Bakgrund: Varje år behöver mer än 10 000 nyfödda barn i Sverige vård på en neonatalvårdsavdelning. Vårdtiden präglas av åtskilliga blodprovstagningar som orsakar barnet smärta och ökat vårdlidande. Sjuksköterskans ansvar innefattar att agera för barnets bästa i alla situationer, men det kan saknas tydliga riktlinjer för hur detta ska ske på arbetsplatsen. Syfte: Syftet med studien är att beskriva sjuksköterskors resonemang och arbetssätt vid blodprovstagning på barn på neonatalvårdsavdelning, samt att undersöka hur barnets bästa finns i fokus vid proceduren. Metod: Studien utformades med en kvalitativ studiedesign i avsikt att generera kunskap om sjuksköterskornas erfarenheter vid blodprovstagning. Tolv intervjuer genomfördes utifrån en semistrukturerad intervjuguide med sjuksköterskor verksamma vid en neonatalvårdsavdelning på ett svenskt universitetssjukhus. Den insamlade datan analyserades genom en induktiv innehållsanalys. Resultat: Vilken stickmetod sjuksköterskorna använde var anpassat efter barnet och situationen. De såg till barnets förutsättningar och planerade provtagningen efter vad barnet klarade av, i samråd med föräldrarna. Sjuksköterskorna strävade efter föräldranärvaro vid provtagningen och åtog adekvata smärtlindringsmetoder i den mån som situationen tillät. Slutsats: Sjuksköterskorna hade genomgående barnets bästa i fokus vid provtagningsproceduren. De såg en komplexitet i sin roll att både vara den som orsakar barnet smärta, men även vara den som ska minska barnets vårdlidande. / Background: Every year, more than 10 000 newborn children require hospitalization in a neonatal intensive care unit. During this time, they are subjected to several painful blood sampling procedures that will cause them suffering to some extent. The nurses’ responsibility is to act on what is best for each child at all times but clearer guidelines for how that should be executed in practical nursing care might be needed. Aim: To describe the reasoning and the working manner of the nurses when performing blood sampling on children. The study also aims to examine how the child’s best interest is taken into account before and during this procedure. Method: A qualitative design was used for this study. Semi-structured interviews were conducted with 12 registered nurses who work in the neonatal intensive care unit at a Swedish University Hospital. Collected data were analysed using inductive content analysis. Results: Regardless of which technique the nurses chose when performing blood sampling it was assessed as the most appropriate one for each child. They took the children’s prerequisites and ability to cope into account and planned the procedure in consensus with their parents. Nurses strove to encourage parents to stay close to and support their children when blood sampling was conducted, and adequate analgesic actions were undertaken. Conclusion: Nurses had the children’s best at heart all through the process of blood sampling. Their role as both inflicting and relieving pain was considered to be complex in the aim to avoid suffering.

Background: Most errors in the venous blood testing process are preanalytical, i.e. they occur before the sample reaches the laboratory. Unlike the laboratory analysis, the preanalytical phase involves several error-prone manual tasks not easily avoided with technological solutions. Despite the importance of the preanalytical phase for a correct test result, little is known about how blood samples are collected in hospitals. Aim: The aim of this thesis was to survey preanalytical procedures in hospitals to identify sources of error. Methods: The first part of this thesis was a questionnaire survey. After a pilot study (Paper I), a questionnaire addressing clinical chemistry testing was completed by venous blood sampling staff (n=314, response rate 94%) in hospital wards and hospital laboratories (Papers II–IV). The second part of this thesis was an experimental study. Haematology, coagulation, platelet function and global coagulation parameters were compared between pneumatic tube-transported samples and samples that had not been transported (Paper V). Results: The results of the questionnaire survey indicate that the desirable procedure for the collection and handling of venous blood samples were not always followed in the wards (Papers II–III). For example, as few as 2.4% of the ward staff reported to always label the test tube immediately before sample collection. Only 22% of the ward staff reported to always use wristbands for patient identification, while 18% reported to always use online laboratory manuals, the only source of updated information. However, a substantial part of the ward staff showed considerable interest in re-education (45%) and willingness to improve routines (44%) for venous blood sampling. Compared to the ward staff, the laboratory staff reported significantly higher proportions of desirable practices regarding test request management, test tube labelling, test information search procedures, and the collection and handling of venous blood samples, but not regarding patient identification. Of the ward staff, only 5.5% had ever filed an error report regarding venous blood sampling, compared to 28% of the laboratory staff (Paper IV). In the experimental study (Paper V), no significant preanalytical effect of pneumatic tube transport was found for most haematology, coagulation and platelet function parameters. However, time-to-clot formation was significantly shorter (16%) in the pneumatic tube-transported samples, indicating an in vitro activation of global coagulation. Conclusions. The questionnaire study of the rated experiences of venous blood sampling ward staff is the first of its kind to survey manual tasks in the preanalytical phase. The results suggest a clinically important risk of preanalytical errors in the surveyed wards. Computerised test request management will eliminate some, but not all, of the identified risks. The better performance reported by the laboratory staff may reflect successful quality improvement initiatives in the laboratories. The current error reporting system needs to be functionally implemented. The experimental study indicates that pneumatic tube transport does not introduce preanalytical errors for regular tests, but manual transport is recommended for analysis with thromboelastographic technique. This thesis underscores the importance of quality improvement in the preanalytical phase of venous blood testing in hospitals.

