EMPIRICAL STUDIES doi: 10.1111/j.1471-6712.2009.00753.

Blood sample collection and patient identification demand

improvement: a questionnaire study of preanalytical practices
in hospital wards and laboratories

Olof Wallin MD, PhD (Physician)1,2, Johan Söderberg MD, PhD (Physician)1,2, Bethany Van Guelpen MSSc,
PhD (Associate Professor)3, Hans Stenlund PhD (Statistician, Senior Lecturer, Professor)4, Kjell Grankvist MD, PhD
(Professor, Senior Consultant)2 and Christine Brulin RNT, PhD (Senior Lecturer, Professor)1
1
Department of Nursing, 2Department of Medical Biosciences, Clinical Chemistry, 3Department of Medical Biosciences, Pathology,
4
Department of Public Health and Clinical Medicine, Epidemiology, Umeå University, Umeå, Sweden

Scand J Caring Sci; 2010; 24; 581–591
Blood sample collection and patient identification
demand improvement: a questionnaire study of pre-
analytical practices in hospital wards and laboratories
Background: Most errors in venous blood testing result from
human mistakes occurring before the sample reach the
laboratory.
Aims: To survey venous blood sampling (VBS) practices in
hospital wards and to compare practices with hospital
laboratories.
Methods: Staff in two hospitals (all wards) and two hospital
laboratories (314 respondents, response rate 94%), com-
pleted a questionnaire addressing issues relevant to the
collection of venous blood samples for clinical chemistry
testing.
Results: The findings suggest that instructions for patient
identification and the collection of venous blood samples
were not always followed. For example, 79% of the
respondents reported the undesirable practice (UDP) of not
always using wristbands for patient identification. Simi-
larly, 87% of the respondents noted the UDP of removing
venous stasis after the sampling is finished. Compared with
the ward staff, a significantly higher proportion of the
laboratory staff reported desirable practices regarding the
collection of venous blood samples. Neither education nor
the existence of established sampling routines was clearly
associated with VBS practices among the ward staff.
Conclusions: The results of this study, the first of its kind,
suggest that a clinically important risk of error is associated
with VBS in the surveyed wards. Most important is the risk
of misidentification of patients. Quality improvement of
blood sample collection is clearly needed, particularly in
hospital wards.
Keywords: adverse events, clinical guidelines, error
research, nursing practice, patient safety, questionnaire,
quality and safety, venous blood sampling.
Submitted 2 May 2008, Accepted 22 September 2009

important example is patient identification, which is an

Background
Medical errors are not only a cause of patient suffering and
occasionally death but are also costly (1). Reduction of
errors is therefore critical for everyone involved in modern
health care. The majority of errors in venous blood testing
have been found to be of preanalytical origin that is
occurring prior to laboratory analysis (2–7). Preanalytical
errors are largely attributable to human error (4). The most
Correspondence to:
Olof Wallin, Department of Medical Biosciences, Clinical Chemistry/
Department of Nursing, Umeå University, Building 6M Second floor,
901 85 Umeå, Sweden.
E-mail: olof.wallin@medbio.umu.se
important source of error in venous blood sampling (VBS)
(8–10). Mistakes in patient identification before VBS can
result in serious adverse events (7, 10, 11), including the
death of the patient (12). However, the most common type
of preanalytical error occurs during the actual sampling
procedure (4). In fact, different VBS staff performing the
procedures, and variances in procedures, can create vari-
ations in the test results (13, 14). General procedures that
can affect the test result include the positioning of the
patient (15–18) and prolonged venous stasis (19–21).
Other examples include the handling of test tubes, such as
inverting test tubes with additives after sampling (22, 23),
for example, with an automatic test tube inverter. Inap-
propriate inversion of test tubes may cause clotting of the
blood, which is an important part of errors in VBS (9, 24–

Ó 2009 The Authors. Journal compilation Ó 2009 Nordic College of Caring Science 581
582 O. Wallin et al.

