Supply chain disruptions due to the SARS‐CoV‐2 pandemic lead to an unusual preanalytical error in measuring hemoglobin concentration in a large medical center

Preanalytical errors are defined as those that occur prior to the testing process (e.g., test request, patient and specimen identification, specimen collection, transport, accessioning and processing) and represent 46–68% of all analytical errors in clinical pathology labs [1, 2]. We present an unusual preanalytical error at our Institution caused by the SARS-CoV-2 pandemic. The sequence of events leading to this error in our Hospital is described chronologically as follows. A series of variable Hemoglobin (Hg) levels was communicated to the Hematology Core Lab at Johns Hopkins Hospital, using a reporting system called HERO. HERO is an acronym for “Hopkins Event Reporting Online,” an online portal for any Johns Hopkins Health System employee to report potential or observed situations, which have, or may in the future, caused harm to patients or staff. HERO tickets are infrequent and the Hematology Core lab receives on average 0–2 HERO(es) per month. However, on April of 2022, a marked increase in notifications were noted totaling 18 (Figure 1A). The HERO descriptions had, in common, variable Hg levels from blood collected from the same patients in relatively short intervals, often within 24 hrs. The values fluctuated randomly upwards or downwards, with no predictable periodicity. Figure 1B andC shows illustrative cases of variableHg values from two patients. During this process, there was no harm to any of the patients. Every HERO ticket requires a complete investigation by the Core lab staff to determine the cause(s) triggering them. An initial assessment rapidly revealed that the discrepant values were not explainable by bleeding, transfusion, hemolysis, or use of novel medications. However, further investigation identified that all specimens were from the Oncology Service located in one specific floor/ward of the Hospital. Moreover, all specimens were collected from central venous catheters (“central lines”) for administration of chemotherapy, which are useful for patients withmalignancies. Since no definitive cause(s) were readily identified, a multidisciplinary team with members of the Pathology and Nursing Departments, and Administrative Staff cooperated to discuss root cause


Supply chain disruptions due to the SARS-CoV-2 pandemic lead
to an unusual preanalytical error in measuring hemoglobin concentration in a large medical center 1 CORRESPONDENCE Preanalytical errors are defined as those that occur prior to the testing process (e.g., test request, patient and specimen identification, specimen collection, transport, accessioning and processing) and represent 46-68% of all analytical errors in clinical pathology labs [1,2]. We present an unusual preanalytical error at our Institution caused by the SARS-CoV-2 pandemic. The sequence of events leading to this error in our Hospital is described chronologically as follows. A series of variable Hemoglobin (Hg) levels was communicated to the Hematology Core Lab at Johns Hopkins Hospital, using a reporting system called HERO. HERO is an acronym for "Hopkins Event Reporting Online," an online portal for any Johns Hopkins Health System employee to report potential or observed situations, which have, or may in the future, caused harm to patients or staff. HERO tickets are infrequent and the Hematology Core lab receives on average 0-2 HERO(es) per month.
However, on April of 2022, a marked increase in notifications were noted totaling 18 ( Figure 1A). The HERO descriptions had, in com- Methodologically, the Sysmex XN-9100 analyzer method to detect Hg uses cyanide-free sodium lauryl sulfate (SLS) and colored complex (SLS-Hg) is analyzed photometrically at 555 nm (4,5). Although this methodology is optimized to minimize interferences, measurement of Hg levels by other techniques was required to exclude an unusual source of interference. Accordingly, we tested blood with a blood gas analyzer ABL800 Flex (Radiometer America, CA) that detects Hg spectrophotometrically, and with a microhematocrit that determines the ratio of the volume of packed red blood cells to the volume of whole blood after centrifugation (4,5). Figure 1D shows a correlation of variable Hg levels in three consecutive days for the same patient (also presented in Figure 1B), estimated with the Sysmex XN-9100 analyzers, Radiometer ABL800 Flex, and the microhematocrit. Figure 1D also includes the date of anal-  To our knowledge, this is the first report of preanalytical error in Hg measurement due to replacement of a vacutainer adapter device secondary to supply chain disruptions caused by the SARS-COV-2 pandemic (6,7,8). Finally, adequate resolution of these adverse events underscores the importance of proper multidisciplinary team communications to identify and mitigate the impact of these errors in the health care system and to improve patient care.

AUTHOR CONTRIBUTIONS
All authors participated in the discussion, interpretation, and writing.

CONFLICT OF INTEREST
The authors have no conflict of interest to declare that is relevant to the content of this article. There is no commercial affiliation.

ETHICS STATEMENT
All procedures were in accordance with the ethical standards of the respective local research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study did not require informed consent or an IRB.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available upon request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.