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Phlebotomist Information and Courses from MediaLab, Inc.

These are the MediaLab courses that cover Phlebotomist and links to relevant pages within the course.

Learn more about laboratory continuing education for medical technologists to earn CE credit for AMT, ASCP, NCA, and state license renewal and recertification. Or get information about laboratory safety and compliance courses that deliver cost-effective OSHA safety training and continuing education to your laboratory's employees.



Department of Transportation (DOT) Federally Regulated Urine Specimen Collection Training
Monitored collection

For monitored collections, the Department of Transportation classifies the following as health professionals: Physician Medical Technologist Medical Laboratory Technician Nurse (RN/LPN) Physician's Assistant/Nurse Practitioner Medical Technician (A medical technician is anyone who is licensed or certified to practice in the institution where the collection is being done. For example, a phlebotomist, EMT, or medical assistant.)

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Dermal Puncture and Capillary Blood Collection
Patient Identification

Patient safety when performing a capillary blood collection includes positive patient identification prior to performing the procedure. The accepted policy in most health care facilities is to use two forms of identification, including a unique number if possible, such as a hospital number or medical record number.Ideally, the patient (or the parent/guardian if the patient is a small child) should be asked to spell his/her name and state his/her date of birth. This may not always be possible, but it will aid in positive patient identification whenever it can be done.The phlebotomist should LOOK at the patient's paperwork while they LISTEN to the patient's response. For inpatients, the patient identification bracelet, which must be attached to the patient's wrist or ankle, should be used to verify patient identity. A hospital number recorded on the bracelet may be used as a second identifier in the case of an inpatient.Paying close attention to these details and correcting any discrepancy discovered will greatly reduce the risk of misidentifying a patient. Always follow the policy of your facility for identification and never shortcut the patient identification procedure.

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Site Preparation

Once the phlebotomist has successfully identified the patient, the next step of the dermal puncture procedure is to locate and determine a site suitable for puncture. If a heelstick in an infant is being performed, the phlebotomist should apply a warming device for approximately 3-5 minutes to the heel to increase blood flow to the area, which will facilitate the collection of the capillary specimen. The use of a warming device is also recommended when a fingerstick is performed, if the hands are cool to the touch.A heat-standardized, pre-packaged, chemically activated heel warmer, or comparable heating agent should always be used to warm the heel of an infant to prevent scalding or burning. The temperature of the heating device should not exceed 42°C.Caution-- do not use a cloth that has been moistened and warmed in a microwave oven. This may have hot spots that could cause injury to the patient. It is also not advisable for the phlebotomist to hold a patient's hand under hot running water. This again could cause an injury. If feasible, the patient could be instructed to warm his or her own hands under running water, but allow the patient to adjust the water temperature.

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Positioning the Puncture Device for a Fingerstick

The fingerstick device should be held firmly against the puncture site. To obtain the best capillary specimen using the finger, align the puncture device perpendicular (horizontal) to the whorls of the fingerprint. This cross-cut of the fingerprint whorls causes the blood to bead at the puncture site, allowing the phlebotomist to efficiently collect the drops of blood into the container. This image illustrates the correct position of the cut in relation to the fingerprint lines.If the puncture is made parallel to the fingerprint whorls (as shown below), the blood will not bead but rather it will travel down the channels between the lines of the fingerprint. This makes it difficult to collect the blood into the container. The phlebotomist may inadvertently "scrape" the blood from the skin while filling the container, resulting in hemolysis and/or clotting of the specimen.The tip of the finger should be avoided. Puncturing the fingertip may cause unnecessary discomfort to the patient.

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Protect Yourself and Your Patient

It is important to remember that the collection of a specimen by dermal puncture may involve the potential of exposure to bloodborne pathogens as well as other safety considerations for both the phlebotomist and the patient. Some important safety reminders are listed in the table below.Safety ReminderReasonCommentGloves are always necessaryBlood contaminates the skin during a capillary blood collection. Gloves protect the phlebotomist from potential exposure to bloodborne pathogens.Gloves must remain intact to be an effective barrier against exposure to potential pathogens. Wear additional personal protective equipment (PPE), such as lab coat or gown when appropriate or required. Safety goggles and surgical mask may be needed if there is a potential for splashes or sprays of blood.May be needed to protect the phlebotomist or may be required to protect the patient from potential infection in some cases.Safety goggles and mask should both be worn to adequately protect the eyes and mucous membranes from exposure to bloodborne pathogens if there is the potential for splashes or sprays of blood. Only have the equipment needed for this procedure at hand and additional equipment out of reach of the patient. Protects the patient from accidental injuryOften, capillary procedures are performed on very young children who are curious and may grab something that could cause injury.

