<p>Quality is the main focus in management of all laboratories. Accurate results of the analyses are not only determined by the analytical procedure but also by preanalytical factors. In the total analytical process of clinical specimens, there are many possible preanalytical sources of error. Monetoring of temperature on test samples of the transport boxes is one way to reduce the mistakes in the preanalytical phase.</p><p>In this study, four laboratories from primary health care were invited to participate. The temperature has been measured on test samples of the transport boxes being delivered to the laboratory.</p><p>In three cases the temperature remained within the limits, but in the fourth case the temperature varied more than the allowed interval. Mistakes found in the preanalytical phase, especially in the handling and processing in the process before complete distribution of test samples to laboratory. This suggests that good communication and cooperation among the personnel is the key to improvement of the laboratory quality.</p>

Quality is the main focus in management of all laboratories. Accurate results of the analyses are not only determined by the analytical procedure but also by preanalytical factors. In the total analytical process of clinical specimens, there are many possible preanalytical sources of error. Monetoring of temperature on test samples of the transport boxes is one way to reduce the mistakes in the preanalytical phase. In this study, four laboratories from primary health care were invited to participate. The temperature has been measured on test samples of the transport boxes being delivered to the laboratory. In three cases the temperature remained within the limits, but in the fourth case the temperature varied more than the allowed interval. Mistakes found in the preanalytical phase, especially in the handling and processing in the process before complete distribution of test samples to laboratory. This suggests that good communication and cooperation among the personnel is the key to improvement of the laboratory quality.

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.

A contagem de plaquetas é um exame de rotina utilizado no auxilío do diagnóstico de diversos distúrbios hemostáticos, além de ser usada no monitoramento de pacientes, portanto existe a necessidade de obter parâmetros fidedignos para assegurar a existência de plaquetopenia ou plaquetose e alterações morfológicas destas células. A comum ocorrência de agregação plaquetária “in vitro” dificulta a análises destes parâmetros, evento devido ao uso incorreto da metodologia de coleta, armazenamento inadequado da amostra, assim como o uso incorreto do anticoagulante. O diagnóstico errôneo de plaquetopenia ou plaquetose pode ter como consequência o direcionamento terapêutico inadequado do paciente. O objetivo deste estudo foi comparar quantitativa e qualitativamente os parâmetros plaquetários em amostras com diferentes anticoagulantes, e diferentes tempo e temperatura de armazenagem. Além disso, foram também objetivos averiguar a diferença entre os métodos de contagem de plaquetas (automático, manual e estimado em lâmina), e a correlação entre o volume plaquetário médio (MPV) e a porcentagem de macroplaquetas, assim como definir um intervalo de referência para a porcentagem de macroplaquetas em uma população de cães sadios. Amostras de sangue foram coletadas através do sistema a vácuo em tubos de EDTA K2 e citrato de sódio 3,2% de 54 cães clinicamente saudáveis. As amostras foram separadas em duas alíquotas e posteriormente armazenadas em pares, um par a temperatura ambiente (25°C) e outro a 4°C por até 6 horas após coleta. Cada alíquota foi avaliada em três momentos diferentes, nos quais as contagens plaquetárias, o MPV, e o escore de agregação foram realizados. A porcentagem de macroplaquetas foi feita apenas nas amostras de EDTA armazenadas a 25°C, no tempo zero após a coleta. Foi observada uma diminuição significativa nas contagens plaquetárias com o passar do tempo e em amostras sob refrigeração, e uma tendência ao aumento dos valores de MPV. As contagens realizadas em amostras de EDTA foram mais elevadas do que aquelas em citrato, e não houve correlação entre o volume de plaquetário médio e a porcentagem de macroplaquetas e, além de que a freqüência de aglomeração foi maior em amostras citratadas armazenadas a 4°C. / The platelet count is a routine examination used in the diagnosis of bleeding disorders and patient monitoring. Therefore, reliable parameters are needed to ensure the existence of thrombocytopenia or thrombocytosis and morphological changes of these cells. The common occurrence of platelet aggregation difficult the analysis of these parameters, this often occurs due to incorrect venipuncture methodology, improper storage of the sample, as well as the incorrect use of anticoagulants. The misdiagnosis of thrombocytopenia or thrombocytosis may result in inappropriate treatment guidance. The aim of this study was to compare the quantitative and qualitative platelet parameters in samples with different anticoagulants, times and temperatures. Additional objectives were to, ascertain the difference between platelet count methods (automatic, manual and estimated) and to verify a possible correlation between the mean platelet volume (MPV) and macroplatelets percentage, as well as to define a reference range for macroplatelets percentage in a healthy population of dogs. Blood was collected from 54 clinically healthy dogs via vacuum system into EDTA K2 and sodium citrate 3.2% tubes. The samples were separated into two aliquots and then stored in pairs, one pair at room temperature (25°C) and another at 4°C for up to 6 hours post sampling. Each sample was evaluated at three different times, in which platelet counts, MPV, and clumping scores were performed. The macroplatelets percentage was done only in EDTA samples stored at 25°C, at zero hour post sampling. The authors observed a statistically significant decrease in platelet counts over time and in refrigerated samples, and a tendency to increased values of MPV. Counts performed in EDTA samples were higher than those in citrate, and there was no correlation between the mean platelet volume and macroplatelets percentage; and besides the frequency of clumping was higher in citrated samples stored at 4°C.

