Standing at the patient’s bedside in the emergency room, I watch as the phlebotomist adjusts the patient’s arm to collect blood samples. The phlebotomist ties the tourniquet around the patient’s arm and searches the antecubital area for a good vein. She does not feel or see one, so she unties the tourniquet and moves to the patient’s hand. After palpating the patient’s hand for several minutes, the phlebotomist cleans the area with alcohol, then performs venipuncture into a small vein. In an attempt to get blood flow, the phlebotomist adjusts the needle; however, after several minutes of no blood return, she removes the needle. The phlebotomist then asks me to pass her a small container from her tray. I pass the tube only to witness the unthinkable: using the micro-tube, she scoops up blood drops on top of the patient’s hand …
Clinical laboratorians depend on phlebotomists to collect quality samples. Phlebotomists are the laboratorians’ pre-analytical coordinators. We are the vanguard of our medical laboratories. Daily, laboratorians report lifesaving or life-altering results. Primary healthcare providers depend on us; they relay clinical lab information to their patients, usually without a second thought as to its accuracy.
When a sample reaches the lab, laboratorians are not going to question whether it is capillary blood in the capillary container—they trust that it is. Having said that, it is possible that after viewing the results, a testing tech may question them. Case in point: I have spoken with colleagues who said that when they questioned a low 2mg/dl Ca level, the phlebotomist admitted having pulled blood that had been from an EDTA tube and put it in a serum separator tube, which does not contain any additive.
It is important for phlebotomists to remember that there are checks and balances when it comes to clinical laboratory testing. Having attended and graduated from an accredited phlebotomy program, and having passed the National Certification Exam, my best advice, based on my years of working as a phlebotomist while attending medical technology school, is to implement a required annual written competency assessment with merit-based reward. Rewards can be as simple as adding half a day to an employee’s paid time-off. The competency assessment should consist of case studies to help the phlebotomist think through the scenario. Not only will this improve the quality of blood samples, but it contributes to saving healthcare operational costs in the end. Preanalytical errors damage an institution’s reputation, diminish confidence in healthcare services, and contribute to a significant increase in the total operating costs, both for hospital and laboratory.1
A phlebotomist must demonstrate proper blood collecting skills at all times. One reason why is that you never know who might be accompanying the patient during the blood draw: it might be someone who will know if you are doing it wrong!
You may think I’m being facetious, but I am not. In fact, I was part of such a situation—not as a phlebotomist, but as a “civilian.” I accompanied a friend to an ER visit and was with her during the blood draw. Here’s what happened:
As the phlebotomist entered the room, I moved to the opposite side of the bed to give her space. Upon entering, the phlebotomist simply announced, “I’m here to draw blood.” She didn’t introduce herself or state which department she was from—which is included in basic phlebotomy training. The phlebotomist then placed the collection tray at the end of the bed on the food stand.
Next, the phlebotomist identified the patient using the two-step identification method, asking the patient to state her name and checking her hospital identification bracelet. The phlebotomist took out all the blood-collecting tools: tourniquet, alcohol pad, butterfly needle set, gauze, and band-aid, as well as, a red and purple top tube. The phlebotomist then tied the tourniquet around the patient’s left arm and searched the antecubital area for a good vein. She did not feel or see one, so she untied the tourniquet and moved to the patient’s left hand. She did not look at the other arm. Again, basic training instructs us to look at both antecubital areas before considering alternate stick sites; after all, the goal is to stick each patient only once. After patting and feeling the patient’s hand for several moments, the phlebotomist identified a small, narrow vein that appeared on top of the hand. She cleansed the area with alcohol and then opened the butterfly needle set.
The phlebotomist then inserted the needle into the vein. After several minutes of no blood return, she removed the needle. A tiny pool of blood formed on top of the patient’s hand and in the tip of the needle; it dropped on top of the patient’s hand. As the needle was removed, the patient yelled, “No more sticking!” The phlebotomist complied and asked me to pass a small container from her tray. I asked, “Which tube?” and told her she could speak in technical terms, as I understood “phlebotomy language.” The phlebotomist said, “Pass me a micro-tube.” I then asked—I couldn’t help myself at this point—“How long was your schooling or training program?” She replied, “One day.”
I gasped, and said “One day!? I’ve heard of one-day programs, but I thought the person was joking. I’ve heard of four month programs and even that is too quick!”