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Which of these pieces of personal protective equipment (PPE) is always required when a dermal puncture is performed to collect a capillary blood specimen?View Page
Using the Fingers for Dermal Puncture

The palmar surface of the fingertip (fleshy pad) of the middle (3) or ring (4) finger is usually selected for puncture for a variety of reasons. The fingertips of these fingers are usually less calloused, have fleshier pads and cause less discomfort for the patient. The thumb (1) is to be avoided because it has a pulse. The index finger (2) tends to be more calloused, which would make collection of the specimen more difficult. This area is also more sensitive for the patient. The pinky finger (5) does not have sufficient tissue depth to prevent injury.When performing a fingerstick, the phlebotomist should puncture either side of the fleshy pad of the middle or ring finger, but not the extreme side of the finger. The exact center of the fleshy pad or the tip of either finger should also be avoided. Avoid areas of the finger that are cold, swollen, inflamed, calloused or cyanotic. The bottom image indicates the correct area to use for skin puncture.

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Using the Heel for Dermal Puncture

A dermal puncture of the heel should only be performed on an infant or small child prior to the age of walking. The age limit for a heel puncture is approximately 12 months of age. After that time, the skin becomes very thick which could prevent the phlebotomist from obtaining a quality specimen for testing. The fleshy bottom of the heel toward the sides are acceptable sites for dermal puncture. Note in the illustration that the white areas are acceptable sites for heel puncture; any area that is red-striped in the image should not be used for blood collection.DO NOT puncture the central area of the bottom of the foot (arch of the foot), the back curvature of the heel, or the toes. These sites must be avoided to prevent damage to nerves, tendons, and cartilage.

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Dermal Puncture vs Venipuncture

In some situations, the phlebotomist will make the decision if a blood specimen will be obtained by dermal puncture or venipuncture. The patient's condition, the age of the patient, the amount of blood needed for testing, and the risks associated with the procedure will help the phlebotomist determine the best method for collection.A dermal puncture requires less precision, therefore it is less critical for the patient to be still or immobilized. However, if the puncture is not performed correctly, or an approved site is not used, the puncture may cause more discomfort, or even injury to the patient.The risk of accidental needlestick injury to the patient and phlebotomist is minimal since the puncture device is designed to retract the needle once the puncture is made. The puncture is quick and standardized for puncture depth. However, the procedure takes longer to complete. This delay in collection of the blood specimen could result in hemolysis or clotting of the blood or tissue fluid contamination of the specimen and specimen rejection by the laboratory.The dermal puncture minimizes the amount of blood taken from the patient. This will be important to consider, especially with infants in an intensive care nursery. However, some laboratory tests require larger amounts of blood for testing; in these cases, capillary collection is not an option.If a patient is dehydrated or has poor peripheral circulation, an adequate blood collection from a dermal puncture may not be possible.

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Puncture Devices

A variety of disposable skin puncture devices are available that will ensure a safe procedure when used properly. Most devices have a spring loaded feature for the blade or the lancet. Once activated, the lancet will automatically puncture the skin using a quick motion. The lancet will immediately retract back into the housing of the device. This design eliminates the possibility of accidental needlestick injury to the phlebotomist. All devices are single use only and must be disposed of in an approved sharps container immediately after activation. An example of an approved sharps container is shown below.It is very important for the phlebotomist to use the puncture device that is designed specifically for the procedure that will be performed. Lancets are manufactured to ensure incisions to a safe depth and length. A special lancet designed for use on babies less than 5 pounds is available and should always be used when performing a heelstick on a premature infant. A lancet designed for puncture of a finger should not be used for the puncture of a heel. A heel incision device is set to a maximum penetration depth of 2.0 mm (some facilities may require even shallower penetration for premature infants). Fingerstick devices may exceed this maximum depth of penetration that is allowed for an infant heel puncture. The bottom image on the left illustrates a lancet style that is typically used for fingersticks. the bottom image on the right is one style of puncture device that is used for heelsticks.