26). Altogether, to ensure correct test results and patient
safety, it is critical with a correct VBS procedure at all times.
Of all test results in blood sample testing, up to 0.5% is
estimated to be erroneous (27). However, the actual error
rate is likely higher (8), as measuring these errors is a
difficult task (5). Of all blood test errors, approximately
one-fourth has consequences for the patient (2, 3, 7).
Given the large numbers of venous blood samples collected
each year, the total number of preanalytical errors with
consequences for patient care becomes unacceptably high.
Venous blood sampling practices in clinical laboratories
are often regulated by accreditation documentation,
meaning that laboratory staff performs VBS practices
according to documented routines, aimed at reducing pre-
analytical errors. Accreditation or certification of VBS in
hospital wards is, however, uncommon. VBS performed by
laboratory staff is associated with lower error rates com-
pared with VBS performed by other staff groups (26, 28–30).
Similarly, preanalytical error rates are higher for inpatient
compared with outpatient samples (4, 31). Thus, the
improvement of VBS practices outside the laboratory, such
as in hospital wards, should be prioritized, in order to reduce
preanalytical error, and thereby increase patient safety.
Despite the known importance of a correct VBS proce-
dure for a correct test result, research to date has mainly
focused on measuring error rates in the laboratory. Thus,
potential sources of error in VBS, such as patient identifi-
cation and sample collection practices, are largely unex-
plored. Only two such studies have been published. The
first study, among laboratory VBS staff reported unsatis-
factory knowledge about important steps in VBS (32). The
second study, from our research group, was a pilot study in
one hospital ward, suggesting that instructions for patient
identification and VBS practices were not always followed
(33). In another study, based on the same subjects as the
present study, the results indicated undesirable test
request, test tube labelling and information search prac-
tices in VBS (34). Taken together, these findings further
highlight the importance of surveying VBS staff outside the
laboratory, in order to identify targets for quality
improvement of blood sample testing.
medical technicians and specific VBS staff employed by the
laboratory. In hospital wards in Sweden, VBS is generally
performed by the enrolled nurses or psychiatric orderlies
employed in each ward. These staff categories perform
basic patient care, as well as other tasks, such as blood
pressure checks and urinary catheterization. Their educa-
tion includes three-years of upper secondary school.
Hospital laboratories in Sweden are mainly staffed by bio-
medical technicians, who are university prepared, conduct
biochemical analyses, manage the analytical equipment,
and perform VBS at the laboratory phlebotomy room.
Participants
In this cross-sectional study, staff responsible for the
majority of VBS in: (1) all wards in two district hospitals
(Hospital A: 230 beds/13 wards, Hospital B: 152 beds/12
wards) and (2) two hospital clinical chemistry laboratories
were included. Only staff working and performing VBS
during the survey period (November 2006–January 2007)
were included in the study. In total, 295 enrolled nurses
and psychiatric orderlies from the wards were eligible for
inclusion. The response rate in the wards was 93%
(n = 274), and the total internal missing rate (items left
blank) was 5.6%. In the laboratories, 40 biomedical tech-
nicians and enrolled nurses were eligible for inclusion. The
response rate in the laboratories was 100%, and the total
internal missing rate was 1.9%.
The standard preanalytical VBS procedure in the sur-
veyed wards and laboratories is summarized in Fig. 1. The

Aim
The aim of the present study was first to describe unde-
sirable VBS practices in hospital wards, and second to
compare these practices with hospital laboratories.

Methods

Context
Internationally, staff categories performing VBS include Figure 1 A summary of the preanalytical part of the venous blood
Registered Nurses, enrolled nurses (also called assistant, testing process in all wards in two district hospitals and in two hospital
practical or licenced-to-practice nurses), physicians, bio- laboratories. The shaded boxes represent areas covered in this paper.

