Clin Chem Lab Med 2015; 53(2): 225–229

Juan Gómez-Salgado, Adolfo Romero*, Isabel S. Caparrós, M. Carmen Barba, Margarita Reina and Carlos Ruiz-Frutos

Preanalytical errors: a preliminary approach to the point of view of primary health care givers DOI 10.1515/cclm-2014-0576 Received May 31, 2014; accepted September 8, 2014; previously published online October 2, 2014

Abstract Background: The presence of errors in the preanalytical phase is a widely studied topic. However, information regarding the perspective of those professionals involved is rather scant. Methods: Two focus groups of professionals from Primary Care involved in the preanalytical phase (general practitioners [GP], community nurses [CN], and other auxiliary health workers, including administrative personnel [AHW]) were convened. A qualitative analysis with a phenomenological approach was performed by using the structure of SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis as a guide, and results were categorized by grouping the resultant dimensions according to this structure. Results: Overall, 12 professionals (3 GP, 6 CN, and 3 AHW) were distributed in two groups. Age and gender distribution were similar between groups. The most commented strengths were organizational capability and teamwork. The main weakness was the workload increase (compared to the short time spent on sample collection). Opportunities were related to workload optimization through on-line analytical requests. Threats were related to the long time elapsed between sample drawing at Primary Care and delivery to the Central Laboratory.

*Corresponding author: Adolfo Romero, Haematology Department, Hospital Universitario Virgen de la Victoria, Campus de Teatinos s/n., 29010 Málaga, Spain, Phone: +34 951 032 302, Fax: +34 951 032 596, Cell number: +34 617 32 83 00, E-mail: [email protected] Juan Gómez-Salgado: Primary Care District Huelva Costa Condado Campiña, Huelva, Andalucía, Spain Isabel S. Caparrós: Haematology Department, University Hospital Virgen de la Victoria, Málaga, Andalucía, Spain M. Carmen Barba and Margarita Reina: Primary Care District Málaga, Málaga, Andalucía, Spain Carlos Ruiz-Frutos: Environmental Health Department, University of Huelva, Spain

Conclusions: The phenomenological approach allows revealing those aspects that cannot be entirely elucidated by objective data measurement. Attitudes considered as positive can be exploited by the institution, whereas those considered as negative alert us to possible future problems. Primary Care professionals offered a different point of view to laboratory staff, but both recognized high workload as the main threat and on-line analytical request as the best opportunity. These perspectives may help to improve detection and decrease the number of errors. Keywords: preanalytical mistakes; primary care; qualitative approach.

Introduction The presence of errors in the preanalytical phase is a widely studied topic. From the early studies by Plebani and Carraro [1], several researchers have investigated the high rates of mistakes in this phase of the laboratory process, while using different approaches and suggesting different solutions to avoid this problem [2–4]. Thus, some researchers focused on the sample quality, specifically the presence of hemolysis, stressing the importance of its absence and analyzing the most likely causes (i.e., blood sampling method or use of pneumatic devices for sample transportation) [5–7]. Others focused on the relationship between the presence of preanalytical errors and the commitment to patients’ safety, stressing the possible misinterpretation of the results [8–10]. This argument became particularly important after the publication of the report “To err is human: Building a safer health system” [11]; a document that contributed strongly to a paradigm shift on how to deal with the problems arising related to patients’ safety. Another line of research has focused on the reporting of malpractices in blood sampling, developing specific questionnaires for the professionals involved in critical steps (e.g., sample labeling), offering a holistic approach to the problem, and adding the information from previous

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226      Gómez-Salgado et al.: Preanalytical errors from preliminary care perspective studies at hospital wards and blood collection rooms [12–17]. Great attention has been paid to the detection and description of these errors [1, 3, 4], followed by the development of actions for preventing them [18], especially after realizing that this problem is far from solved, despite the technological developments that have occurred during the last 10 years [3]. Finally, an observational study sought to identify the sources of errors, which may occur from sample drawing at the health care point to the sample delivery at the central laboratory (CL) [19]. However, information regarding the perspective of the professionals involved in the preanalytical phase is rather scant. In a recent report on the perspective of a laboratory on this topic, we noted that both negative (weaknesses and threats) and positive aspects (strengths and opportunities) arose from organizational aspects, though positive ones were also influenced by staff professionalism and commitment [20]. To the best of our knowledge, no study has dealt with the perspective of primary health care professionals on preanalytical errors. The present study aims to explore the perspective of primary care professionals, applying the same methodology previously used for laboratory personnel.