I passed the micro-tube to the phlebotomist, and the phlebotomist did the unthinkable: using the micro-tube, the phlebotomist scooped up the one or two drops of blood that were on top of the patient’s hand.
As calmly as I could, I asked, “When did they start doing that?” The phlebotomist responded, “Doing what?” I said, “Started putting venous blood into a capillary container.” “Oh, they don’t,” answered the phlebotomist, “I am just trying to get some blood.”
Filled with both anger and disbelief, I remained outwardly calm and stopped talking. Then I started thinking: she only attended a one-day program; why are one-day programs even allowed? Whose fault is this?
For one, it’s a faulty system. We are in an era of “do it, bring it, got to have it quick.” That hurry-up kind of attitude prevails in much of society, and, sadly, clinical healthcare often falls prey, too. But you can’t blame “the system.” The phlebotomist is ultimately responsible, and in this particular instance, the phlebotomist is at fault. Venous blood should not be collected into a capillary tube or a micro-tube. Phlebotomists must know the clinical significance of venous blood in a capillary tube: that venous blood values run slightly higher—and sometimes slightly higher values can make a difference in patient treatment.
With regard to the scooping of venous blood into a capillary container, according to retired hematology professor Lani Collins, MS, BSMT(ASCP), SH, venous blood in a capillary tube will mimic arterial blood value, which may be a little higher. This is not a good practice. Laboratorians depend on capillary blood being stored in a micro-container, because that is what they are designed for.
It was a harrowing ER experience for me—and I was not even the patient! The experience underscored the importance of case study annual competency assessments for all phlebotomists. Phlebotomists must, without exception, use good techniques when collecting a blood specimen. They must collect venous blood in the correct tube. They must ensure that capillary blood, such as a finger stick or a heel stick, only is collected in a micro-tube. They must understand that they are pre-analytical coordinators. They must understand the clinical context of what they are doing—that results are only as good as the specimens received. Laboratorians are trained to interpret results and can tell when there is a discrepancy—the checks and balances I referred to above—but it should only be a rare specimen that needs to be redrawn.
Results on a patient’s chart are taken at face value; at that moment in time, diagnosis and treatment begin. Laboratory results must be correct. They must be collected in the correct tube. Phlebotomists have to get it right during the most important pre-analytical stage of clinical laboratory testing: specimen collection.
REFERENCE
- Green S. The cost of poor blood specimen quality and errors in
pre-analytical processes. Clinical Biochemical. 2013:46(13):1175-1179.
Part of your responsibility as the laboratory manager is to be in tune with safety concerns and considerations of your staff, including the phlebotomists. To ensure your team of phlebotomists has the interest of the patient and themselves always at heart, review the following checklists and post in a prominent location in your lab.
How phlebotomists put themselves at risk:
Drawing without gloves. Being a better phlebotomist means making no exception to this rule.
Compromising gloves. Gloves by definition have fingers. If you’re tearing the tip of your glove off, you’re no longer wearing a glove. See “drawing without gloves” above.
Not changing gloves between patients. Better phlebotomists don’t need to be lectured about passing deadly bugs from one patient to another, and consider glove changes between patients to be good insurance.
Not adhering to hand hygiene protocols. Better phlebotomists also wash their hands between glove changes or use an alcohol-based cleaner. Sure it slows them down, but the seconds lost is protection gained.
Failure to don additional personal protective equipment, or PPE (e.g., lab coat, face protection), when appropriate. Blood is a liquid, and liquids splatter. You can be a better phlebotomist by gowning up and protecting your face when drawing or processing blood samples.
Anchoring from above and below the puncture site. If you routinely put your index finger above the intended puncture site to anchor the vein, you’re setting yourself up for a needlestick.
Drawing with syringes when tube-holder assemblies will suffice. Better phlebotomists don’t use syringes unless they have to because they know how much more vulnerable they are statistically to an accidental needlestick.
Not having a sharps container at the point of use. Being a better phlebotomist means having a sharps container always within reach at the point of use. They don’t take the risk of having to transport a contaminated needle, even when the point is concealed.
Using conventional (non-safety) devices. Among the better phlebotomists, going retro on safety is inconceivable.
Recapping needles. You can be a better, and safer, phlebotomist if you vow to never recap a clean needle. That’s because if you break this habit for even an unused needle, you’ll never, ever recap a dirty one.
Using butterfly sets without a tube holder or syringe attached. When mediocre phlebotomists use a butterfly set, they pierce the tube stopper with the back-end needle without benefit of a tube holder; better phlebotomists know better, and use a tube holder adapter or syringe.