Ó 2009 The Authors. Journal compilation Ó 2009 Nordic College of Caring Science

participants in the wards mainly handled inpatients,
whereas those in the laboratories handled both inpatients
and outpatients. The laboratory manuals, and thus the
instructions for VBS, were equivalent in all wards and
laboratories.
Measurements
Data were collected by means of a questionnaire, based on
the standardized VBS instructions available to the partici-
pants (Table 1), and addressing the collection and handling
of venous blood samples in plastic vacuum test tubes for
clinical chemistry laboratory tests. The questionnaire was
refined from a questionnaire developed in a previous pilot
study (33), taking into consideration responses to items
and comments from the participants.
Content validity was achieved by a thorough review of
the literature, followed by extensive discussions with
professionals on different aspects on VBS and question-
naires, including nursing professionals, heads of wards,
senior consultants in clinical chemistry, VBS instructors, a
quality control officer from a clinical chemistry laboratory,
and researchers with considerable experience in ques-
Table 1 Instructions for patient identification and the collection and
handling of venous blood samples in all wards in two district hospitals
and in two hospital laboratories
Preanalytical step Instruction from the laboratory
Patient rest Sitting or supine for more than 15 minutes prior
to sampling.
Patient By asking the patient to state name and Swedish
identification identification number (which can be compared
with a social security number), and by checking
ID card with photo or ID wristband.
Stasis If stasis is necessary, it is used for the shortest
time possible and should be removed (max
1 minute) before the first venous blood sample
is collected.
Handling of Each tube is filled until the vacuum effect is lost.
test tubes Tubes with additives are inverted 8–10 times. If
tubes with different substances are used, they are
filled in a predetermined order. Test tubes are
stored in a vertical position for at least 30 minutes,
unless otherwise stated, and are then handled
according to local sampling instructions.
Figure 2 Example of three items from the
questionnaire. The items were categorized into
undesirable practice (UDP), representing an
incorrect practice, and desirable practice, rep-
resenting a correct practice.
Ó 2009 The Authors. Journal compilation Ó 2009 Nordic College of Caring Science
Blood collection practices 583
tionnaire design. In order to obtain face validity, the
questionnaire was further evaluated and discussed on two
occasions in a focus group consisting of seven enrolled
nurses with considerable experience of practical VBS in a
wide range of settings. Criterion validity and test–retest
reliability were not measured.
The final version of the questionnaire consisted of 56
items. Some items had dichotomous responses, whereas
others, in order to focus on the frequency of a perfor-
mance, included a scale of response alternatives, ranging
from never to always. As the present study focuses on
patient identification, patient rest, stasis removal and
specimen handling after VBS, the 19 items related to these
areas, as well as background information on the study
participants, were included in the results.
Background items
Responses to the item regarding frequency of sampling
were grouped into the categories ‘at least weekly’ or ‘more
seldom’. Age was divided into 10-year intervals, and years
of employment were divided into 5-year intervals. The
participants were considered to be further educated if their
latest reported education in VBS was at least one year later
than their original VBS education (included in their formal
education). The wards were categorized as surgical
(including orthopaedic), medical, psychiatric, intensive
care (including postoperative), women’s health/paediatrics
and emergency.
Items concerning VBS practices
As described in Fig. 2 and Table 2, all items regarding VBS
practices were divided into either undesirable practice
(UDP), representing an incorrect practice or desirable
practice, representing a correct practice. Two stages of the
procedures stasis removal and test tube storage were con-
structed. The items included in each stage had four
response alternatives, ranging from never to always. Each
response was given a value ranging from one to four, with
increasing values representing more desirable practice. For
each procedure (stasis removal and test tube storage), an
average score was calculated and divided at the third
quartile into UDP and desirable practice.
The responses to the item regarding patient rest were
divided into ‘15 minutes or less’, representing UDP, and
584 O. Wallin et al.

Table 2 Frequency of preanalytical procedures in all wards in two district hospitals and in two hospital laboratories

Never (%) Seldom (%) Often (%) Always (%) Total (n)

How and how often do you check the identity of a patient when collecting venous blood samples?
(a) By asking the patient to state his/her name W – 1.5 8.1 91 273
and Swedish identification number L – 2.5 2.5 95 40
(b) Since I already know the patient, I don’t have W 83 8.7 6.0 2.6 265
to check this L 92 2.6 – 5.1 39
(c) By checking the wristbanda W 4.0 39 36 22 247
(d) By asking the patients family W 69 20 6.7 4.5 267
L 32 58 – 11 38
(e) By checking the patient’s health care card W 57 21 8.2 14 267
L 58 30 2.5 10 40
If you use stasis when performing venous sampling, when do you remove it?
(a) Before the first sample is collected W 47 35 14 3.6 252
L 28 33 33 7.5 40
(b) During sampling W 5.4 28 50 17 257
L 7.5 13 35 45 40
(c) After the sampling is finished W 14 28 29 30 259
L 60 35 2.5 2.5 40
How often do you carry out the following tasks?
(a) Invert each test tube with additives several W 1.5 5.1 35 58 273
times immediately, before the next test tube is L 2.6 13 10 74 39
filled
(b) Use an automatic test tube inverter W 97 2.7 – 0.4 259
L – 2.5 10 88 40
How do you store the test tubes immediately after sampling?
(a) I lay them on a workbench or other similar W 31 37 26 5.9 255
location L 82 18 – – 39
(b) In the pocket of my laboratory coat or uniform W 96 3.6 0.4 – 250
L 100 – – – 39
(c) In a test tube stand W 7.1 11 36 47 269
L – – 2.5 98 40
0–5b 6–15b >15 Do not check Total (n)
How long (in minutes) do you usually allow your W 22 6.8 18 53 264
patient to rest (supine or sitting) prior to venous
blood sampling?
L – 40 33 28 40
a
Psychiatric wards were excluded as they do not use wristbands. Laboratories were excluded as they handle both inpatients with wristbands and
outpatients without wristbands.
b
Two categories in the questionnaire.
W, Wards; L, Laboratories.
The shaded areas represent undesirable practices.