A contagem de plaquetas é um exame de rotina utilizado no auxilío do diagnóstico de diversos distúrbios hemostáticos, além de ser usada no monitoramento de pacientes, portanto existe a necessidade de obter parâmetros fidedignos para assegurar a existência de plaquetopenia ou plaquetose e alterações morfológicas destas células. A comum ocorrência de agregação plaquetária “in vitro” dificulta a análises destes parâmetros, evento devido ao uso incorreto da metodologia de coleta, armazenamento inadequado da amostra, assim como o uso incorreto do anticoagulante. O diagnóstico errôneo de plaquetopenia ou plaquetose pode ter como consequência o direcionamento terapêutico inadequado do paciente. O objetivo deste estudo foi comparar quantitativa e qualitativamente os parâmetros plaquetários em amostras com diferentes anticoagulantes, e diferentes tempo e temperatura de armazenagem. Além disso, foram também objetivos averiguar a diferença entre os métodos de contagem de plaquetas (automático, manual e estimado em lâmina), e a correlação entre o volume plaquetário médio (MPV) e a porcentagem de macroplaquetas, assim como definir um intervalo de referência para a porcentagem de macroplaquetas em uma população de cães sadios. Amostras de sangue foram coletadas através do sistema a vácuo em tubos de EDTA K2 e citrato de sódio 3,2% de 54 cães clinicamente saudáveis. As amostras foram separadas em duas alíquotas e posteriormente armazenadas em pares, um par a temperatura ambiente (25°C) e outro a 4°C por até 6 horas após coleta. Cada alíquota foi avaliada em três momentos diferentes, nos quais as contagens plaquetárias, o MPV, e o escore de agregação foram realizados. A porcentagem de macroplaquetas foi feita apenas nas amostras de EDTA armazenadas a 25°C, no tempo zero após a coleta. Foi observada uma diminuição significativa nas contagens plaquetárias com o passar do tempo e em amostras sob refrigeração, e uma tendência ao aumento dos valores de MPV. As contagens realizadas em amostras de EDTA foram mais elevadas do que aquelas em citrato, e não houve correlação entre o volume de plaquetário médio e a porcentagem de macroplaquetas e, além de que a freqüência de aglomeração foi maior em amostras citratadas armazenadas a 4°C. / The platelet count is a routine examination used in the diagnosis of bleeding disorders and patient monitoring. Therefore, reliable parameters are needed to ensure the existence of thrombocytopenia or thrombocytosis and morphological changes of these cells. The common occurrence of platelet aggregation difficult the analysis of these parameters, this often occurs due to incorrect venipuncture methodology, improper storage of the sample, as well as the incorrect use of anticoagulants. The misdiagnosis of thrombocytopenia or thrombocytosis may result in inappropriate treatment guidance. The aim of this study was to compare the quantitative and qualitative platelet parameters in samples with different anticoagulants, times and temperatures. Additional objectives were to, ascertain the difference between platelet count methods (automatic, manual and estimated) and to verify a possible correlation between the mean platelet volume (MPV) and macroplatelets percentage, as well as to define a reference range for macroplatelets percentage in a healthy population of dogs. Blood was collected from 54 clinically healthy dogs via vacuum system into EDTA K2 and sodium citrate 3.2% tubes. The samples were separated into two aliquots and then stored in pairs, one pair at room temperature (25°C) and another at 4°C for up to 6 hours post sampling. Each sample was evaluated at three different times, in which platelet counts, MPV, and clumping scores were performed. The macroplatelets percentage was done only in EDTA samples stored at 25°C, at zero hour post sampling. The authors observed a statistically significant decrease in platelet counts over time and in refrigerated samples, and a tendency to increased values of MPV. Counts performed in EDTA samples were higher than those in citrate, and there was no correlation between the mean platelet volume and macroplatelets percentage; and besides the frequency of clumping was higher in citrated samples stored at 4°C.

