Hemolysis: A Call for Shared Standards

A new peer-reviewed Call to Action published in the Journal of Applied Laboratory Medicine (JALM) urges hospitals to address the risks of undetected in vitro hemolysis, a preanalytical error that can negatively impact patient care. One of the report's contributing authors, W. Frank Peacock, MD, FACEP, FACC, FESC, Professor of Emergency Medicine at the Henry JN Taub Department of Emergency Medicine, expands on that message by emphasizing the need for collaboration across specialties.

Titled "Handling Hemolytic Blood Samples from High-Risk Clinical Areas: A Call to Action," the multi-author report highlights how hemolysis can lead to misinterpretation of critical test results, most notably potassium, and calls for hospitals to better manage hemolysis, especially in high-risk settings such as emergency departments (ED) and intensive care units (ICU).¹

Dr. Peacock believes that technological advancements alone are not enough to achieve successful outcomes. Greater communication and shared accountability across clinical departments are equally critical. From the ED and laboratory to the ICU and operating room (OR), every member of the care team plays a role in ensuring timely, accurate results that support better patient outcomes.

Hospitals function as interdependent clinical units: performance in one area can directly affect decision-making and throughput in another. The ED, for example, depends on timely and reliable laboratory results to support rapid triage and treatment decisions.

Expert Perspective: A Call for Data‑Driven Hemolysis Prevention

Dr. W. Frank Peacock, Professor of Emergency Medicine at Baylor College of Medicine—and a co-author of the Journal of Applied Laboratory Medicine “Call to Action” on managing hemolyzed specimens in high-risk clinical areas—emphasizes that high-acuity environments require clear communication and shared expectations between frontline clinical teams and the laboratory. In his view, one issue that should unify stakeholders across settings is the need for data-driven monitoring and targeted prevention of in vitro hemolysis in whole blood potassium testing—because hemolysis remains one of the most common and clinically consequential preanalytical errors.^1,2

The Clinical Risk of Undetected In Vitro Hemolysis

Consider a 23-year-old patient presenting to the ED with fever. Blood is drawn, and the reported potassium is unexpectedly elevated, despite no clinical signs of hyperkalemia. In vitro hemolysis can produce spuriously high potassium results, due to red cell rupture and release of intracellular contents—creating risk for repeat testing, delays, or inappropriate clinical intervention.³

Hemolysis is common in ED samples. Reports in ED populations have described hemolysis rates as high as 18.1%, and site-specific surveys demonstrate that hemolysis prevalence can vary substantially by patient location.¹

In the above scenario, the clinical response may be to question preanalytical interference and obtain a repeat specimen when results do not match the clinical picture. A sample recollection that returns a normal potassium supports the conclusion that the original result was affected by in vitro hemolysis, rather than true hyperkalemia.³

Dr. Peacock notes that these scenarios are common in emergency care—underscoring that hemolysis is not only a laboratory issue; it is a patient safety and operational issue that affects decision-making, length of stay, and resource utilization.³

“The lack of certainty is the problem,” he explained. “There isn’t an ED physician who doesn’t struggle with hemolysis.”

Why Monitoring and Standardization Matter

A key challenge is the uneven distribution of hemolysis across hospital care settings. Hemolysis is not necessarily isolated to a single department or collection method, and the factors contributing to it can differ across an organization. Understanding where hemolysis is occurring, how frequently it happens, and what may be driving it can help hospitals identify patterns and determine where improvements are needed most.

The variability is the reason broad “awareness” is necessary, but insufficient. Effective reduction typically requires:

Routine monitoring (e.g., tracking hemolysis rates by unit and collection method)^1-3

• Identifying high-risk processes (e.g., catheter draws, technique variability, transport issues)^1,3,9
• Targeted prevention and training in the settings driving the highest rates^1,3,9
• Clear laboratory policies establishing how hemolyzed results are flagged, reported, and managed^3,8

Lippi et al. describe this approach explicitly: process monitoring, combined with education and prevention, guided by investigation of where risk is greatest.¹

From a quality-improvement perspective, the challenge is not only knowing hemolysis is common, but identifying it quickly enough to manage results consistently.

“I don’t have over an hour to wait,” said Dr. Peacock. “As an ED clinician, time is of the utmost importance.”

Whole blood hemolysis detection at the point of care—such as with the GEM® Premier™ 7000 with iQM®3 blood gas testing system—enables rapid flagging of potassium values potentially impacted by hemolysis within 45 seconds of collection, supporting more consistent specimen handling.^4,5

Aligning Practice Across Settings

Reducing in vitro hemolysis does not require the ED, ICU, and OR to function as a single, integrated team day to day. Rather, prevention succeeds when high-acuity clinical areas and the laboratory are aligned on:

• Standardized collection and handling practices^1,3,9
• Consistent criteria for identifying and communicating hemolysis³
• Feedback loops that enable quality improvement ^1,3

Because acute care settings and the laboratory are interdependent, hemolysis prevention depends on shared standards and shared accountability. Without them, missed or inconsistently managed hemolysis can drive delays, sample recollection, and clinically misleading results (particularly potassium).^1,3,6,7

References

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