‘more than 15 minutes’, representing desirable practice.
For the item regarding identification by wristband, all
responses from the psychiatric wards and the laboratories
were excluded, as these wards did not use wristbands for
all patients.
Procedure
Permission was obtained from the head of each ward or
laboratory to perform the survey, as well as a list of all
subjects including information on sex, job title, working
hours and the existence of documented unit specific
routines for VBS practices. The head informed the subjects
about the study according to standardized instructions,
and distributed the questionnaire together with an
introduction, a description of the survey and an un-
marked envelope, in an envelope marked with the sub-
ject’s name. Participants were assured confidentiality, that
is, results would only be presented at group level, par-
ticipation was voluntary, and participants could withdraw
from the study at anytime without declaring a reason. The
head of each ward or laboratory collected the unmarked
sealed envelopes containing the completed question-
naires. Each questionnaire was coded in order to allow

Ó 2009 The Authors. Journal compilation Ó 2009 Nordic College of Caring Science
 Blood collection practices 585

reminders to be sent to nonresponders. Only the investi-
gators had access to the code key, and all questionnaires
were anonymized prior to entry into the data file. After
2 weeks, a reminder was distributed, and after 4 weeks a
similar reminder and a new questionnaire were sent to
those subjects who still had not returned the completed
questionnaire (n = 14).
Statistical analysis
Data from the completed questionnaires, as well as the
respondent’s background information, were coded and
manually transferred to an Excel data sheet (Microsoft
Corp., Redmond, WA, USA). SPSS 13.0 for Macintosh and
SPSS 14.0 for Windows (SPSS Inc., Chicago, IL, USA) were
used for all statistical analyses. Chi-squared test or Fischer’s
exact test was used to compare categorical variables. The
significance level was set at p < 0.05.
remaining 8.8% were psychiatric orderlies. Of the partici-
pants in the wards, 91% reported having a formal
education in VBS and 6.2% reported also having received
further education in VBS. According to the heads of the
wards, two of the 25 wards (6.2% of subjects) had docu-
mented unit specific VBS routines.
The mean age of the participants in the laboratories was
45 years, and the mean duration of employment was
18 years. Of these subjects, 98% were women, 85%
worked full-time, and 39% performed VBS at least weekly.
Regarding occupation, 95% were biomedical technicians,
and the remaining 5.0% were enrolled nurses. Almost all
participants in the laboratories reported having a formal
education in VBS (95%) and 30% reported having
received further education in VBS. Both laboratories had
documented unit specific routines for VBS according to the
heads of the laboratories. For detailed background infor-
mation of all participants see Table 3.

Ethical considerations Patient identification in VBS

The study was approved by the Regional Ethical Review
Board (06–104M). The returning of the questionnaire
was accepted as informed consent. One ethical issue
specific to the study is possible feelings of guilt among
participants, if the results should indicate inadequate
VBS practices. As the heads of the wards and laborato-
ries distributed the questionnaire, the VBS staff may also
have felt obligated to respond. However, these risks were
minimized by collecting the questionnaires in sealed
unmarked envelopes, and by presenting results only on
the group level.
Results
The results for patient identification are presented in
Tables 2 and 4. Of the respondents in the wards, 9.6%
reported the UDP of not asking the patient to state his/her
name and Swedish identification number prior to VBS.
Furthermore, 17% reported the UDP of not checking
patient identity, because of ‘already knowing the patient’.
The majority (79%) of the respondents in the wards
reported the UDP of not checking the wristband during
patient identification, and almost half (43%) reported the
UDP of using the patient’s health care card for identifica-
tion of the patient. No significant differences in responses
with respect to patient identification were found between
the wards and the laboratories.