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Miscellaneous Equipment

In addition to the puncture device, additional equipment is required to perform a safe and successful dermal puncture and to collect an acceptable specimen. This may include any of the items discussed below.Plastic microcollection devices: Plastic microcollection devices are small plastic tubes designed to collect capillary blood from a dermal puncture wound. Each small collection tube is color-coded in the same manner as blood collection tubes used for venipuncture. The color of the cap of each container tube corresponds to the type of additive inside the tube, most often an anticoagulant. The additive coats the inside of the tube. Examples of microcollection devices are shown below. Heel warmer: It is best practice to warm the heel of an infant with a warming device known as a heel warmer. The heel warmer, when activated, is designed to warm its contents to a standardized temperature. This temperature will be hot enough to effectively warm the heel and facilitate blood flow to the area without causing heat injury to the patient. It is unacceptable to warm a cloth using a microwave. There may be "hot spots" on the cloth that could potentially burn the patient. Keep in mind, what may feel warm to you, the phlebotomist, may feel hot to your patient!Plastic or Mylar-wrapped capillary tube: In some facilities blood from a capillary puncture is collected directly into a capillary tube. These tubes are very delicate and must be used with great caution. As soon as the tube is two thirds to three-fourths filled, one end is sealed to prevent blood from leaking out.Glass microscope slides: In some facilities, the person collecting the capillary specimen may also be required to prepare a blood smear for laboratory examination. A drop of blood is placed directly on a glass slide and spread to create an area for cell examination. If you are required to prepare blood smears, remember that the slide is considered infectious until fixed or stained. It is also important to remember that glass is a sharps hazard. If not used correctly, the glass may cause injury to both the patient and the phlebotomist. Be as cautious with a glass slide containing blood as you are with a contaminated needle. Dispose of glass slides that will not be used for testing in approved sharps containers.Alcohol and gauze pads: Alcohol is the disinfectant of choice for dermal puncture. The alcohol must be allowed to air dry, which will prevent hemolysis of the specimen and discomfort for the patient. A piece of clean or sterile gauze is used to wipe away the first drop of blood. Gauze is also used to apply pressure to the wound after the specimen collection is complete to stop the wound from bleeding.Iodine or other approved cleaning agents may be used as an alternative to alcohol.Bandage: It may be necessary to apply a bandage to the puncture wound on a finger or heel if the site continues to bleed. However, it is NOT recommended to bandage the finger of a child who is 2-years-old or younger since the bandage may become a choking hazard if the child puts that finger in his/her mouth.Personal protective equipment (PPE): All health care professionals that may come in contact with blood and/or body fluids while performing a laboratory procedure are required to wear intact gloves. It is against safety guidelines to alter gloves in any way that may compromise the integrity of the gloves. Eye protection, such as safety goggles, is recommended if there is the possibility of a splash of blood while collecting a capillary blood specimen. In many facilities, special gowns are required in some patient areas such as special-care nurseries. Always follow the policies of your facility in regard to PPE.

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Oh No...The Blood Has Stopped Flowing

On occasion, blood may stop flowing from the punctured site before the required amount of blood is obtained. When this happens, it is not recommended to squeeze harder. This only serves to cut off the supply of blood to the capillary bed. Additionally, squeezing with too much force, especially on the heel of an infant, may cause injury to the patient. The phlebotomist should never scrape the skin with the collection device in an attempt to scoop up the blood that is laying on the surface of the finger or heel. This could cause the blood specimen to hemolyze, making the specimen unacceptable for some laboratory tests. Always allow the drop to flow freely into the collection tube.If a clot has formed, an attempt could be made to dislodge it and re-establish blood flow by wiping the puncture site again with a new alcohol pad, massaging the finger or heel gently, and attempting to recollect the specimen once the alcohol has dried. If blood is not flowing freely from the initial puncture, it may be necessary to perform a second puncture to obtain enough blood for the testing required. If a second puncture must be performed, do not repuncture the same site.

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Protect Me From the Light

Some specimens routinely collected for testing by using a capillary puncture are adversely affected by exposure to light. One example is a specimen collected for bilirubin testing that is obtained from a newborn. When obtaining the specimen for this testing, it is important for the phlebotomist to recognize the effect of light on the specimen. Room light or sunlight can metabolize the bilirubin in the specimen to a different compound. This will cause a falsely lower bilirubin level. A neonatal bilirubin specimen should be obtained in a dark-colored (amber) container. Alternately, a clear or white container can be immediately wrapped in aluminum foil following the blood collection, preventing the blood from exposure to light.

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The Need for Metabolic Testing on Newborns

Many state governments in the United States mandate that all newborns be tested for metabolic disorders very soon after birth. This required testing is used to determine if the infant has a metabolic disorder that could adversely affect a child's development. If discovered early, many of the effects of the metabolic disorder can be alleviated or averted. Not every state tests or screens for the same disorders, so the phlebotomist must be certain to understand the requirements for the state in which they reside. There is a movement to standardize testing throughout the United States.Typically, the method used to screen for the presence of newborn metabolic disorders is collection of capillary blood on a filter paper card. It is imperative that the phlebotomist follows the very specific directions for the collection of these samples. If a specimen is submitted to the state laboratory for testing and deemed unacceptable, the specimen would have to be re-collected. The infant would then have to be subjected to a second invasive puncture procedure, causing stress and trauma to the infant as well as the parents. More importantly, the need to obtain a second specimen can also cause a delay in treatment.