Materials and methods Design After approval by our Institutional Research Ethics Committee, we convened two face-to-face group interviews of professionals from Primary Care Centres (PCC) involved in the preanalytical phase (general practitioners [GP], community nurses [CN], and other auxiliary personnel, including administrative personnel). Participants were selected among professionals from the PCC “Las Delicias” (Málaga city district), PCC “Coín,” and PCC “Alhaurín el Grande” (Guadalhorce rural district) on the basis of fulfilling two inclusion criteria: capability for transmitting information regarding the investigated issue, and “social significance” (meaning that preanalytical work in the process must be represented by a key person in each focus group session). A member of the research team chaired both sessions and was supported by an observer, following a common guideline (A4 sheets giving each participant so they could write their opinions with a SWOT diagram, and an oral description, one to one, of these opinions, which were recorded and also annotated: see Table 1) and formulating simple questions, directly referring to Strengths, Weaknesses, Opportunities and Threats (SWOT) perceived in the preanalytical phase. Each participant was asked to explain all the SWOTs detected in the different steps of the preanalytical phase, according to their own experience; this referred to the whole preanalytical phase and not only to the steps for which they were responsible.

Table 1 Overall scheme of SWOT sessions. Topic

Approximate time spent

Presentation Brief description of SWOT methodology and A4 sheet delivery for writing to participants Writing reviews according to the SWOT guide Reading text written one to one


3 min 5 min


5–10 min 10 min

Discussion and end of the session

10 min

Participants were not compelled to respond to every item during the interview, and they could express their opinion at any moment during the meeting, although we suggested following the order provided by the SWOT structure as mentioned previously. The sessions were audio recorded, and hand annotations were taken by the chairperson. We transcribed the interviews, and the observer’s field notes were incorporated to enrich the transcriptions with the attitudes and atmosphere in the group. Information saturation was achieved after 37 and 42 min, respectively.

Analysis Usually, SWOT analysis is seen as the final step of the strategic analysis [21]. However, we use the SWOT structure as a guide: we performed a qualitative analysis with a phenomenological approach, offering a different approach to obtain the information provided by the research participants, based on the qualitative paradigm. We categorized the results by grouping the resultant dimensions according to SWOT structure for obtaining dimensions, which explain the phenomenon. The number of comments are recorded and counted to establish the importance of discourses based on the number of times they were mentioned.

Results Overall, 16 professionals met the inclusion criteria, but only 12 attended the sessions (three GP, six CN, and three auxiliary personnel) and were distributed in two groups (six and six). Age, occupation (workplace), and gender were similarly distributed between groups. The number of comments for each item is indicated in squared brackets. The most commented strengths were the organizational framework and teamwork [4], with problem solving capability [4], and utilization of an intranet-based test request [3]. The main weakness was the increase in workload (related to little time available for blood sampling; i.e., if they have 1  h for blood sampling and the same number of patients, a lower number of nurses results in a shorter

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Gómez-Salgado et al.: Preanalytical errors from preliminary care perspective      227

time for each blood sampling) [4]. The participants also reported the absence of detailed analytical test profile for specific request (e.g., basic hemostasis) [3], delays in sample transportation [2], long distance between PCC and central laboratories [2], some characteristics of patients (e.g., elderly people, usually with poor venous access, requiring more time for sampling) [2], and a lack of flexibility in some analytical requests (e.g., electronic forms are used only for analytical profiles, but not for singleparameter requests) [2]. The opportunities were related to the optimization of the workload through on-line electronic forms for analytical requests [5], and the adoption of some protocol modifications for improving the whole process (e.g., centrifugation of samples at PCC, refrigerated transport) [2]. The threats were related to the long time elapsed from blood sampling at PCC to sample delivery at the Central Laboratory, problems with cold storage (e.g., damaged refrigerators), the persistence of high workloads over an extended period, and problems with the use of paper forms when the requested tests were not included in the electronic form [3] (see details in Table 2). There are more opinions (results) than participants because they were invited to express themselves freely, without limitations. Table 2 Strengths, Weaknesses, Opportunities and Threats declared by participants in the focus groups.   Strengths    Organization framework and management of work    Problem solving capability and teamwork    Utilization of web application for test request   Weaknesses    Work overload    Lack of detailed analytical test profile for specific request (or  poorly designed)  Delay in sample’s transportation    Long length of routes for samples delivery    Characteristics of patients (elderly, foreigners)    Poor flexibility in some analytical determinations   Opportunities    Optimization of the web application (ATRM)    Protocol improvements (centrifugation at origin, refrigerated  transport, etc) Threats    Problems with cold storage (damaged refrigerators)    Long time elapsed from blood sampling at PC to sample   delivery at the CL  Persistence of high workloads over the time    Problems with paper formularies for specific test request   ATRM, analytical test requesting module (electronic form); PC, Primary Care; CL, Central Laboratory.

