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Mix-up of samples in blood gas testing

Avoid mixing up blood gas samples and get the correct results for your patient

In blood gas testing, the mix-up of blood gas samples has significant consequences on patient care, costs and healthcare management. One of the main objectives of the preanalytical phase is correctly associating the results from the analysis of the sample with the correct patient. [1]

Consequences of the mix-up of blood gas samples

Accurate specimen labeling is critical. Mixing up samples can occur due to healthcare professionals failing to match patient identifiers with the correct order, failing to label a sample immediately after blood collection or transcription errors from manual data entry. [1-2]

These errors may have serious consequences. The mix-up of blood gas samples can lead to misdiagnosis, failure to provide proper care, lost billing opportunities or the requirement of resampling. Mixing up blood gas samples can lead to results of no clinical value or worse, adverse patient outcomes. [1]

Avoiding the mix-up of blood gas samples, a priority

The Clinical and Laboratory Standards Institute (CLSI) recommends labeling blood gas samples with the patient’s full name and second identifier. [3]

Mixing up blood gas samples is a growing concern. In December 2016, the U.S. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released their annual National Patient Safety Goals, the purpose of which is to improve patient safety. The JCAHO listed “identifying patients correctly” as their number one National Patient Safety Goal for 2017. [4]

1st Automatic, integrated with safePICO syringes

Identify patients correctly and obtain a smoother workflow with 1st Automatic. This automated data registration system connects the caregiver, the sample, and the patient. 1st Automatic works with the safePICO syringe for correct, automatic linkage between the blood gas sample you collect and the patient.

The safePICO syringe is designed to help you reduce the risk of preanalytical errors. In addition to mixing up blood gas samples, examples of such errors are clots in, hemolysis of or air bubbles in the sample, or needlestick injuries


1. Kahn S. Specimen mislabeling: A significant and costly cause of potentially serious medical errors. www.acutecaretesting.org Apr 2005.
2. Skurup A. Preanalytics: The First Step for Accurate Blood Gas Results. www.radiometer.com/en/webinars/preanalytics-the-first-step-for-accurate-blood-gas-results Oct 2016.
3. CLSI. Blood Gas and pH Analysis and Related Measurements; Approved Guideline—Second Edition. CLSI document C46-A2 [ISBN 1-56238-694-8). Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087 USA, 2009.
4. The Joint Commission. Hospital: 2017 National Patient Safety Goals. Accessed May 2017.

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