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The directions for this testing facility requires the filling of all 5 circles on the filter card.Which of the cards that were collected for metabolic testing on newborns is filled correctly?View Page
Hematology Specimens

In some institutions, the phlebotomist is responsible for collecting specimens that will be directly tested to yield results for hematology studies.Blood Smear FilmsIf it is the practice of the institution, the phlebotomist may make a blood film slide directly from the blood flowing at a dermal puncture site. In this case, a drop of blood is allowed to fall directly onto the glass slide. The image below illustrates the approximate size of the drop that should be used.Using a second glass slide, the phlebotomist should spread the blood by first aligning the edge of the spreader slide in front of the drop of blood, pulling back into the drop so that it is evenly distributed behind the spreader slide as shown in the image below. Then spread the blood forward, maintaining an angle of approximately 20° between the slides. The finished slide should be at least 2.5 cm in length, there should be a gradual transition in thickness from thick to thin, ending in a feather edge. The blood smear should be made at the beginning of the dermal puncture procedure to avoid formation of microclots. Remember that the glass slides used to make the blood smear are considered sharps and can cause accidental puncture injury to both the patient and the phlebotomist. Dispose of the spreader slide in a sharps container. Also, until the smear is stained or fixed, the blood film is considered potentially infectious so bloodborne pathogen precautions must be followed.Microhematocrit collectionIn some institutions, capillary blood specimens are collected directly into heparinized capillary tubes, which are then analyzed to determine packed cell volume. These results can be used to indicate the presence of anemia. At least two capillary tubes should be filled for microhematocrit testing. The capillary tubes should be filled with blood to about two- thirds the length of the tube. One end of each tube should then be sealed to prevent blood from escaping. The sealant may be sealing clay or commercially-provided covers that are made specifically for the microhematocrit system that is in use. Capillary tubes should be plastic or mylar-wrapped glass tubes. Plain glass capillary tubes should not be used to prevent the possible transmission of bloodborne pathogens if the tube broke and punctured through the glove and skin of the phlebotomist.It is imperative that the specimens are labeled appropriately with patient information. This can be accomplished by inserting the capillary tubes into a second larger blood collection tube that is labeled with the patient name and second identifier, such as hospital or medical record number and capping the large tube. Taping the capillary tubes individually to a paper requisition with the patient information is an alternate method.

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Capillary Blood Gases

In some instances, the health care provider may request an analysis of the capillary blood for blood gases. This is most often requested on infants. Collection of this specimen requires a skilled phlebotomist and specialized equipment. The patient must be positively identified. All appropriate PPE must be used. The procedure for site selection, preparation and puncture is identical to other infant dermal punctures, however, capillary blood gases are always drawn first if other capillary blood specimens will be collected.Blood specimens for capillary gases are always collected in long, large-bore heparinized glass tubes. Blood should be drawn into the tube using capillary action. The phlebotomist should start filling the tube using a large well-formed drop of blood, drawing continuously as the blood flows. Each tube must be filled completely end to end as shown in the image on the right. Every effort must be made to avoid drawing air bubbles or air gaps into the tubes as these could adversely affect the results of the test. Before sealing both ends of the tube, the phlebotomist will insert a tiny metal "flea" into the blood-filled tube and slide a magnet lengthwise back and forth on the outside of the tube. The magnet will cause the flea to move back and forth inside the tube mixing the specimen with the anticoagulant coated on the inside of the tube. This technique should also prevent the blood from clotting, which could result in specimen rejection by the laboratory.The properly filled glass tubes must be delivered to the analyzing laboratory in a timely manner. Delay in specimen delivery may adversely affect the quality of the patient results.

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Using Sucrose as an Analgesic Prior to Heel Puncture and Capillary Blood Collection

Recent research has indicated that an appropriate dilution of sucrose solution when administered to an infant may serve as a pain relief measure. In some institutions, the nursing staff may require that an infant receive several drops of sucrose immediately prior to the puncture of a heel. This may release endorphins to relieve pain and reduce crying by the infant. Excessive crying may adversely affect some test results such as white blood cell count and capillary blood gases.If it is the policy of your institution to administer a sucrose solution, coordinate the timing of the dermal puncture with the administration of the sucrose solution by the clinical staff. Outpatients would also require the intervention of a nursing staff member to provide the sucrose solution. Phlebotomists are not licensed to administer medications or drugs. Therefore, it is typically NOT the responsibility or duty of the phlebotomist to administer sucrose solution. There may be contraindications for sucrose administration with some infants. Therefore, the clinical person in charge of the patient's care must determine if it is safe to administer the solution. As with all procedures, follow the policies and guidelines of your facility.

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Lead: An Important Public Health Concern

Lead may be found on surfaces touched by children and adults. Lead may be present in the paint that was used in older homes or apartments, and it has even been detected in the paint used on some toys.Elevated lead levels in children can cause developmental delays. Many state governments closely monitor the presence of lead in children. To accomplish this, government agencies require official forms be completed and submitted for each patient at the time of specimen collection for lead testing. It is the responsibility of both the phlebotomist and healthcare provider to submit the completed form with the specimen. If an elevated lead level is obtained, the government authority can then track and monitor follow-up treatment for the patient. When the phlebotomist determines that a capillary puncture on the finger will be used to collect a specimen for lead testing, it is imperative that the patient's hands be washed with soap and water prior to the start of the collection to ensure the skin is free of any contaminant that could falsely elevate the test result. The patient should thoroughly wash his or her hands or if the patient is a child, the parent or guardian could be asked to assist the child. If necessary, wash the patient's hands yourself.It is important to note that washing hands with soap and water aids in removing surface lead but is not a substitute for the cleaning step in the blood collection procedure. The finger must still be cleansed with alcohol and allowed to dry before a dermal puncture is made.