A contagem de plaquetas é um exame de rotina utilizado no auxilío do diagnóstico de diversos distúrbios hemostáticos, além de ser usada no monitoramento de pacientes, portanto existe a necessidade de obter parâmetros fidedignos para assegurar a existência de plaquetopenia ou plaquetose e alterações morfológicas destas células. A comum ocorrência de agregação plaquetária “in vitro” dificulta a análises destes parâmetros, evento devido ao uso incorreto da metodologia de coleta, armazenamento inadequado da amostra, assim como o uso incorreto do anticoagulante. O diagnóstico errôneo de plaquetopenia ou plaquetose pode ter como consequência o direcionamento terapêutico inadequado do paciente. O objetivo deste estudo foi comparar quantitativa e qualitativamente os parâmetros plaquetários em amostras com diferentes anticoagulantes, e diferentes tempo e temperatura de armazenagem. Além disso, foram também objetivos averiguar a diferença entre os métodos de contagem de plaquetas (automático, manual e estimado em lâmina), e a correlação entre o volume plaquetário médio (MPV) e a porcentagem de macroplaquetas, assim como definir um intervalo de referência para a porcentagem de macroplaquetas em uma população de cães sadios. Amostras de sangue foram coletadas através do sistema a vácuo em tubos de EDTA K2 e citrato de sódio 3,2% de 54 cães clinicamente saudáveis. As amostras foram separadas em duas alíquotas e posteriormente armazenadas em pares, um par a temperatura ambiente (25°C) e outro a 4°C por até 6 horas após coleta. Cada alíquota foi avaliada em três momentos diferentes, nos quais as contagens plaquetárias, o MPV, e o escore de agregação foram realizados. A porcentagem de macroplaquetas foi feita apenas nas amostras de EDTA armazenadas a 25°C, no tempo zero após a coleta. Foi observada uma diminuição significativa nas contagens plaquetárias com o passar do tempo e em amostras sob refrigeração, e uma tendência ao aumento dos valores de MPV. As contagens realizadas em amostras de EDTA foram mais elevadas do que aquelas em citrato, e não houve correlação entre o volume de plaquetário médio e a porcentagem de macroplaquetas e, além de que a freqüência de aglomeração foi maior em amostras citratadas armazenadas a 4°C. / The platelet count is a routine examination used in the diagnosis of bleeding disorders and patient monitoring. Therefore, reliable parameters are needed to ensure the existence of thrombocytopenia or thrombocytosis and morphological changes of these cells. The common occurrence of platelet aggregation difficult the analysis of these parameters, this often occurs due to incorrect venipuncture methodology, improper storage of the sample, as well as the incorrect use of anticoagulants. The misdiagnosis of thrombocytopenia or thrombocytosis may result in inappropriate treatment guidance. The aim of this study was to compare the quantitative and qualitative platelet parameters in samples with different anticoagulants, times and temperatures. Additional objectives were to, ascertain the difference between platelet count methods (automatic, manual and estimated) and to verify a possible correlation between the mean platelet volume (MPV) and macroplatelets percentage, as well as to define a reference range for macroplatelets percentage in a healthy population of dogs. Blood was collected from 54 clinically healthy dogs via vacuum system into EDTA K2 and sodium citrate 3.2% tubes. The samples were separated into two aliquots and then stored in pairs, one pair at room temperature (25°C) and another at 4°C for up to 6 hours post sampling. Each sample was evaluated at three different times, in which platelet counts, MPV, and clumping scores were performed. The macroplatelets percentage was done only in EDTA samples stored at 25°C, at zero hour post sampling. The authors observed a statistically significant decrease in platelet counts over time and in refrigerated samples, and a tendency to increased values of MPV. Counts performed in EDTA samples were higher than those in citrate, and there was no correlation between the mean platelet volume and macroplatelets percentage; and besides the frequency of clumping was higher in citrated samples stored at 4°C.

