![]() Key Words: sample request, LIS, patient identification change PREANALYTICAL CASES IN CEREBROSPINAL FLUID ANALYSIS In case of patient identification change, a warning is given now the system asks whether to use the new identification from the given time on or to overwrite the patient´s data. When the request was activated in LIS, the first identification of the patient was overwritten.ĬONCLUSIONS: The computer company was asked to prepare a new software version of LIS. After the patient was moved to the hospital department, the second request was made with the insurance card, whereby the system detected the right family name. The request was probably made without the health insurance card, by asking the patient and indicating her girl´s family name. RESULTS: The emergency department did not provide the information how the first request was created. In summary, the laboratory found the sample of PATIENT X with changed identification to PATIENT Y in LIS. Instead of it, the identification of PATIENT Y was placed. LIS had no longer the identification of PATIENT X. According to both departments, PATIENT Y was moved from the emergency department and PATIENT X was the only person who was moved to the internal department in that time period. Again the request was created in HIS and activated in LIS, but the sample could not be found. Later the laboratory received a request from an internal hospital department for additional tests for PATIENT Y, whereby the sample should be already in the laboratory. The request was done in the hospital information system (HIS) and transmited to LIS. The request is usually done with the help of patient´s health insurance card with a unique number to prevent errors in identification. METHODS: Our laboratory received a sample request for a female patient (PATIENT X, with X presenting her family name) from the emergency department. Gorenjak 1ġ Department for Laboratory Diagnostics, University Clinical Centre Maribor, SloveniaīACKGROUND-AIM: We present a case report of unexpected change of patient identification in the laboratory information system (LIS) after activating two different sample requests for the same patient. Key Words: spurious hyperkalemia, blood gas analysis, preanalytical phase PREANALYTICAL CASE REPORT - UNEXPECTED CHANGE OF PATIENT IDENTIFICATION IN LISĮ. Investigation of the case revealed that spurious hemolysis was attributable to syringe transportation to the laboratory in direct contract with ice for ~15 min.ĬONCLUSIONS: This case emphasizes the importance of fulfilling strict criteria for blood sample transportation and the urgent need of equipping point of care analyzers with interference indices. The potassium value in centrifuged heparinized plasma was also consistent with hyperkalemia (i.e., 5.5 mmol/L). The visual analysis of plasma after centrifugation was already consistent with the presence of hemolysis, which was then confirmed by high hemolysis index (i.e., 50 0.5 g/L). Both potassium and hemolysis index were then measured in this heparinized plasma, using Cobas 8000. Due to suspect of spurious hemolysis, the heparinized blood was transferred from the syringe into a plastic tube and centrifuged. The analysis, performed on Cobas 8000 (Roche Diagnostics) revealed normal values of plasma potassium (i.e., 4.6 mmol/L local reference range in plasma, 3.5-5.0 mmol/L) and hemolysis index (i.e., 5 0.05 g/L). ![]() ![]() This result was unexpected by the requesting clinician, so that a second venous blood sample was immediately drawn by direct venipuncture into a 3.5 mL lithium-heparin blood tube (Vacutest, Kima), and sent to the laboratory for repeating potassium testing. RESULTS: Blood gas analysis, performed with GEM Premier 4000 (Instrumentation Laboratory), revealed a substantially normal blood gas profile except a high value of potassium (i.e., 5.2 mmol/L local reference range on whole blood, 3.5-4.5 mmol/L). Venous blood was drawn by a nurse into a 3.0 mL heparinized syringe (Smiths Medical), and sent to the central laboratory, for analysis of blood gases. METHODS: A 51-year old male patient was admitted to the local hospital with dyspnea. Lippi 1ġ Section of Clinical Biochemistry, University Hospital of Verona, Verona, ItalyīACKGROUND-AIM: We describe a paradigmatic case of spurious hyperkalemia in blood gas analysis due to inappropriate transport conditions of a heparinized syringe. Alexander von Meyer (DE) Preanalytical cases A PARADIGMATIC CASE OF SPURIOUS HYPERKALEMIA IN BLOOD GAS ANALYSIS ![]()
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