Supply chain disruptions due to the SARS-CoV-2 pandemic lead to an unusual preanalytical error in measuring hemoglobin concentration in a large medical center

eJHaem

article

Samuel M. Law¹  Rochelle Hardy¹  Danna Anderson¹  Lona Small¹  Jennifer Hurley¹  Leon Beggs¹  Yanka Campbell²  MiKaela Olsen²  Tina Mancini-Flegel¹  Al Valentine¹  Michael J. Borowitz¹  Ivo M. B. Francischetti¹ 

[1] Department of Pathology, Johns Hopkins University School of Medicine;Johns Hopkins Medical Institutions, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

关键词: hemoglobin;    preanalytical;    Sars-Cov-2;   

DOI  :  10.1002/jha2.626

来源: Wiley

【 摘 要 】

Preanalytical errors are defined as those that occur prior to the testingprocess (e.g., test request, patient and specimen identification, specimen collection, transport, accessioning and processing) and represent46–68% of all analytical errors in clinical pathology labs [1, 2]. Wepresent an unusual preanalytical error at our Institution caused by theSARS-CoV-2 pandemic. The sequence of events leading to this error inour Hospital is described chronologically as follows. A series of variable Hemoglobin (Hg) levels was communicated to the HematologyCore Lab at Johns Hopkins Hospital, using a reporting system calledHERO. HERO is an acronym for “Hopkins Event Reporting Online,” anonline portal for any Johns Hopkins Health System employee to reportpotential or observed situations, which have, or may in the future,caused harm to patients or staff. HERO tickets are infrequent and theHematology Core lab receives on average 0–2 HERO(es) per month.However, on April of 2022, a marked increase in notifications werenoted totaling 18 (Figure 1A). The HERO descriptions had, in common, variable Hg levels from blood collected from the same patientsin relatively short intervals, often within 24 hrs. The values fluctuated randomly upwards or downwards, with no predictable periodicity.Figure 1B andCshows illustrative cases of variable Hg values from twopatients. During this process, there was no harm to any of the patients.Every HERO ticket requires a complete investigation by the Corelab staff to determine the cause(s) triggering them. An initial assessment rapidly revealed that the discrepant values were not explainableby bleeding, transfusion, hemolysis, or use of novel medications. However, further investigation identified that all specimens were from theOncology Service located in one specific floor/ward of the Hospital.Moreover, all specimens were collected from central venous catheters(“central lines”) for administration of chemotherapy, which are usefulfor patients with malignancies.

【 授权许可】

Unknown