responsible for perceptions of inadequate laboratory service. OBJECTIVE: To monitor outlier test reporting rates for emergency department stat potassium results and routine inpatient morning blood tests. DESIGN: In 2 different monitors, each conducted for 2 years, laboratory personnel in institutions enrolled in the College of American Pathologists (CAP) Q-Tracks program tracked the percentages of emergency department stat potassium results and/or the percentages of morning rounds routine test results that were reported later than self-imposed reporting deadlines. SETTING: A total of 291 hospitals participating in 2 CAP Q-Tracks monitors. RESULTS: Participants monitored 225,140 stat emergency department potassium TATs, of which 33,402 (14.8%) were outliers, and 1,055040 routine morning test reporting times, of which 123,554 (11.7%) were outliers. For both monitors, there was a significant (P <.05) downward trend in the outlier rates as the number of quarters in which participants submitted data increased. CONCLUSION: Outlier reporting rates for emergency department stat potassium and routine morning test results decreased during the 2-year period of continuous monitoring. The CAP Q-Tracks program provides an effective vehicle by which providers of laboratory services may improve the timeliness with which they deliver the results of laboratory tests.

Biochemical markers of myocardial injury test turnaround time: a College of American Pathologists Q-Probes study of 7020 troponin and 4368 creatine kinase-MB determinations in 159 institutions.

CONTEXT: Rapid diagnosis of acute myocardial infarction in patients presenting to emergency departments (EDs) with chest pain may determine the types, and predict the outcomes of, the therapy those patients receive. The amount of time consumed in establishing diagnoses of acute myocardial infarction may depend in part on that consumed in the generation of the blood test results measuring myocardial injury. OBJECTIVE: To determine the normative rates of turnaround time (TAT) for biochemical markers of myocardial injury and to examine hospital and laboratory practices associated with faster TATs. DESIGN: Laboratory personnel in institutions enrolled in the College of American Pathologists Q-Probes Program measured the order-to-report TATs for serum creatine kinase-MB and/or serum troponin (I or T) for patients presenting to their hospital EDs with symptoms of acute myocardial infarction. Laboratory personnel also completed detailed questionnaires characterizing their laboratories' and hospitals' practices related to testing for biochemical markers of myocardial injury. ED physicians completed questionnaires indicating their satisfaction with testing for biochemical markers of myocardial injury in their hospitals. SETTING: A total of 159 hospitals, predominantly located in the United States, participating in the College of American Pathologists Q-Probes Program. RESULTS: Most (82%) laboratory participants indicated that they believed a reasonable order-to-report TATs for biochemical markers of myocardial injury to be 60 minutes or less. Most (75%) of the 1352 ED physicians who completed satisfaction questionnaires believed that the results of tests measuring myocardial injury should be reported back to them in 45 minutes or less, measured from the time that they ordered those tests. Participants submitted TAT data for 7020 troponin and 4368 creatine kinase-MB determinations. On average, they reported 90% of myocardial injury marker results in slightly more than 90 minutes measured from the time that those tests were ordered. Among the fastest performing 25% of participants (75th percentile and above), median order-to-report troponin and creatine kinase-MB TATs were equal to 50 and 48.3 minutes or less, respectively. Shorter troponin TATs were associated with performing cardiac marker studies in EDs or other peripheral laboratories compared to (1) performing tests in central hospital laboratories, and (2) having cardiac marker specimens obtained by laboratory rather than by nonlaboratory personnel. CONCLUSION: The TAT expectations of the ED physicians using the results of laboratory tests measuring myocardial injury exceed those of the laboratory personnel providing the results of those tests. The actual TATs of myocardial injury testing meet the expectations of neither the providers of those tests nor the users of those test results. Improving TAT performance will require that the providers and users of laboratory services work together to develop standards that meet the needs of the medical staff and that are reasonably achievable by laboratory personnel.

Audit of transfusion procedures in 660 hospitals. A College of American Pathologists Q-Probes study of patient identification and vital sign monitoring frequencies in 16494 transfusions.