Failure to immediately activate the needle’s safety feature. Being better means being faster when it comes to clicking the needle’s safety feature or otherwise concealing the contaminated sharp.
Not discarding the needle and tube-holder assembly as a single unit. Removing the contaminated needle from a blood collection device is not the practice of the better phlebotomists out there. They know they must be disposed of as one complete unit.
Allowing sharps containers to overflow. For better phlebotomists, their cup runs over with caution, but their sharps containers never run over with needles.
Not using a safety-transfer device to evacuate a syringe. There’s only one proper way to empty a blood-filled syringe, and healthcare’s better phlebotomists know to remove the contaminated needle after activating the safety feature, discarding it, and attaching a safety transfer device to fill the tubes.
Using non-retractable skin puncture devices. If you’re one of the better phlebotomists, you have a wide variety of devices at your disposal for a variety of blood collection circumstance, but non-retractable skin puncture devices are not among them.
How phlebotomists put their patients at risk:
Failure to properly identify their patients. One thing all of the better phlebotomists have in common is that they make no exception to the proper procedure in identifying their patients. Even when the patient is their best friend, they still ask them to state their name.
Failure to safely position their patient. The better the phlebotomist, the more aware they are of the risk of patients fainting. That’s why they never draw patients who are sitting upright on their bed or an exam table, or in chairs without arm rests.
Inserting the needle at an excessive angle. Good phlebotomist know not to insert the needle at an excessive angle; better phlebotomists know what that maximum angle is and why it shouldn’t be exceeded.
Drawing from the basilic vein when safer veins are available. Being a better phlebotomist means knowing where the nerves are in the antecubital area and avoiding the basilic vein unless there are no other antecubital options.
Drawing from an unacceptable site. If you know the acceptable sites for venipuncture are the antecubital area, lateral (thumb) side of the wrist, the back of the hand and the feet/ankles (with physician’s permission), you’re a better phlebotomist than those who don’t.
Failing to immediately terminate the draw when a nerve has been provoked. Better phlebotomists bear the burden of backing out when blood draws bring bolts of shooting pain or boisterous bursts of unbearable burning.
Providing inadequate pressure to the puncture site. Pressure is something better phlebotomists know well and work to their patients’ advantage by making sure it’s applied firm and long enough so that sites don’t bleed long after they’ve left the patient.
Bandaging the site without performing a two-point check. Better phlebotomists take at least 10 seconds to observe a site after pressure is released to make sure the degree and extent of pressure was adequate.
Not anticipating adverse reactions. Studies say five out of every 200 patients will pass out during or after a blood draw. Better phlebotomists anticipate they all will and are prepared to react. One way they don’t react, though, is by using ammonia inhalants, which may complicate matters for patients who have respiratory conditions.
Prelabeling sample tubes. To be a better phlebotomist, forbid yourself from ever labeling tubes before they’re filled. Sure, you like to be organized, but should the draw fail and you forget to throw away the empty, labeled tubes, you’ve put the next patient at risk. Better phlebotomists know being organized is good, but not when doing so creates the potential for errors.
Not labeling samples at the patient’s side. Better phlebotomists always label the samples they draw in the presence of the patient. When feasible, they also have the patient verify the information on the tube. It’s just an added layer of safety and reassurance for both patient and collector. Better phlebotomists are also brave and courageous, rejecting unlabeled samples that are drawn by others.
Sacrificing safety for expediency. Better phlebotomists don’t cut procedural corners in an effort to increase productivity. So what if you shave a minute off your collection time? If you compromise patient safety in the process, you’re just better and faster at placing more patients at risk. Besides, doing things right is always more efficient than doing things over.
Multitasking. While under their care, better phlebotomists make their patient their primary focus. They know that little gaps in attention lead to gaping holes in safety and strive to keep distractions and disruptions to a minimum.
To ensure patient and collector safety, engineering and work practice controls have their place. The best phlebotomists understand that compliance with safety protocols is not just about engaging the right device at the right time in the right way. It also includes engaging the heart and mind, and knowing the choices you make-even when no one is watching-not only makes you a better phlebotomist, but your facility a better place for patients.
Lisa O. Balance is the director of Online Education for the Center of Phlebotomy Education Inc. in Corydon, IN. Portions of this were reprinted with permission from Phlebotomy Today, ©2011 Center for Phlebotomy Education Inc.