There is substantial information available covering the need for and the risk associated with jeopardized laboratory safety. However, few of these resources focus on the safety of staff members performing work during the preanalytical phases of laboratory diagnostics and testing. The members of the lab team who collect, transport, and process samples and specimens in preparation for testing are invaluable to the overall functions of the lab, and their safety is as important as that of any other laboratory employee.

With this in mind, there are specific safety pitfalls in the work associated with pre-analytical processes, and safety training and oversight are necessary for these employees to excel at avoiding accidents and injuries.

Specimen Collection and Personal Protective Equipment

The Occupational Safety and Health Administration (OSHA) governs much of the work of phlebotomists and other providers who may collect patient specimens via its Bloodborne Pathogens standard (1910.1030).¹ The standard requires that phlebotomists use gloves during blood collection (except in a blood donation center). Gloves also are needed for the handling of primary blood tubes and specimen containers once they are filled. Notably, the exterior of the containers is considered contaminated at all stages of sample processing.

Once specimens are collected, they should be labeled (in full view of the patient) and placed inside of a specimen transport bag or in a rack. Gloves should be properly removed followed by standard hand hygiene. Gloves are never to be used for more than one patient encounter, nor should they be reused.

OSHA does not require laboratory coats for phlebotomists while collecting specimens. A 2007 OSHA Letter of Interpretation states, “Laboratory coats…are not typically needed as personal protective equipment (PPE) during routine venipuncture.” The letter does go on to state that employers should perform risk assessments for any potential exposure situation in order to make decisions about lab coat use. In other words, if you perform a risk assessment and determine there is a high risk of blood spatter above the wrist or glove when performing a venipuncture, then it is advisable to use lab coats. Remember, cloth scrub jackets are not true laboratory coats, and they do not qualify as PPE, as they are absorbent and not fluid resistant.

OSHA does not permit personnel to wear PPE out of an area once it is used there. If staff members leave the laboratory department to assist with specimen collections on other units, they should bring the necessary disposable PPE with them or ensure the procedure area will provide it. In some institutions, lab employees assist with bone marrow collections, fine needle tissue aspirations, and other specialized procedures. Gloves, lab coats, face shields, and other PPE should be used as required during these procedures and discarded onsite once the procedure is ended. Respirators (N95) also may be necessary in certain cases where lung or respiratory samples are collected. If tight-fitting respirators are used, be sure staff are fit-tested annually.

Specimen Collection Ergonomics

The ergonomics of phlebotomy are sometimes overlooked because the process takes place outside the laboratory department itself. Preventing musculoskeletal disorders (MSDs) is vital for these employees, and there are many potential areas of harm if good practices are not followed, regardless of practice location.

When collecting blood in a patient room, it is important to raise the head of the bed if possible. It also is good practice to sit when collecting samples, rather than stand and bend over for any length of time. Avoid awkward positions that stress back, shoulder, or arm muscles. If a patient must be moved to perform the venipuncture, never attempt it alone; always ask for assistance. Avoid sitting on the patient’s bed, as there may be tubing or soiled and contaminated sheets.

Some ergonomics considerations are the same in the outpatient setting as the inpatient setting, such as sitting when possible and generally avoiding awkward positions while collecting samples. Phlebotomy chairs often are equipped with a bar on which the patient can rest their arm during the venipuncture. These bars are adjustable, and they should be adjusted for the comfort of both the patient and the phlebotomist.

Ergonomics injuries are not uncommon for staff in outpatient collection settings. Despite a natural inclination, employees should avoid trying to move, lift, or help patients stand without help. In general, avoid any repetitive motions throughout the day to help prevent musculoskeletal injuries.

Packaging and Handling of Specimens in Transport

Specimen collection containers—blood tubes, urine collection cups, etc—are referred to as the primary container. OSHA states that if the primary container is contaminated, the specimen must be placed into a secondary container which prevents leakage and further contamination during handling and transport.²

When considering specimen collection processes, the outside of every primary specimen container should be considered contaminated. When gloves are used for venipuncture, closing and labeling specimen cups, and when performing other collection duties, they become contaminated with blood, body fluids, and possible pathogens. That contamination may not be visible, but since contaminated PPE is being used when handling primary containers, the outside of those containers should always be considered contaminated also. As a reminder, gloves should always be worn when handling primary containers.

A typical secondary container for transporting lab specimens is a plastic specimen transport bag. If the specimens in the bag are transported within a single facility, a biohazard symbol on the bag is not required, as long as the items inside are easily identifiable as specimens. If the bags leave the facility, OSHA requires that they are labeled with a biohazard symbol (see FIGURE 1).

The outside of secondary specimen containers should be considered uncontaminated and can be handled without gloves. However, in the course of action, place primary specimens into secondary bags using gloves, remove gloves and perform hand hygiene, then seal the bags and transport them without gloves. Further, place one specimen type into each bag (eg, do not place urine specimens in the same bag with tubes of blood). Place the specimens from a single patient into each transport bag. This helps prevent patient misidentification errors at the point of collection and in the laboratory.

Once bags are received into the laboratory, they should be handled with gloves on. The laboratory processing staff will be opening and reaching into the bags, so proper PPE will be necessary at that point. Specimen bags should be discarded appropriately, and they should never be reused.

Specimen Processing and PPE

Any phlebotomists, lab assistants, or ancillary lab staff processing specimens inside the laboratory department need to use proper PPE. Specimen processing may include opening specimen bags, centrifugation, pouring off specimens, or packaging them for transport to another lab. Laboratory coats and gloves are required for these activities, and face protection is also necessary if specimens are opened or poured.

Again, in accordance with OSHA requirements, phlebotomists who wear PPE and process specimens in the lab cannot use the same lab coat outside of the department. If it is determined that lab coats are needed for phlebotomy, a separate coat must be used.