Participants Procedure and specimen handling in VBS

In the wards, the mean age of the participants was
50 years, and the mean duration of employment was
12 years. Of these subjects, 96% were women, 51%
worked full-time, and 84% performed VBS at least weekly.
Regarding occupation, 91% were enrolled nurses, and the
For the detailed results of patient rest, stasis removal and
specimen handling in VBS, see Tables 2 and 4. Almost all
(87%) of the respondents in the wards noted the UDP of
removing the stasis after the sampling is finished. Almost
half (42%) of the respondents in the wards reported the

Table 3 Age, years employed in the unit and frequency of venous blood sampling in all wards in two district hospitals and in two hospital laboratories

Years of age <25 26–35 36–45 46–55 >56 Total (n)

Wards (%) 2.9 6.6 12 49 30 272

Laboratories (%) 7.5 15 20 38 20 40
Years employed at unit <5 6–10 11–15 16–20 >21 Total (n)
Wards (%) 25 28 18 8.2 21 269
Laboratories (%) 35 2.5 7.5 2.5 53 40
Frequency of venous blood sampling Daily Weekly Monthly More seldom Never Total (n)
Wards (%) 41 42 10 6.6 0 274
Laboratories (%) 5.1 33 56 5.1 0 39

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586 O. Wallin et al.

Table 4 Statistical comparisons of undesirable practices between all wards in two district hospitals and in two hospital laboratories

Laboratories Wards

% n % n v2 df p

Do not identify by asking for name and number 5.0 2 9.6 26 – 0.553a
Do not identify because of already knowing the patient 7.7 3 17 46 2.31 0.125b
Identify by asking the family 11 4 11 30 – 1.0a
Identify by checking the patients health care card 43 17 43 115 0.01 0.946b
Stasis removal after sampling 60 24 83 209 11.71 0.001b
Do not invert the test tube after sampling 26 10 42 114 3.71 0.054b
Do not use an automatic test tube inverter 2.5 1 99.6 258 282.01 <0.001b
Horizontal test tube storage 18 7 69 179 38.31 <0.001b
Do not allow the patient to rest >15 minutes before sampling 68 27 82 216 4.41 0.035b

p-values measured with aFischer’s exact test or bChi-squared test.

UDP of not inverting test tubes with additives after sam-

pling, and only one participant (0.4%) reported the
desirable practice of using an automatic test tube inverter.
Two-thirds (69%) of the participants in the wards reported
the UDP of storing test tubes horizontally (for example
lying on a bench top), while 54% noted the UDP of not
using a test tube stand for vertical test tube storage. The
vast majority (82%) of the respondents in the wards
reported the UDP of allowing the patient to rest for
15 minutes or less before VBS.
For all significant differences in responses (Table 4),
the ward staff reported more UDPs, compared with
the laboratory staff. This was the case for stasis removal
prior to sample collection (p = 0.001), use of an auto-
matic test tube inverter (p < 0.001), horizontal test tube
storage (p < 0.001) and patient rest prior to VBS
(p = 0.035).
VBS practices related to type of ward
All statistically significant comparisons among types of
wards are presented in Table 5. A higher proportion of
participants in psychiatric (13%), intensive care (23%) and
women’s health/paediatric (21%) wards, compared with
all other wards (0–7.4%), reported the UDP of not asking
the patient to state name and Swedish personal identifi-
cation number prior to VBS (p < 0.001). Similarly, a
higher proportion of respondents in psychiatric (38%) and
women’s health/paediatric (34%) wards, compared with
all other wards (5.1–19%), reported the UDP of not
checking patient identity because of ‘already knowing the
patient’ (p < 0.001). Almost all respondents in the surgical
(93%) and medical (88%) wards reported the UDP of not
using the wristbands for patient identification, compared
with 41–69% in all other wards (p < 0.001).