CONTEXT: Hemolytic transfusion reactions are often the result of failure to follow established identification and monitoring procedures. OBJECTIVE: To measure the frequencies with which health care workers completed specific transfusion procedures required for laboratory and blood bank accreditation. DESIGN: In 2 separate studies, participants in the College of American Pathologists Q-Probes laboratory quality improvement program audited nonemergent red blood cell transfusions prospectively and completed questionnaires profiling their institutions' transfusion policies. SETTING AND PARTICIPANTS: A total of 660 institutions, predominantly in the United States, at which transfusion medicine services are provided. MAIN OUTCOMES MEASURES: The percentages of transfusions for which participants completed 4 specific components of patient and blood unit identifications, and for which participants monitored vital signs at 3 specific intervals during transfusions. RESULTS: In the first study, all components of patient identification procedures were performed in 62.3%, and all required patient vital sign monitoring was performed in 81.6% of 12 448 transfusions audited. The median frequencies with which institutions participating in the first study performed all patient identification and monitoring procedures were 69.0% and 90.2%, respectively. In the second study, all components of patient identification were performed in 25.4% and all patient vital sign monitoring was performed in 88.3% of 4046 transfusions audited. The median frequencies with which institutions participating in the second study performed all patient identification and monitoring procedures were 10.0% and 95.0%, respectively. Individual practices and/or institutional policies associated with greater frequencies of patient identification and/or vital sign monitoring included transporting units of blood directly to patient bedsides, having no more than 1 individual handle blood units in route, checking unit labels against physicians' orders, having patients wear identification tags (wristbands), reading identification information aloud when 2 or more transfusionists participated, using written checklists to guide the administration of blood, instructing health care personnel in transfusion practices, and routinely auditing the administration of transfusions. CONCLUSIONS: In many hospitals, the functions of identification and vital sign monitoring of patients receiving blood transfusions do not meet laboratory and blood bank accreditation standards. Differences in hospital transfusion policies influence how well health care workers comply with standard practices. We would expect that efforts designed to perfect transfusion policies might also improve performance in those hospitals in which practice compliance is substandard.

Operating room blood delivery turnaround time: a College of American Pathologists Q-Probe Study of 12647 units of blood components in 466 institutions.

OBJECTIVES: To determine the normative distribution of time elapsed for blood bank personnel to fill nonscheduled operating room (OR) blood component orders in hospital communities throughout the United States, and to examine hospital blood bank practices associated with faster blood component delivery times. DESIGN: Participants in the College of American Pathologists Q-Probes laboratory quality improvement program collected data prospectively on the times elapsed for blood bank personnel to fill nonscheduled emergent orders from hospital ORs for red blood cell (RBC) products, fresh frozen plasma (FFP), and platelets (PLTs). Participants also completed questionnaires describing their hospitals' and blood banks' laboratory and transfusion practices. SETTING AND PARTICIPANTS: Four hundred sixty-six public and private institutions located in 48 states in the United States (n = 444), Canada (n = 9), Australia (n = 8), the United Kingdom (n = 4), and Spain (n = 1). MAIN OUTCOME MEASURES: The median time elapsed between requests for blood components by OR personnel and the retrieval of those components by blood component transport personnel, and the median time elapsed between requests for blood components by OR personnel and the arrival of those components in ORs. RESULTS: Participants submitted data on 12 647 units of RBCs, FFP, and PLTs. The median aggregate request-to-retrieval turnaround times (TATs) for RBCs, FFP, and PLTs ranged from 30 to 35 minutes, and the median aggregate request-to-arrival TATs for RBCs, FFP, and PLTs ranged from 33 to 39 minutes. Most of the TAT was consumed by events occurring prior to, rather than after release of components from blood banks. Shorter prerelease TATs were associated with having surgical schedules that listed patients' names and procedures available to blood bank personnel prior to surgeries, and having adequate clotted specimens in the blood bank and completed type-and-screen procedures performed before requests for blood components were submitted to blood banks. Among the fastest-performing 10% of participants (90th percentile and above), request-to-retrieval TATs ranged from 12 to 24 minutes for the 3 blood components, whereas among the slowest-performing 10% of participants (10th percentile and below), request-to-retrieval TATs ranged from 63 to 115 minutes for the 3 components. Median TATs ranged from 33 to 37 minutes for the 3 components. Institutions with TATs in the fastest-performing 25th percentile more frequently stored cross-matched RBCs in the OR daily, stocked PLTs for unexpected surgical use, stored PLTs in or near the OR, and had laboratory rather than nonlaboratory personnel deliver components to the OR than did those institutions with TATs in the slowest-performing 25th percentile. CONCLUSIONS: Hospital blood bank personnel can deliver blood components to the OR in slightly longer than 30 minutes, measured from the time that those units are requested by OR personnel. Practices aimed at saving time before components are released from blood banks will be more efficient in reducing overall TAT than those practices aimed at saving time after components are released from blood banks. Specific practices associated with shorter blood delivery TATs included providing blood bank personnel with access to the names of surgical patients potentially requiring blood components, having pretransfusion testing completed on those patients prior to surgery, having ample blood products on hand, and having laboratory personnel control blood product delivery.

