Blood Collection Tubes Testify in Court: A Collection of Errors

1
Blood Collection Tubes Testify in Court A
Collection of Errors

• George Roberts, EdD, CLS(NCA)
• Josie Roberts, CLS(NCA)

2
Introduction

• Here I am, fill me up!
• Not good learning situation for todays students
• Teachers compared to TV and computer
• Students want more and want to be entertained
• Assume blood collection tubes can talk and tell
  their own unique stories as witnesses on the
  stand in a courtroom setting

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• Earnst, Dennis, MT(ASCP). Center for Phlebotomy
  Education, If Tubes Could Talk, 2007-2008.

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The Setting

• Local courtroom
• Malpractice suit has been filed involving sample
  collection practices
• I serve as the prosecuting attorney
• Josie serves as the various witnesses (blood
  collection tubes)
• You, our audience, will serve as the jury
• We will not tell the defense side of the case
  today

5
The Opening Statement

• Ladies and gentlemen of the jury, today the
  prosecution will present the facts of the case
  and will prove beyond the shadow of a doubt that
  the phlebotomist, John Doe, in this case
  committed numerous critical errors
• Mislabeling of tubes
• Incomplete draws
• Improper specimen handling
• Lack of knowledge and application of CLSI
  Standards

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The Opening Statement (2)

• While not denying that other laboratorians could
  have intervened and prevented some or all of
  these errors, actions taken by Phlebotomist John
  Doe, CLS Jill Doe, CLT James Doe, and Lab
  Assistant Mary Doe ultimately led to erroneous
  test results that impacted the diagnosis and
  treatment of Patient Jane Smith on Thursday,
  January 20, 2009.
• You will hear testimony substantiating these
  facts from the actual blood collection tubes that
  were collected and tested in this case.
• We ask that you render your verdict based on the
  facts that we will present.

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First Witness

• The prosecution calls its first witness Ms. Blue
  Top to the stand. Do you swear to tell the
  truth, the whole truth, and nothing but the truth
  so help you God?

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Light Blue Top

• Would you please tell the court your name?

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Light Blue Top

• What is your job in the lab?

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Light Blue Top

• What qualifies you for the job that you perform?

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Light Blue Top

• How does a phlebotomist determine that the tube
  is at least 90 full?

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Light Blue Top

• Lets back up for just a minute and clarify a
  statement you made a little earlier. What do you
  mean by chelates calcium ions?

13
Light Blue Top

• Are there any other important facts that the
  court needs to know about you?

14
Light Blue Top

• Please explain to the court why you should be the
  first in the order of draw?

15
Light Blue Top

• Just give us the facts, please Ms. Blue Top!

16
Light Blue Top

• Maam, please stick with the facts!

17
Light Blue Top

• Are there other additional FACTS that you would
  like for the court know?

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Light Blue Top

• What is the CLSIs recommended order of draw?

19
Light Blue Top

• I suppose this standard makes it wrong to fill
  tubes based on their size (smallest to largest)
  rather than based on the color of the cap?

20
Light Blue Top

• What is the relevance of your testimony to the
  case at hand?

21
Light Blue Top

• I must admit that you are well qualified for the
  job that you do!

22
Light Blue Top

• Thank your for your time and expertise you have
  given to the court today.

23
Red Top

• The prosecution would like to call its second
  witness Ms. Red Top. Please have a seat in the
  witness box. Do you swear to tell the truth, the
  whole truth, and nothing but the truth so help
  you God?

24
Red Top

• Would you please tell the court your name and
  what you do?

25
Red Top

• What is this serum that you produce?

26
Red Top

• Are you the only tube that produces serum?

27
Red Top

• You stated earlier that if you are allowed to
  sit long enough you clot and produce serum. How
  long do you have to sit to clot? Why is your
  clotting process so important?

28
Red Top

• So Red Tops are pretty important when producing
  results that are used to diagnose and treat
  patients?

29
Red Top

• Formerly, you were first in the order of draw
  after blood cultures. Why were you moved from
  before Light Blue Top to after Light Blue Top?