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HIPAA Privacy and Security Rules
Case Study: Minimum Necessary Use & Disclosure You are a phlebotomist at a specimen collection center. A patient arrives with orders for a blood glucose test and a lipid profile. You get the patient's address, phone number, health insurance coverage, and ask how long ago he ate his most recent meal. You then ask him about his recent auto accident, his wound infection, and his family. You write down all the extra information. Under the HIPAA Privacy Regulations, which of the following information requests is acceptable?View Page

Medical Error Prevention (retired)
Which statement describes an Adverse Event?View Page

Medicare Compliance for Clinical Laboratories
Case Study 5

The setting is a nursing home where a phlebotomist from the laboratory goes to draw blood samples each day. The phlebotomist picks up the requisitions for blood tests at the nursing station and then goes to the various rooms to draw blood from the patients. She notices that every requisition has an Advanced Beneficiary Notice (ABN) attached to it that is signed by the patient, even when the tests that were ordered don't need them. She asks the nurse at the station but she informs the phlebotomist that she doesn't know anything about it because it is done on the night shift.She lets the phlebotomist know that she will inform the nursing supervisor about it when she arrives at 9:00 AM. The phlebotomist completes her blood draws and returns to the laboratory. What should the phlebotomist do, if anything, in addition to her letting the nurse know about the problem?Correct Answer: The phlebotomist should report the incident to her supervisor upon returning to the laboratory.Discussion: Since the laboratory is submitting the claims for Medicare patients from whom the phlebotomist collects blood specimens, the problem is the lab's problem. However, it is not going to change the fact that the ABNs were already signed by the patients, if the phlebotomist refuses to collect specimens from these patients or if the nursing personnel are required to remove the ABNs. By contacting the supervisor, an appropriate representative from the laboratory can follow up with the nursing supervisor to ensure they understand the laws and regulations that govern ABNs.

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Phlebotomists and Equipment in Client Offices

Laboratories may place phlebotomists or other employees in a physician office if all of the following are done: Employee only performs laboratory related tasks. There is a written understanding given to the physician about what the employee can and cannot do. Periodic audits are done to ensure the employee is following these policies. Laboratories may place printers, computers, fax machines or other equipment or products in client offices as long as they ensure that: The physician understands the equipment belongs to the laboratory. It is used for laboratory purposes like receiving reports or ordering tests. Periodic audits are done to ensure that the client is using the equipment only for laboratory related activities.

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Medicare Compliance for Clinical Laboratories (retired)
Phlebotomists and equipment in client offices

Laboratories may place phlebotomists or other employees in a physician office if all of the following are done: Employee only performs laboratory related tasks. There is a written understanding given to the physician about what the employee can and cannot do. Periodic audits are done to ensure the employee is following these policies. Laboratories may place printers, computers, fax machines or other equipment or products in client offices as long as they ensure that: The physician understands the equipment belongs to the laboratory. It is used for laboratory purposes like receiving reports or ordering tests. Periodic audits are done to ensure that the client is using the equipment only for laboratory related activities.

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Case Study 10

The setting is nursing home where a phlebotomist from the laboratory goes to draw blood samples each day. The phlebotomist picks up the requisitions for blood test orders at the nursing station and then goes to the various rooms to draw blood from the patients. She notices that every requisition has an Advanced Beneficiary Notice (ABN) attached to it that is signed by the patient, even when the tests that were ordered don't need them. She asks the nurse at the station but she informs the phlebotomist that she doesn't know anything about it because it is done on the night shift.She lets the phlebotomist know that she will inform the nursing supervisor about it when she arrives at 9:00 AM. The phlebotomist completes her blood draws and returns to the laboratory. What should the phlebotomist do, if anything, in addition to her letting the nurse know about the problem?Correct Answer: The phlebotomist should report the incident to her supervisor upon returning to the laboratory.Discussion: Since the laboratory is submitting the claims for any Medicare patients that the phlebotomist might draw, the problem is the labs problem. However, it is not going to change the fact that the ABNs were already signed by the patients if the phlebotomist refuses to draw them or if the nursing personnel are required to remove them. By contacting the supervisor, an appropriate representative from the laboratory can follow up with the nursing supervisor to ensure they understand the laws and regulations that govern ABNs.

