Laboratory safety in the pre-analytic phase
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February 1, 2018
Editor’s note: In this guest column, Dan Scungio, MT(ASCP), SLS, laboratory safety officer for Sentara Healthcare, a multihospital system in Virginia, and otherwise known as “Dan, the Lab Safety Man,” discusses the important issues that affect your job every day.
Scenario 1: The courier suddenly became sleepy in the middle of his daily driving route. It was cold outside, and he had all the windows in the vehicle closed. He also had filled his cooler with four pounds of dry ice, which was sitting in his back seat. He lost consciousness behind the wheel, only avoiding an accident by sheer luck.
Scenario 2: There was no education at the hospital for specimen collection staff regarding proper label placement on collection tubes. Since the complete blood count analyzer would not accept tubes with labels that were too long, the lab techs kept a razor blade handy to slice off extra label paper. It wasn’t long before someone cut a finger.
Scenario 3: The phlebotomist completed the outpatient collection, but the large elderly patient was unable to stand up from the chair without assistance. The phlebotomist bent at the waist and attempted to lift the patient to standing. The back muscle pull that followed kept the phlebotomist out of work for two weeks.
Every laboratorian understands the value of quality in the pre-analytic phase of laboratory testing. If you have ever worked in a facility where phlebotomy has been decentralized and is no longer overseen by the laboratory, you may have experienced the many pitfalls due to inadequate specimen collection techniques. Laboratorians by nature want to provide good diagnostic results, and compromised specimens hinder that resolve. Sometimes, however, the aspects of safety that are important during the pre-analytic phase of lab testing get overlooked.
To address the issue in scenario 1, the dry ice courier, consider the impacts of this necessary service. For many laboratories, couriers are a vital part of the pre-analytic process. They bring specimens from clients and other labs, and their safety should be considered as well. Teaching dry ice safety is vital if it is used, and both couriers and lab staff need to know how to handle it appropriately. Dry ice sublimates (or changes to gas from a solid state), so it should never be placed into a sealed container, or the building pressure from expansion will cause the container to explode. Couriers should never place more than one pound of dry ice inside a vehicle, and the windows should be opened when transporting it to create good ventilation. The gas created from dry ice quickly reduces the oxygen content in the air, and the elevated carbon dioxide levels can cause unconsciousness or even death. Never place dry ice leftovers in the sink for disposal. While it might be fun to run water on it to see movie-style special effects, the cold temperatures can burst sink pipes and even dislodge the entire sink.
To address the issue in scenario 2, the labels on collection tubes, here is what you should do. If specimens often arrive in the testing area without being ready for analysis (for instance, the labels aren’t placed properly), go to the source of the error to make corrections. If inappropriate labeling is a constant problem, staff will create workarounds to get the work done, and some of these workarounds may not be safe. Poorly labeled samples may prompt a lab tech to remove gloves to adjust the labels, and that should never occur. The use of sharp blades may be another workaround— one that can cause injuries. Be sure to explain to specimen collection staff the importance of proper labeling. Taking the time to do labels right might delay turnaround times, but it will also help keep lab workers safe.
To address the issue in scenario 3, the phlebotomist’s back injury, needle safety and ergonomics should be considered during blood collection from patients. Using a needle with an attached safety device and activating it as soon as possible are important steps in needlestick prevention. Make sure there is a sharps disposal container near the point of collection or wherever needles are used so that the potential hazard can be eliminated quickly. When collecting blood, be sure to raise the bed height (or the arm height if in a chair) so that excessive bending is avoided. Use a chair or a task stool while performing the collection to maintain better posture throughout the procedure. Never attempt to lift patients by yourself; always ask for help. Thousands of back injuries occur every year in healthcare due to avoidable patient lifting errors.
Lab quality and safety are often related, especially during the pre-analytical phase of testing. Proper collection, labeling, and processing are all vital in providing high-quality lab results. Similarly, the pre-analytical process can’t be done well without proper safety considerations. Safety events can cause staff injuries, longer turnaround times, and potential errors with test results. Make sure staff understand the impact of good quality as well as safety in the pre-analytical phase.
A light touch
The other day I went to get a haircut (yes, even though I don’t have the hair I used to have, I still go to a barber shop from time to time). The stylist was good at carrying a conversation. I began to notice as she continued her work, however, that her touch was anything but gentle. She combed with vigor, leaving what I imagined were indentations on my tender scalp. At the end she hefted the clippers to trim up the hairs on my neck. I have experienced haircuts in the past that were given much more gently, and the results were the same minus the mental and possible physical scarring. As I drove away, I started to think about my experience’s applications to laboratory safety.
In my years as a lab safety officer, I have had to learn how to give feedback to those in the lab who are not following proper safety procedures. It is important. Usually if I need to speak to someone, the person is in danger of becoming injured or exposed to some hazard. The safety coaching moment is necessary.
The book Crucial Confrontations (by Grenny, McMillan, and Switzler) is an excellent resource that can be used to teach how to provide important coaching in any setting. One thing I learned from that book is that if someone is acting inappropriately — doing something unsafe, for example — there are at least six possible sources of influence potentially guiding the person’s actions. Let’s use an example: You walk into the lab and see Mary on the phone at the hematology bench with no lab coat and no gloves. Why is she doing that? Did she have proper training? Is the PPE located in a convenient area for staff to get quickly? Was Mary on her way to a break but no one else was there to answer the phone? Is Mary a person who is usually noncompliant? Is Mary following the general safety culture in the lab?
How you approach Mary here is critical. You could yell at her. You could angrily tell her to get PPE since you’ve discussed this with her before. You could tell her she will be written up. Then let’s say Mary hangs up the phone and tells you she just learned her mother has passed away. That certainly changes the scenario, and it casts a negative (perhaps permanent) pall on your working relationship. That will be difficult to change, and it will be harder to influence Mary in any way about safety in the future. It is vital to be careful about any coaching event you have in the laboratory. Your approach affects the outcome, and much of that approach is determined by what you are thinking as you begin. A light touch in a coaching situation will produce more gains than a heavy hand. It will also build your credibility as a safety advocate in the department.
Approaching Mary is the right thing to do, no matter her situation. She is at a lab bench touching contaminated surfaces with no PPE. That needs to be dealt with. If you ignore it, you promote the behavior, and if others witness that, then you are responsible for untold harm to the overall lab safety culture. Even if Mary tells you she received bad news, it is still important to point out her inappropriate safety behavior, especially if you have seen the behavior before; however, it should be done at a later time.
Haircuts and coaching for lab safety occur in very different arenas, but performing these actions with a gentle, light touch is one way to make sure both outcomes are positive. A light touch can help ensure there are no types of scars, and a good outcome in the lab helps improve the overall culture — a goal every lab safety professional should desire.