Specimen Transport and Pneumatic Tube Systems

Many facilities use a pneumatic tube system (PTS) to transport a variety of items including laboratory specimens, yet they are not designed specifically for this purpose. Given that a PTS is a complex network of machinery (see FIGURE 2), it must be properly utilized by the lab to ensure the integrity of patient specimens and the safety of those using the system. Thus, there are several safety and specimen integrity considerations that must be considered when this convenient method of transport is available.

A validation process should be performed whenever using a PTS for specimen transport, as the system has the potential to substantially affect specimen integrity. Acceleration of the transport carrier, deceleration, jostling, and time of transport all may impose negative effects on the specimens during transport. CLSI’s document, Handling, Transport, Processing, and Storage of Blood Specimens for Routine Laboratory Examinations (PRE04) describes how PTS validation should be completed.³

As part of the validation process, duplicate specimens should be collected from volunteers. One set is then transported via the PTS, and the others are hand-delivered to the laboratory. The duplicate specimens are evaluated for cellular damage caused by transport and hemolysis indicators (eg, hemoglobin, potassium, LDH) make for a good measurement of the effects of PTS use on samples.

Creating policies dictating which types of specimens should be transported via PTS is another worthwhile safety initiative. Some specimens may leak during transportation, and the results of certain types of spills in the system could be disastrous. It is also possible for a specimen to become rerouted or lost during PTS transport, so specimens that cannot be recollected (ie, surgical specimens) should never be sent through this system. Further, the cellular material in body fluids (cerebrospinal fluid, synovial fluid) is delicate, so these also should be hand delivered to the lab. Chemicals and pathology specimens in formalin or other fixatives should never be transported using a PTS, nor should needles and other sharps.

All respiratory specimens (swabs, sputum samples, tracheal aspirates) should be hand delivered to the laboratory. The CDC recognizes that shaking specimens is an aerosol-generating process, which means the use of a PTS can easily aerosolize respiratory specimens during transport.⁴ The staff members opening those carrier tubes are then at risk for exposure to dangerous pathogens including tuberculosis, influenza, COVID, and more. Sending respiratory specimens via the PTS for the convenience of staff in other departments poses a real threat for laboratorians opening the carriers and receiving the samples.

If a specimen leaks inside of its carrier, remove the wet foam insert (dispose of it into a biohazard trash container), disinfect the carrier with a 10% bleach solution, and replace the foam. If the leak or spill has spread to the outside of the carrier, shut down the portion of the tube system affected. Clean and disinfect the carrier tube and run a disinfectant carrier through the system before reopening the system for use. Some system manufacturers may use other means for disinfection. Regardless, be sure to have procedures in place before the PTS is put in use by the laboratory.

Conclusion

Clearly, the preanalytical side of laboratory testing covers a wide variety of activities. Packaging highly infectious specimens for shipping, dry ice safety, and even courier safety issues likewise must be considered. Safety is a critical concern for all laboratory staff from the moment a laboratory specimen is generated, and oversight of the specimen pathway steps should be a part of the overall laboratory safety program. Be sure to audit every preanalytical process in and out of your laboratory to maintain high specimen quality and to ensure safety for all staff who collect and handle laboratory specimens.

References

1. Occupational Safety and Health Administration (OSHA). Standard number 1910.103 – Bloodborne pathogens. Accessed 3/30/24: osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030
2. OSHA. Directives; Enforcement procedures for the occupational exposure to bloodborne pathogens. Accessed 3/30/24: osha.gov/enforcement/directives/cpl-2-244d
3. CLSI. Handling, Transport, Processing, and Storage of Blood Specimens for Routine Laboratory Examinations. 1st ed. CLSI guideline PRE04. Clinical and Laboratory Standards Institute. 2023.
4. Mullins GR, Harrison JH, Bruns DE. Smartphones Can Monitor Medical Center Pneumatic Tube Systems. Clin Chem. 2016;62(6):891-893.

Daniel J. Scungio, MLS(ASCP)SLS, CQA(ASQ), has over 25 years’ experience as a certified medical technologist. He worked as a laboratory generalist in hospitals ranging from 75 to 800 beds before becoming a laboratory manager, a position in which he served for 10 years. Dan is now the laboratory safety officer for Sentara Healthcare, a system of more than seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. As “Dan the Lab Safety Man,” he also serves as a professional speaker, trainer, and lab safety consultant. Dan received his BS in medical technology from the State University of New York at Buffalo.

SIDEBAR 1

Preanalytical Pitfall #1: Pre-assembled Needles

In busy specimen collection areas, team members must be as efficient as possible. At some phlebotomy locations, a common practice is to take time before the shift to connect the draw needle to the needle hub, a process known as “pre-assembling” (see FIGURE 3), in order to save time later. However, this is bad practice, and it is specifically recommended against by the Clinical & Laboratory Standards Institute (CLSI). For patients, this practice might give the appearance of the use of previously used needles. Some manufacturers now make a needle that comes pre-attached to the hub, but the entire unit is wrapped in a package that should be opened in front of the patient.

SIDEBAR 2

Preanalytical Pitfall #2: Foam in the Pneumatic Tube System

Specimens being readied for transport in a pneumatic tube system should be placed in leak-proof specimen transport bags. The bags are then placed inside of a carrier that contains foam inserts. The foam helps to cushion the specimens against strong jostling and vibrations during transport (see FIGURE 4). On occasion, other departments may remove the foam to send larger items. Make sure the foam is replaced before sending lab specimens. A good practice in larger facilities is to assign specific PTS carriers to the lab if possible. This also helps with infection control; it is not good practice to send medications, for example, in the same carrier used for lab specimens.