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Phlebotomy
Discussion

When the results on Mr. John Ready were called to the nurse, she was very surprised that the result of his CBC was normal. The nurse explained to the lab tech that Mr. John Ready had a known diagnosis of lower GI bleeding. His hemoglobin had been very low for the past 24 hours because of the internal bleeding, and she thought it was very surprising that his hemoglobin had normalized so quickly without having received a blood transfusion. Mr. Ready's doctor decided the patient should be redrawn to ensure a correct result. The nurse further questioned if the phlebotomist could possibly have drawn the wrong patient because earlier that day Mr. Ready had been moved to room 831, and room 825 was presently occupied by a patient named Walter Redding. If Julie had checked the patient's armband, she would have realized that the patient in 825 was the wrong patient.Relevant topics:Importance of patient ID, Patient identification continued, Specimen labeling, Specimen labeling Continued, Blood bank specimens

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Case

Julie Smith was a newly certified phlebotomist and had been working at Northwood Hospital for several months. As she approached room 825, she looked on her collection list to verify this was the correct room for her first collection. Indeed it was, even though there was no patient name on the door. Her collection list told her the patient in room 825 was a 55 year old male named John Ready. After knocking several times, Julie entered the room to find a middle aged man who appeared to be sleeping. Julie approached the patient and said, "Good day Mr. Ready. My name is Julie and I am from the lab. I need to draw blood for some tests ordered by your doctor." The man awoke and seemed irritated as Julie repeated herself. The patient responded and told Julie to do whatever she needed to do so he could go back to sleep Julie then proceeded to do the venipuncture.

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Discussion

A phlebotomist should never use an arm with restricted usage for the venipuncture. Even if no sign is posted, the patient may tell you not to use a particular arm for various reasons, i.e. previous mastectomy, history of phlebitis, active AV fistula, etc. Do not draw blood above an IV line. If blood is taken from a vein above an IV line it might be diluted by the IV fluid, which could cause incorrect test results. In this case, Bobby should choose a vein on the dorsum of Mrs. Grayson's hand, below the IV. A butterfly needle would facilitate drawing blood from these small hand veins.Relevant topics:Alternate sites, Sites to avoid, Signs, Arms to avoid

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Case

Bobby Jones, a phlebotomist at Georgetown Hospital, entered the room of Mrs. Mary Grayson with a physician's order to draw some blood work. After properly greeting Mrs. Grayson, identifying himself and checking her armband, Bobby prepared for the venipuncture. He suddenly notice a sign posted above the bed that read: "Restricted left arm usage. Previous mastectomy - Do no use left arm for venipuncture." Bobby set up his equipment to use her right arm and noticed an IV line in Mrs. Grayson's right arm positioned in a vein slightly above her wrist on the dorsum (top) of her forearm.

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Case

Marcie Moore was a phlebotomist at a community hospital in Atlanta. It was her week to collect the pediatric unit and she was on her way to the room of a newborn for which she had just received orders to draw a STAT BMP (chem-7) and bilirubin. After informing the mother of the baby about the test she needed to perform, Marcie set up to perform a heel stick on the baby. Marcie chose a site on the outer edge of the heel on the bottom of the baby's foot ( the correct area for a heel stick) and made a small incision with a Tenderfoot lancet after cleaning the site well with alcohol.She immediately began collecting the blood in the correct tube for the BMP and bilirubin. Blood flow was not strong so Marcie squeezed the baby's foot a little to help the blood come out faster – the newborn was screaming and Marcie could tell it was making the mother uncomfortable. She wanted to hurry and get done so the mother could hold the baby.After the chemistry tech ran the blood tests on the tube, she informed Marcie that the newborn had a panic potassium level which did not coincide with the previous blood work on the newborn. Also the chemistry instrument could not perform the bilirubin due to hemolysis. Marcie was asked to recollect the specimen.

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Case

James Brown, a phlebotomist from the laboratory went to the second floor of Memorial Hospital to draw a STAT BMP (chem-8), CBC, and PT on a patient. The patient was in critical condition so the lab results were crucial for treatment. James quickened his pace in order to speed up the result time. He collected the specimens and took them back to the lab. However, the technologist in hematology and coagulation notified him that he would need to recollect the specimen because the CBC and PT were clotted.

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What could have caused the clotting?View Page
Case

John Wagner, a phlebotomist at General Hospital, went up to the 7th floor to draw routine blood work on a patient. As he approached the door of the patient's room he noticed a red stop sign on the door with the words "Respiratory Isolation" written on it.

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Case

Julie Smith, a newly certified phlebotomist at Northlake Hospital, entered a patient's room on the third floor for a routine blood draw. The patient was an elderly woman who had very small fragile veins. Julie therefore decided to use a safety butterfly needle attached to a Vacutainer tube in order to draw the blood. When Julie was finished with the venipuncture, she detached the butterfly needle from the Vacutainer, and approached the Biohazard needle disposal box. She noticed that the disposal box was full , but decided to try to fit the butterfly into the box anyway. Holding the butterfly by the tubing, she tried to push the butterfly into the box. The needle suddenly recoiled and stuck Julie's finger. Julie left the patient's room in a panic and headed back to the lab to report the needle stick injury.