n 4 4 3 4 3 2 2 2 2 5 2

3 3 3 3

Discussion Though the presence of errors in the preanalytical phase is an undisputed fact, and most of their causes have been identified, its correction is not so straightforward. Different approaches to the problem have contributed greatly to explaining its complexity, but an approximation to the opinion of professionals involved in this process is lacking. Several researchers have performed qualitative approaches to this problem among nurses from PCC, using a questionnaire, which mostly dealt with technical issues, but not specifically with personal perspectives [12, 16]. In this regard, when asking a group of laboratory professionals for their views on this problem, a previous study revealed their involvement in this phase and also their views on what kind of problems exert a major influence on the carrying out of their professional activity [20]. With this exception, an approach to the problem from the phenomenological point of view has not been accomplished. This approach allows us not only to validate models or hypotheses but also to develop new concepts and ideas on the basis of collected data. It also allows the researcher to have a full vision of the field of interest, as individuals’ perceptions are not just reduced to variables, but considered as a whole [22]. To this end, the search for information was structured using the technique of focus groups [21], with the SWOT analysis as a guide for structuring the perspectives offered by participants. We should bear in mind that SWOT is actually a methodology, which is oriented mainly toward helping in making decisions on any aspect, which needs to be resolved or improved. It has a strategic focus, as it lets one realize that threats come from the future and the weakness from the present, but chronic weakness can be also considered as a threat [22]. However, this is a different way of using SWOT because, usually, this analysis does not include a phenomenological analysis. The phenomenological approach allows revealing those aspects that cannot be elucidated by objective data measurement. It is difficult to measure the commitment of professionals in the solution of problems, but it is possible to know how important these problems are considered by the professionals. According to the data depicted in Table 2, participants sought staff professionalism and commitment as basic tools to avoid or minimize preanalytical errors. This way, attitudes considered as positive (strengths and opportunities) can be exploited by the institution, whereas those considered as negative (weaknesses and threats) alert us to possible future problems.

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228      Gómez-Salgado et al.: Preanalytical errors from preliminary care perspective In agreement with previous views from CL staff [20], for PCC professionals, problems associated with the current context of the economic crisis (such as the decrease in the number of professionals and the consequent increase in workloads), along with practical deficiencies (such as the difficulties in ensuring the conservation of samples), are considered as threats (Table 1). In contrast, PCC personnel did not consider the lack of training programs as a threat, whereas it was an important issue for laboratory staff. This is perceived by CL staff as a lack of knowledge of laboratory procedures among PCC professionals (unknown known or unknown unknowns). Although we have highlighted the sources of preanalytical mistakes we have not detected any improvements, probably because we have not received any feedback yet, although we have planned an input session with PCC staff in the course of the current year. However, we will undertake a failure mode analysis and effects (FMEA) to optimize the preanalytical process, together with a specific training activity for primary care professionals [20]. New research projects by our team set a sample increase, in order to include health system managers and professionals from different health departments and geographical areas in our country. Finally, we consider that the information obtained will allow a more comprehensive understanding of the sources of preanalytical errors, something that should always be a priority for healthcare professionals. In addition, the additional insights from two different, but complementary, scientific paradigms should provide new points of view, contributing to better identification of problems and, therefore, to better planning and implementation of valid solutions. We know there were only a limited number of participants in this study, and we used a convenient sample. We understand that widely wider sample would be necessary in order to be able to generalize the findings elsewhere, but all these data, together with the professionals’ perception of “being heard,” should provide a wider range of intervention possibilities, many of which would have not been detected otherwise. Acknowledgments: The authors wish to thank Manuel Muñoz, GIEMSA, School of Medicine, University of Málaga, Spain, for his collaboration in translation and revision of the manuscript. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission. Financial support: This study was partially supported by project Fondo de Investigaciones Sanitarias (FIS) grant PI

FIS 1099/12 from “Instituto de Salud Carlos III” Ministerio de Sanidad y Política Social. Gobierno de Españ a. (Health Ministry, Spanish Government). Employment or leadership: None declared. Honorarium: None declared. Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

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Preanalytical errors: a preliminary approach to the point of view of primary health care givers.

The presence of errors in the preanalytical phase is a widely studied topic. However, information regarding the perspective of those professionals inv...
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