Quality indicators of fresh frozen plasma and platelet utilization.

OBJECTIVE: To determine the normative rates of expiration and wastage for units of fresh frozen plasma (FFP) and platelets (PLTs) in hospital communities throughout the United States, and to examine hospital blood bank practices associated with more desirable (lower) rates. DESIGN: In 3 separate studies, participants in the College of American Pathologists Q-Probes laboratory quality improvement program collected data retrospectively on the numbers of units of FFP and PLTs that expired (outdated) prior to being used and that were wasted due to mishandling. Participants also completed questionnaires describing their hospitals' and blood banks' laboratory and transfusion practices. SETTING AND PARTICIPANTS: One thousand six hundred thirty-nine public and private institutions, more than 80% of which were known to be located in the United States. MAIN OUTCOME MEASURES: Quality indicators of FFP and PLT utilization: the rates of expiration and wastage of units of FFP and PLTs. RESULTS: Participants submitted data on 8 981 796 units of FFP and PLTs. In all 3 studies, aggregate combined FFP and PLT expiration rates ranged from 5.8% to 6.4% and aggregate combined FFP and PLT wastage rates ranged from 2.0% to 2.5%. Among the top-performing 10% of participants (90th percentile and above), FFP and PLT expiration rates were 0.6% or lower and FFP and PLT wastage rates were 0.5% or lower. Among the bottom-performing 10% of participants (10th percentile and below), expiration rates were 13.8% or higher and wastage rates were 6.8% or higher. We were unable to associate selected hospital characteristics or blood bank practices with lower rates of FFP and PLT utilization. CONCLUSIONS: The rates of FFP and PLT expiration and wastage vary greatly among hospitals in the United States. Hospital blood bank personnel are capable of achieving FFP and PLT expiration and wastage rates below 1%.

Outpatient phlebotomy success and reasons for specimen rejection.

OBJECTIVES: To determine the rate with which blood collection is successful on the initial phlebotomy encounter, the rate with which laboratory personnel judge specimens unsuitable for analysis, and the practice characteristics associated with fewer unsuccessful collections and fewer rejected specimens. DESIGN: Clinical laboratories participating in the College of American Pathologists Q-Probes laboratory improvement program prospectively characterized the outcome of outpatient phlebotomies for 3 months or until 20 unsuccessful phlebotomy encounters occurred. By questionnaire, participants provided information about test ordering, patient preparation, and specimen collection. SETTING AND PARTICIPANTS: Institutions in the United States (n = 202), Canada (n = 4), Australia (n = 3), and South Korea (n = 1). MAIN OUTCOME MEASURES: Percentage of successful encounters and percentage of unsuitable specimens. RESULTS: Of 833289 encounters, 829723 were successful. Phlebotomies were unsuccessful because patients were not fasting as directed (32.2%), phlebotomy orders were missing information (22.5%), patients specimens were difficult to draw (13.0%), patients left the collection area before specimens were collected (11.8%), patients were improperly prepared for reasons other than fasting (6.3%), patients presented at the wrong time (3.1%), or for other reasons (11.8%). Only 2153 specimens (0.3%) were unsuitable; these samples were hemolyzed (18.1%), of insufficient quantity (16.0%), clotted (13.4%), lost or not received in the laboratory (11.5%), inadequately labeled (5.8%), at variance with previous or expected results (4.8%), or unacceptable for other reasons (31.1%). Facilities staffed by laboratory-administered phlebotomists reported higher success rates than facilities staffed by nonlaboratory-administered phlebotomists (P =.002). CONCLUSIONS: Most outpatient phlebotomy encounters are successful and result in specimens suitable for laboratory analysis.