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Licentiatavhandling (sammanfattning) Uppsala : Sveriges lantbruksuniversitet. / Härtill 3 uppsatser.

Since laboratory tests influence as much as 70% of the medical decisions, errors throughout the blood sampling process may jeopardize the safety of the patient. Research has shown that the pre-analytical phase of the blood sampling process is where the most errors occur. Moreover, this phase is said to be the most influential part of the total testing process, due to maximal involvement of humans. In this study, the pre-analytical errors in the blood sample handling process and their causes were investigated. Therefore, a literature study was performed, and first-hand data was collected through interviews. A total of 8 interviews was conducted in Sweden, Belgium, and the Netherlands. From these interviews, qualitative data was collected and analysed with a thematic approach. The 5 themes that were obtained are: nurse vs. lab technician, sample identification, logistics, location dependency of sample quality, and hospital management. Each theme included multiple observations and conclusions. One specific observation was a lack of communication and knowledge management amongst nurses and lab technicians. To minimize this gap between nurse and lab technician from a knowledge transfer perspective, a conceptual framework was constructed. This framework can be used both from an academic and practical point of view. This research has both academic and practical implications. Within the academic perspective, empirical data is gathered among hospitals in three different countries, which is compared to data found in academic literature. Moreover, with the analysis of the empirics gathered in this study and the framework that is proposed, a contribution is made to knowledge management within hospitals. From a practical perspective, a contribution is made in helping to minimise the pre-analytical errors in their blood sampling process, while giving the hospital a better understanding of the lack of communication and knowledge management amongst their key employees. By strengthening the communication and knowledge transfer, errors can be avoided. This would not only benefit the speed and accuracy of the diagnose process, but also benefit the nurses and lab technicians in workload. / Eftersom laboratorietester påverkar så mycket som 70 % av de medicinska besluten kan fel i blodprovstagningen äventyra patientsäkerheten. Forskning visar att det är i den föranalytiska fasen av blodprovstagningsprocessen som de flesta felen uppstår. Dessutom sägs denna fas vara den mest inflytelserika delen av den totala provtagningsprocessen, på grund av den höga graden av människors inblandning. Denna studie undersökte de föranalytiska felen i blodprovshanteringen och deras orsaker. En litteraturstudien genomfördes, och förstahandsuppgifter samlades in genom intervjuer. Totalt åtta intervjuer genomfördes i Sverige, Belgien och Nederländerna. Från dessa intervjuer samlades kvalitativa data in och analyserades med en tematisk ansats. De fem teman som erhölls var: sjuksköterska jämte laboratorietekniker, providentifiering, logistik, platsberoende provkvalitet och sjukhusledning. Varje tema innehöll flera observationer och slutsatser. En specifik observation var bristen på kommunikation och kunskapshantering mellan sjuksköterskor och laboratorietekniker. För att minimera denna klyfta mellan sjuksköterska och laboratorietekniker ur ett kunskapsöverföringsperspektiv konstruerades en konceptuell ram. Denna ram kan användas både ur akademisk och praktisk synvinkel. Denna forskning har både akademiska och praktiska konsekvenser. Utifrån det akademiska perspektivet samlades empiriska data in bland sjukhus i tre olika länder, som jämförs med data i den existerande litteraturen. Med analysen av den empiri som samlats in i den här studien och det ramverk som föreslås ges dessutom ett bidrag till kunskapshantering inom sjukhus. Ur ett praktiskt perspektiv bidrar detta till att minimera de föranalytiska felen i blodprovstagningsprocessen, samtidigt som sjukhuset får en bättre förståelse för bristen på kommunikation och kunskapshantering bland sina nyckelpersoner. Genom att stärka kommunikationen och kunskapsöverföringen kan fel undvikas. Detta skulle inte bara gynna diagnostikprocessens snabbhet och noggrannhet, utan även avlasta sjuksköterskorna och laboratorieteknikernas arbetsbörda.