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Case

A phlebotomist at Monroe Medical Center will be collecting a lavender top tube, a green top tube, a light-blue top tube, and a serum separator tube from a patient. For safety reasons, the laboratory has transitioned to using all plastic tubes.

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Case

Bobby Jones, a phlebotomist at Georgetown Hospital, was called to the pre-op area to perform a bleeding time. Bleeding times may be requested on selected preoperative patients to help assure that they will not bleed excessively during surgery. Bobby gathered the appropriate equipment, then placed the blood pressure cuff of the patient's upper arm, and pumped it to 40 mm Hg. After finding the appropriate site (a few inches below the elbow on the inside of the forearm), Bobby cleaned the site with an alcohol pad and immediately made the incision with a Surgicutt parallel to the bend of the elbow. Bobby then wiped away the first drop of blood with an alcohol pad, and blotted the incision every 30 seconds thereafter. Fifteen minutes later the patient was still bleeding.

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Discussion

The blood pressure cuff was correctly inflated to 40 mmHg. The site for the incision is indeed the inside of the forearm a few inches below the bend of the elbow, and the cut was correctly made parallel to the bend of the elbow. However, the phlebotomist did not allow the alcohol to dry, and then made the additional mistake of wiping the incision with alcohol. Alcohol will retard blood coagulation, resulting in a falsely elevated bleeding time. It is also important to ask the patient about medications taken within the past week. Certain medications, particularly aspirin, will result in an elevated bleeding time.Relevant topics:Bleeding time: introduction 1, Bleeding time: introduction 2, Bleeding time: performance, Bleeding time, Apply blood pressure cuff, Bleeding time: prepare the site

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Discussion

The phlebotomist should always carefully observe the patient for clues about his mental and physical condition. In this case, the patient verbally expressed her fear of needles. In other cases, such fear may be expressed on the patient's face or through other clues. It may help to engage apprehensive patients in conversation during the venipuncture to keep their mind off the procedure.As soon as the patient stated that she felt faint, the procedure should have been terminated. If a sitting patient faints, placing her head between her knees will help to revive her. Make sure the patient does not injure herself. Ammonium (smelling) salts, if in use at your institution, should be used cautiously, since they can be irritating. Get help from the nursing staff or a physician. Stay with the patient at least 15 minutes. The patient should not leave the area for at least 30 minutes. Make sure other appropriate institutional procedures are followed after fainting.Relevant topics:Fainting, Fainting continued

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Case

A phlebotomist at an outpatient drawing station prepares to collect blood from a patient who is scheduled for surgery the next day. The patient tells the phlebotomist that she is afraid of needles. The phlebotomist assures the patient that everything will be fine. He seats the patient in a phlebotomy chair. He talks the patient through the beginning of the venipuncture and she seemed to be doing fine. As the second of four tubes is being drawn, the patient suddenly blurts out that she fells very dizzy and is going to faint.

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What should the phlebotomist do now?View Page
Discussion

Insufficient blood volume may cause erroneous test results, and specimen rejection. When blood flow stops, it can mean several things:The bevel of the needle may be pressed against the wall of the blood vessel. If this is the case, moving the needle slightly may cause blood to begin flowing again.The vein may have collapsed due to the vacuum of the tube. If moving the needle slightly does not re-establish blood flow, you will have to recollect the patient.The needle may have gone all the way through the vein. Pulling the needle back slightly may cause blood to resume flowing. The tube you are using may have insufficient vacuum. Try another tube. Never vigorously probe the patient's arm with a needle. At the first sign of discomfort the needle should be withdrawn. The patient may then be redrawn be yourself or another phlebotomist.Relevant topics: Insufficient volume, Partial collection tubes, What if no blood flows

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Case

A phlebotomist was collecting STAT blood work on a patient when blood flow unexpectedly stopped. The light blue top tube being drawn at the time was only about one third full – less than the minimum volume required for this particular tube. A red top tube had already been drawn for a cross match, and a PT was the only other test ordered.

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What could the phlebotomist do at this point to renew blood flow?View Page
Case

A phlebotomist at Memorial Hills Hospital entered the room of a 6 year old patient. The only test ordered was a CBC, so the phlebotomist decided to do a finger stick. After gathering proper supplies for the finger stick, the phlebotomist began the procedure by putting on gloves and wiping the tip and side of the patient's ring finger with alcohol. He positioned the safety lancet between the ball and the side of the finger and made a small incision. The child cried as the blood was collected.