Abstract Breast carcinoma is a heterogeneous disease with a prognosis that varies from excellent to very poor. Traditional tumour parameters and biological factors that are also predictive for treatment response are used in determining breast carcinoma prognosis and selecting appropriate treatment. Gelatinases MMP-2 and MMP-9 have been shown to associate with tumour progression. Their tissue inhibitors TIMP-1 and -2 are multifunctional molecules that have been suggested as prognostic markers in some previous reports. In the present work, the expression and prognostic value of gelatinases MMP-2 and MMP-9 and their tissue inhibitors TIMP-1 and -2 were assessed in primary breast carcinoma. The material consisted of a total of 416 patients. Tissue expression of TIMP-1 and -2 was analysed in a population of 203 patients using immunohistochemistry. Circulating gelatinases and their inhibitors were studied using ELISA in two different populations of 71 at preoperative state and 213 patients at pre- and postoperative state. High expression of TIMP-1 immunoreactive protein positively correlated with high histological grade of the tumour and associated with aggressive disease course in grade 2–3 subpopulation. High preoperative plasma TIMP-1 was prognostic for relapse in a modern patient series after a median follow-up time of 18 months. TIMP-1 as a continuous variable was prognostic in Cox regression univariate analysis, and was an independent prognostic variable superior to nodal status in multivariate analysis. High preoperative serum TIMP-1 was an independent prognostic variable for poor disease-specific survival, and TIMP-1 was found to maintain its prognostic value when assessed independently with different ELISA analyses, and was not very sensitive for preanalytical conditions. In addition, low circulating preoperative serum MMP-2 was observed to associate with high stage and positive nodal status in breast carcinoma. These results indicate that circulating TIMP-1 may be a potential new marker of worsened prognosis in breast carcinoma, although careful validation of assay platforms and identification of the sources of physiological variation are needed before it can be adopted into clinical decision-making.

Clinicians rely heavily on accurate laboratory results to diagnose and treat their patients. Laboratory errors can occur in any area of total testing phases, but more than half of the errors occur in the preanalytical phase. Framed by the total quality management theory, the purpose of this multiple case study was to explore medical laboratory managers' strategies to reduce preanalytical errors. A purposive sample of 2 organizations with laboratories in southern California participated in semistructured face-to-face interviews. Company A had 2 participants and 3 participants participated in the study from Company B. Each participant had at least 5 years of laboratory experience, with a minimum of 2 years of management experience in preanalytical testing, and had completed one project to minimize laboratory errors. Thematic analysis exposed 5 main themes: quality improvement, recognition, reward, and empowerment, education and training, communication, and patient satisfaction. The participants highlighted the need for organizations to concentrate on quality management to achieve patient satisfaction. To achieve quality services, medical laboratory managers noted the importance of employee engagement, education and training, and communication as successful strategies to mitigate preanalytical errors. The recommendation for action is for laboratory leaders to review and apply effective strategies exposed by the data in this study to reduce preanalytical errors in their medical laboratory. Positive implications of this study include reduction of preanalytical errors, increased operational cost, and improved patient experience.