Table 5 Significant differences in undesirable practices between types of wards in two district hospitals

Surgical Medical Psychiatric Intensive Women’s Emergency All wards

% (n)a % (n) % (n) care % (n)b health % (n)c % (n) % (n) v2 df p

Do not identify by asking for name 0 6.5 (6) 13 (3) 23 (7) 21 (8) 7.4 (2) 9.5 (26) – <0.001d
and number
Do not identify because of already 5.1 (3) 15 (13) 38 (9) 10 (3) 34 (13) 19 (5) 17 (46) – <0.001d
knowing the patient
Do not identify by checking 93 (56) 88 (79) – 65 (20) 69 (27) 41 (11) 78 (193) 40.3 4 <0.001e
the wristband
Identify by asking the family 1.7 (1) 2.3 (2) 0 3.3 (1) 23 (9) 63 (17) 11 (30) – <0.001d
Identify by checking the patients 19 (11) 30 (26) 29 (7) 60 (18) 77 (30) 85 (23) 43 (115) 64.1 5 <0.001e
health care card
Stasis removal after sampling 93 (50) 85 (72) 64 (14) 93 (28) 79 (27) 69 (18) 83 (209) – 0.008d
Horizontal test tube storage 52 (30) 64 (56) 73 (16) 89 (24) 87 (33) 71 (20) 69 (179) 20.0 5 0.001e
Do not allow the patient to rest 82 (46) 74 (66) 96 (23) 65 (20) 97 (36) 93 (25) 82 (216) – <0.001d
>15 minutes before sampling

Including: aOrthopaedic. bPostsurgery. cPaediatric. p-values measured with dFischer’s exact test or eChi-squared test.

Ó 2009 The Authors. Journal compilation Ó 2009 Nordic College of Caring Science
 Blood collection practices 587

Table 6 Significant differences in undesirable practices between subgroups of respondents in all wards in two district hospitals

% n % n

Educateda Not educateda v2 df p

Do not identify by checking the wristband 81 180 54 13 8.9 1 0.003c

Do not allow the patient to rest >15 minutes before sampling 84 201 63 15 – 0.022d
Further Not further
educateda educateda

Identify by asking the family 31 5 9.3 22 0.018d

Do not identify by checking the wristband 47 7 80 174 0.006d
Weeklyb More seldomb

Do not identify because of already knowing the patient 15 33 29 13 5.0 1 0.025c

Horizontal test tube storage 64 140 93 39 13.7 1 <0.001c
Full-time Part-time

Do not invert the test tube after sampling 34 47 50 67 7.9 1 0.005c

a
Education in venous blood sampling.
b
Frequency of venous blood sampling.
p-values measured with cChi-squared test or dFischer’s exact test.

test tube storage (93 vs. 64%, respectively, p < 0.001).

VBS practices related to VBS education and routines in the
wards
Significant associations between VBS practices and VBS
education in the wards are presented in Table 6. A higher
proportion of respondents in the wards with, vs. without, a
formal education in VBS noted the UDPs of not checking
the wristband during patient identification (81 vs. 54%,
p = 0.003), and of not allowing the patient to rest for
15 minutes or more prior to VBS (84 vs. 63%, p = 0.022).
The UDP of patient identification by asking the family was
also more often reported by ward staff with, vs. without,
further education in VBS (31 vs. 9.3%, p = 0.018). How-
ever, a lesser proportion of respondents in the wards with,
vs. without, further education in VBS reported the UDP of
not identifying the patient by the wristband (47 vs. 80%,
p = 0.006). No statistically significant differences in
response frequencies were found between the wards at
which the head of the ward reported having documented
unit specific VBS routines (two wards, 6.2% of respon-
dents), compared with the wards where no such routines
were reported (23 wards, 94% of respondents).
VBS practices related to frequency of VBS in the wards
Results for VBS practices related to the frequency of VBS in
the wards are presented in Table 6. The UDP of not
checking patient identity, because of ‘already knowing the
patient’, was more commonly reported in the wards where
the respondents reported to perform VBS less than once a
week, compared with at least weekly (29 vs. 15%,
p = 0.025). This was also the case for the UDP of horizontal
With respect to working hours, a higher proportion of
those in the wards working part-time, vs. full-time,
reported the UDP of storing the test tubes horizontally (50
vs. 34%, p = 0.005).
Discussion
Improving the accuracy of patient identification is the
highest priority for patient safety (35). This is the single
most important step in blood testing. For example, patient
identification at VBS may be the major source of error in
blood transfusions, and is largely the result of noncom-
pliance with guidelines (8). Critical patient identification
errors in blood testing have been reported to occur in up to
one per 1000 procedures or specimens (9). It is estimated
that misidentification of laboratory specimens results in
160 000 adverse advents every year in the USA (10).
The results in this study demonstrate serious shortcom-
ings in the identification procedures in the surveyed wards.
For example, almost half of the participants reported using
health care cards for patient identification. The health care
card, issued to all residents of Sweden, contains name,
address and Swedish identification number, but no pho-
tograph, and should therefore never be used for identifi-
cation purposes. Furthermore, the vast majority of
respondents in the wards reported to not always using
wristbands for identification of inpatients. Our findings are
in line with previous studies, indicating that patient
identification procedures in VBS require urgent attention.
Although unacceptable, some of the results regarding
patient identification may have logical explanations. Not