30
Red Top

• Great! Now tell me some more ways that
  laboratory personnel can invalidate your test
  results.

31
Red Top

• Is there anything else that the court needs to
  know?

32
Red Top

• What is the significance of your testimony to the
  case at hand?

33
Red Top

• Thank you Ms. Red Top for your very enlightening
  testimony. You may step down from the witness
  stand.

34
Green Top

• The prosecution would like to call its third
  witness Ms. Green Top. Please have a seat in
  the witness stand. Do you swear to tell the
  truth, the whole truth, and nothing but the truth
  so help you God?

35
Green Top

• Please tell us your name, where you reside, and
  what you do.

36
Green Top

• Are there other important facts that the court
  needs to know about you?

37
Green Top

• What other tests can you be used for?

38
Green Top

• Now, as I understand the situation you were
  delivered to the lab, inspected by Lab Assistant
  Mary Doe, and thrown in the biohazard container.
  Why did this happen?

39
Green Top

• Are you capable of producing an accurate result?

40
Green Top

• Why is being unlabeled so bad? You were received
  along with all of the other properly labeled tube
  John Doe collected?

41
Green Top

• Please tell the court the relevance of your
  testimony to the case being presented today.

42
Green Top

• Thank you Green Top for standing up for patient
  rights and quality care!

43
Purple Top

• The prosecution calls Ms. Purple Top to the
  stand. Please have a seat in the witness box.
  Do you swear to tell the truth, the whole truth,
  and nothing but the truth so help you God?

44
Purple Top

• Please state your name and occupation for the
  court.

45
Purple Top

• You state that you prepare blood cells for
  counting. How do you do that?

46
Purple Top

• What tests are performed on your whole blood?

47
Purple Top

• So which of these tests is the most important?

48
Purple Top

• What is this differential you mentioned?
• Neutrophil Lymphocyte Eosinophil

49
Purple Top

• If your EDTA, Blue Tops sodium citrate, and
  Green Tops heparin all keep blood from clotting,
  why cant you be used interchangeably and not
  make so much fuss over the color of the tube?

50
Purple Top

• So you are like Blue Top and Green Top. How
  underfilled can you be before the results become
  inaccurate?

51
Purple Top

• What if you have a difficult patient and collect
  two partially filled EDTA tubes? Cant you just
  pour them together and come up with one full tube?

52
Purple Top

• What is this delta check thing you just mentioned?

53
Purple Top

• What if a sample of blood is collected from a
  patient and a few minutes later the phlebotomist
  discovers that he overlooked an order that
  requires a Purple Top. He has an extra Red Top
  and decides to pour it into the Purple Top.
  Isnt that acceptable?

54
Purple Top

• Cant you just take a stick and remove the clots
  before you run the test?

55
Purple Top

• I believe that I read somewhere that you can also
  be used in Blood Bank. Is that correct?

56
Purple Top

• Is there anything else you would like for the
  court to know about you?

57
Purple Top

• What is the significance of your testimony to the
  case before the court?

58
Purple Top

• Are there other colors of tubes used in the blood
  collection process?

59
Purple Top

• Thanks Ms. Purple Top for your contributions to
  this case and patient care.

60
Summation

• Phlebotomist John Doe violated order of draw
  protocol
• Demonstrated lack of knowledge of the Clinical
  and Laboratory Standards institute regarding
  blood collection

61
Summation 2

• CLS Jill Doe did not follow laboratory protocol
  and practice guidelines

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Summation 3

• Phlebotomist John Doe violated cardinal CLSI
  standard by not labeling a tube of blood
• CLS Jill Doe thus had to use a sample that caused
  an increased turn-around-time

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Summation 4

• CLT James Doe failed to reject an unacceptable
  sample and reported out erroneous results

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Summation 5

• Goals of the laboratory
• Goals not met
• Problems caused to patient

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Jurys Verdict

• Ladies and gentlemen of the jury, how do you find
  the defendants guilty or not guilty?