Background Venous blood tests constitute an important part in the diagnosis and treatment of patients. However, test results are often viewed as objective values rather than the end result of a complex process. This has clinical importance since most errors arise before the sample reaches the laboratory. Such preanalytical errors affect patient safety and are often due to human mistakes in the collection and handling of the sample. The preanalytical performance of venous blood testing in primary health care, where the majority of the patients contact with care occurs, has not previously been reported. Aims To investigate venous blood sampling practices and the prevalence of haemolysed blood samples in primary health care. Methods A questionnaire investigated the collection and handling of venous blood samples in primary health care centres in two county councils and in two hospital clinical laboratories. Haemolysis index was used to evaluate the prevalence of haemolysed blood samples sent from primary health care centres, nursing homes and a hospital emergency department. Results and discussion The results indicate that recommended preanalytical procedures were not always followed in the surveyed primary health care centres. For example, only 54% reported to always use name and Swedish identification number, and 5% to use photo-ID, the two recommended means for patient identification. Only 12% reported to always label the test tubes prior to blood collection. This increases the possibility of sample mix-up. As few as 6% reported to always allow the patient to rest at least 15 minutes before blood collection, desirable for a correct test result. Only 31% reported to have filed an incident report regarding venous blood sampling, indicating underreporting of incidents in the preanalytical phase. Major differences in the prevalence of haemolysed blood samples were found. For example, samples collected in the primary health care centre with the highest prevalence of haemolysed samples were six times (95% CI 4.0 to 9.2) more often haemolysed compared to the centre with the lowest prevalence. The significant variation in haemolysed samples is likely to reflect varying preanalytical conditions. Conclusions This thesis indicates that the preanalytical procedure in primary health care is associated with an increased risk of errors with consequences for patient safety and care. Monitoring of haemolysis index could be a valuable tool for estimating preanalytical sample quality. Further studies and interventions aimed at the preanalytical phase in primary health care are clearly needed.

Quantitative Untersuchungen krankheitsspezifischer oder krankheitsassoziierter metabolischer Signaturen in humanen Körperflüssigkeiten („Clinical Metabolomics“) haben zum Ziel neue Ansätze für diagnostische oder therapeutische Konzepte zu entwickeln. Die simultane quantitative Analytik von Aminosäuren (AS) und Acylcarnitinen (AC) mittels Tandem-Massenspektrometrie (MS/MS) ermöglicht die Erfassung wichtiger Stoffwechselwege des humanen Metabolismus. Hierzu zählen der Stoffwechsel der ketogenen AS, des Harnstoffzyklus oder der β-Oxidation langkettiger Fettsäuren. Allerdings wird die Konzentration der verschiedenen metabolischen Parameter in humanen Körperflüssigkeiten durch eine Vielzahl präanalytischer in vitro Störfaktoren und in vivo Einflussgrößen beeinflusst. Diese können zu signifikanten Veränderungen der Laborergebnisse führen. Im Rahmen meiner Promotionsarbeit wurden in vitro Störfaktoren (Probenmaterial, Lagerung u. a.) und in vivo Einflussgrößen (Ernährung, physische Aktivität) untersucht und ein standardisiertes Präanalytik-Protokoll entwickelt. Dazu wurden pro Probe 3 µL Trockenblut (TB), 10 µL Serum oder Plasma nach Butylierung mittels Elektrospray-Ionisations-MS/MS analysiert und jeweils 26 AS und 35 AC in 1,5 Minuten simultan bestimmt. Als Ergebnis der zahlreichen systematischen Präanalytik-Untersuchungen konnten signifikante Konzentrationsunterschiede der Metabolite zwischen kapillärer und venöser Blutentnahme sowie in Abhängigkeit des Hämatokrits gefunden werden. Im Vergleich zu Serum und antikoaguliertem Plasma (EDTA, Citrat, Heparin) waren die Konzentrationen der langkettigen AC im TB 5-fach höher. Nahrungsaufnahme und körperliche Aktivität führten ebenfalls zu signifikanten Veränderungen der AS- und AC-Konzentrationen. Durch Optimierung des Probenaufarbeitungsprotokolls konnte die Variabilität zwischen den Messtagen für 17 AS und 6 AC auf < 20 % gesenkt werden. Die Ergebnisse meiner Promotionsarbeit unterstreichen den Einfluss präanalytischer Faktoren auf die Metabolomanalytik. Durch Etablierung und Einhaltung standardisierter präanalytischer Protokolle kann die präanalytische Varianz der Ergebnisse deutlich verringert werden. Sie stellen somit eine wichtige Voraussetzung für eine qualitativ hochwertige Metabolomanalytik im Rahmen klinischer Studien zur Identifizierung neuer Biomarker dar.