Ó 2009 The Authors. Journal compilation Ó 2009 Nordic College of Caring Science
588 O. Wallin et al.
asking the patient for name and Swedish identification
number was more commonly reported in the psychiatric,
intensive care and women’s health/paediatric wards,
where patients more often have an impaired ability to
communicate. Already knowing that the patient as the
means of identification was also more commonly reported
in the psychiatric wards, which may be due to the longer
durations of stay among patients there. However, in the
medical and surgical wards, almost all respondents re-
ported not using wristbands for identification purposes.
This is a serious finding, since samples are collected from
patients with impaired consciousness in these wards.
Although less likely to have such potentially tragic
consequences as patient identification errors, errors during
the actual sampling procedure are believed to be the most
common type of preanalytical error (4). For example,
incorrect positioning of the patient before and during VBS
(15–18) and prolonged venous stasis (19–21) may have
clinically significant effects on test results. This study sug-
gests that both of these issues, as well as vertical storage of
test tubes after sampling (for proper coagulation of serum
samples), could all be improved in the wards surveyed. As
the most remarkable finding, almost all respondents in the
wards reported removing stasis after VBS. Our results also
indicate that inversion of test tubes was not performed
according to international recommendations (22, 23) and
VBS instructions in the laboratory manual. However, some
studies report that inappropriate test tube inversion does
not introduce clinically important preanalytical error for
coagulation and haematological testing, at least in healthy
volunteers (36–39).
The findings for the laboratories were significantly better
than those for the wards, which is in line with previous
studies (4, 26, 28–31). Some opportunities for preanalyti-
cal errors differ between inpatient and outpatient VBS, for
example, the risk of blood sample dilution by intravenous
infusions in inpatients. However, no such differences were
addressed in the present study. Furthermore, the labora-
tory manuals, and thus the instructions for VBS, were
equivalent for all participants. Differences in conditions
between the wards and the laboratories are therefore not
likely to explain the differences in the results.
The laboratories surveyed are accredited in accordance
with the international ISO/IEC 17025 standard, which
regulates sample collection performed by laboratory per-
sonnel. Very few hospital wards in Sweden are accredited
or certified according to the international ISO 9000 system.
Both laboratories had documented routines for VBS,
according to the head of the laboratory, compared with
only two of the 25 wards. Furthermore, both laboratories
had introduced a mandatory and regularly renewed com-
petence certificate for all VBS staff. Therefore, certification
and routines for VBS in the laboratories may have con-
tributed to the better VBS practices among laboratory staff
compared with ward staff. However, no significant differ-
Ó 2009 The Authors. Journal compilation Ó 2009 Nordic College of Caring Science
ences between the wards and the laboratories were found
with respect to patient identification, suggesting that the
need for improvement of the preanalytical process is not
limited to the wards.
Some of the results indicated better VBS practices among
respondents performing VBS more often (more frequently
or full-time work). This suggests that continuity may be
important for maintaining high quality VBS. In contrast,
despite the better VBS reported by the laboratory staff,
only 39% of the respondents from the laboratories per-
formed VBS weekly, compared with 84% of the respon-
dents from the wards. This leads us to speculate that
accreditation, certification, routines and education may
compensate for a lack of continuity, and may therefore be
especially important for VBS staff who perform VBS less
frequently.
The level of basic education for VBS staff varies inter-
nationally but the prevalence and types of preanalytical
errors seem to be fairly constant when comparing studies
from all over the world (2–7). This supports the finding of
the present study that education was not a major deter-
minant of VBS quality, in line with a previous report (32).
Furthermore, VBS is a very limited task that should always
be performed identically, according to the laboratory
manual, which is generally based on international rec-
ommendations (23). Enrolled nurses and psychiatric
orderlies have been responsible for the vast majority of
VBS in hospital wards for several decades in Sweden. They
are generally the most experienced VBS staff in hospital
wards in Sweden, and are therefore most comparable with
other VBS staff categories in hospital wards internation-
ally.
Finally, the results of the present and previous studies
raise the question of which quality improvement strategies
that might be suitable for the preanalytical phase of blood
testing. Standardization of preanalytical sampling proce-
dures (17, 40, 41), external quality control programs (42)
and easy-to-read instructions together with convenient
access to necessary equipment (43) can all improve the
accuracy of the test result. In addition, continuous moni-
toring (44–46), feedback from laboratories (47) and
improvement of equipment design (48) can reduce iden-
tification errors. These measures might therefore be
effective means of improving the preanalytical phase,
including VBS in hospital wards, and thus increasing
patient safety.
Methodological considerations
In designing the questionnaire for this study, we intended
to develop a tool that could be used to evaluate VBS
practices on the group level. Given the extensive devel-
opment process for the questionnaire, including a focus
group and a pilot study (33), the face and content validity
are likely to be reasonable. To the best of knowledge, no

