Can Time Determine Preanalytical Quality? A Temporal Analysis of Specimen Rejection Rates

Objective: Preanalytical errors account for the vast majority of preanalytical incidents and remain a fundamental threat to the reliability of test results. Although the types and frequencies of these errors have been extensively studied in the literature, their time-dependent variability has received comparatively little attention. This study aimed to evaluate how preanalytical specimen rejection rates vary across intraday time intervals and to assess the independent influence of time on preanalytical quality. Methods: This retrospective observational study included a total of 579,845 specimens accepted by the central laboratory of Istanbul Atlas University Hospital between January 2024 and December 2025. Specimens were analyzed with respect to preanalytical rejection reasons, the distribution and rate of these reasons across clinical units, and time of day. Each day was divided into six equal four-hour intervals: Z1 (00:00-04:00), Z2 (04:00-08:00), Z3 (08:00-12:00), Z4 (12:00-16:00), Z5 (16:00-20:00), and Z6 (20:00-24:00). Statistical analyses were performed using the Pearson chi-square test, and effect sizes were quantified using Cramér's V coefficient. Results: Of the 579,845 specimens examined, 4365 were rejected, yielding an overall rejection rate of 0.79%. Rejection rates were found to be non-uniformly distributed across the day (p < 0.001). The highest rejection rate was observed during the Z2 interval (04:00-08:00) at 1.98%, whereas the lowest was recorded during Z3 (08:00-12:00) at 0.45%. Negative binomial regression analysis identified the Z2 interval as the only time period independently associated with an increased rejection risk Incidence Rate Ratio (IRR) = 1.63; 95% Confidence Interval (CI): 1.22-2.19. Among clinical units, the highest rejection rate was recorded in the emergency department (1.92%). Analysis of error types revealed that the majority of rejections were attributable to hemolysis (47.5%) and clotted specimens (26.3%). Hemolysis rates peaked in the emergency department, while clotted specimens occurred more frequently within intensive care units. Analysis of time and error interactions revealed that clotted specimens peaked during Z1 and Z2, whereas hemolysis became the primary cause of rejection during Z3 and Z4. Conclusions: Preanalytical specimen rejection rates exhibited significant variation according to time of day, clinical unit, and error type, with time emerging as a factor independently associated with preanalytical quality. The coexistence of elevated rejection risk during Z2 (04:00-08:00) and markedly low rejection rates during Z3 (08:00-12:00) indicates that the relationship between workload and error frequency is not linear. Although hemolysis and clotted specimens constituted the dominant error types, their distribution followed distinct patterns depending on the clinical unit and time interval. These results underscore the necessity of time-based monitoring to pinpoint unit-specific risks, providing a clear roadmap for targeted quality improvement interventions.