other instrument or golden standard existed to measure
practical VBS, and direct observation were judged to be too
prone to ‘good behaviour’ bias to be useful for assessing
validity. For these reasons, criterion validity has not been
obtained for the questionnaire. However, as any bias in
responses would be expected to tend toward ‘good
behaviour,’ the inadequacies observed in this study seem
likely to represent, or perhaps even underestimate, areas of
practical VBS in need of improvement.
Test–retest reliability was not measured in this study.
Stability indices are most appropriate for enduring attri-
butes such as personality or height (49) and therefore less
suitable for measures of practices. A test–retest can be
affected by changes in behaviour and knowledge over
time, independent of the stability of the measure, as well as
by memory interference or a change of practice as a direct
result of the first administration (49). As the results are
used to draw conclusions on the group level only, with a
large sample size, the test–retest reliability is of less
importance (50).
A major strength of this study is the sample, which
included all staff responsible for the majority of VBS in two
hospitals. Despite the relatively large sample size, a greater
number of participants would have provided more statis-
tical power for subgroup analyses. The response rate was
very high, and the subjects were informed about the
importance of answering all questions truthfully. The
results of this study were largely in line with those of a
previous pilot study (33), but confirmation of the findings
in other settings would of course be valuable.
Conclusions
To our knowledge, this is the first study to survey patient
identification and the collection and handling of venous
blood samples in hospital wards. The results indicate that
standardized instructions were not always followed, which
could have consequences for patient safety. Laboratory
staff, whose accreditation and certification covers the
process of VBS, reported better practices with respect to
specimen collection and handling, but not patient identi-
fication.
The major implication of this study is the increased
recognition of the need for quality improvement of sample
collection in hospital wards. Local measures initiated and
maintained in cooperation with laboratory staff, such as a
competence certificate for VBS staff is recommended.
Further studies of VBS practices are clearly needed, in
Sweden and internationally.
Acknowledgements
We thank Johan Hultdin, Inger Rautio, Andreas Jonsson,
Susanna Hermansson and Ann-Britt Lindström in the
Clinical Chemistry Laboratory, Umeå University Hospital;
Ó 2009 The Authors. Journal compilation Ó 2009 Nordic College of Caring Science
Blood collection practices 589
Ulf Jansson at Laboratory Medicine, Västernorrland
County Council; Birgitta Nilsson, Birgitta Berglund and
Åsa Lundsten at Medical Biosciences, Umeå University; the
heads of the examined units; the enrolled nurses, psychi-
atric orderlies and the biomedical technologists in the
examined units; the enrolled nurses in the work pool at
Umeå University Hospital; the Faculty of Medicine, Umeå
University and the Swedish National Board of Health and
Welfare.
Funding
This study was funded by the Faculty of Medicine, Umeå
University, Umeå, Sweden and the National Board of
Health and Welfare in Sweden.
Author contributions
Olof Wallin, Johan Söderberg, Bethany Van Guelpen, Kjell
Grankvist, Christine Brulin designed the study; Olof Wallin
and Johan Söderberg were involved in data collection; Olof
Wallin, Johan Söderberg, Bethany Van Guelpen, Hans
Stenlund, Kjell Grankvist, Christine Brulin performed data
analysis; Hans Stenlund was involved in statistical works;
Olof Wallin, Johan Söderberg, Bethany Van Guelpen,
Hans Stenlund, Kjell Grankvist, Christine Brulin prepared
the manuscript.
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