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Case

A phlebotomist from the laboratory at Midtown Memorial Hospital was working evening shift. Her shift ended at 11 PM and it was 10:30 PM. She suddenly got orders for a STAT blood culture on the second floor. The order specified blood culture times two, 30 minutes apart. The phlebotomist went to the patient's room and decided to collect both blood cultures at the same time form the same site so she would be able to leave on time without having to come back in thirty minutes to collect the second set. She also wanted to "save" the patient from an extra stick. While the phlebotomist was preparing for the collection, she realized she didn't have any Betadine on her tray, and decided she would just clean the site twice with alcohol. She finished the blood culture collections and was able to leave by 11 PM.

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Discussion

This phlebotomist violated hospital procedures in several ways that could adversely impact patient care: Cleaning the site only with alcohol, not iodine, could result in a false-positive contaminated blood culture. This might result in the patient receiving unnecessary intravenous antibiotics, and could prolong the patients hospital stay unnecessarily. Drawing both cultures at the same time lessens the chance of recovering a bloodstream organism.Drawing both cultures from the same site might result in both of them being contaminated, making it very difficult for the physician to distinguish contamination from a "real" bloodstream infection.Relevant topics:Blood cultures: introduction, Avoid skin contamination, Blood culture site preparation 1, Blood culture site preparation 2

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What did the phlebotomist do wrong?View Page
Butterfly needle - Butterfly needles and needle-stick injuries

Butterfly needles, because of their flexibility, are the number one cause of needle-stick injuries among phlebotomists.Use extra caution when using butterfly needles.

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What is a phlebotomist's role in a health care facility?

The phlebotomist collects blood & other specimens which ultimately provide doctors and nurses with laboratory test information critical to patient care.He or she therefore plays a vital role in any health care system.

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What is a phlebotomist's role in health care facility? [continued]

Phlebotomists work in a variety of settings including: Hospitals Physician Offices Nursing Homes Home Health Care Clinics, and Military facilities. A well trained phlebotomist will therefore have a variety of job opportunities available.Other medical professionals, including nurses, respiratory therapists, and medical assistants may also be trained to collect blood specimens.

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What is phlebotomy?

Phlebotomy, also known as venipuncture, means collecting blood from veins.Phlebotomists, by definition, collect venous blood, but perform a variety of other important medical tasks as well.

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What is a phlebotomist?

A phlebotomist is a medical professional who:Collects blood and other specimens.Prepares specimens for testing. Interacts with patients & health care professionals.

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What is a phlebotomist? [continued]

An experienced phlebotomist should be knowledgeable in the collection of: - Venous blood specimens - Capillary blood specimens - Blood culture specimens - Urine specimens - Throat cultures, and - Medicolegal specimens requiring chain of custody. He or she may also need to know how to: - Process specimens - Perform point-of-care tests, and - Collection specimens from IV lines and central venous lines, under appropriate supervision.

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Laboratory work-flow cycle

The work flow of any medical laboratory involves these basic steps: Physician orders lab tests. Order is received in lab. Work list and labels generated by lab. Phlebotomist is dispatched to patient.

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Work-flow cycle: patient ID to specimen processing

Phlebotomist positively identifies patient. Phlebotomist draws and labels blood specimen. Specimen is transported to laboratory. Specimen is accessioned and processed in lab.

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Laboratory work-flow cycle: phlebotomist role

As a professional phlebotomist, you have a critical role in this basic work-flow cycle. The rest of this program contains the information you need to begin training in this important profession.

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Professionalism: maintaining confidentiality

Phlebotomists are ethically and legally required to keep patient information confidential. Reveal patient information including medical history and results only to authorized individuals as defined by your laboratory's policies & procedures. Do not discuss test results with patients without a written order from the ordering physician.

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Introduction

Physicians need to know the blood concentration of certain drugs in order to select the best dose for their patients.As a phlebotomist, you might be asked to draw peak (highest), and trough (lowest) levels of various therapeutic drugs.

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Risk Management in the Clinical Laboratory
Employee Competence Assessment

It is important that job-related performance standards be established for each position in the laboratory (e.g. medical laboratory scientist, medical laboratory technician, phlebotomist, and laboratory aide). The standards should be distinctly stated and clearly communicated (both in writing and verbally) to the employee so that the employee fully understands what is expected. It is also important to remember that when performing an employee performance evaluation, an individual's performance must only be compared to the established performance standard. If the employee's performance falls below an established performance standard, it should be clearly articulated to the employee where he/she needs to improve to meet the standard. The supervisor should then meet with the employee at established intervals to discuss whether the employee is making progress toward meeting the established standard. In addition, it is important that supervisors understand how to conduct and properly document an evaluation. Documentation, however, should not be limited just to the annual or biannual evaluation review. Performance problems for all employees should be documented regularly. Apply policies consistently to all employees and in all situations; avoid inconsistent enforcement. Ensure that all personnel documentation is reviewed only by those individuals who have a "need to know." The review process is not to be a means for someone to publicly embarrass an employee.

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Routine Venipuncture
What is Venipuncture?

Venipuncture is the collection of blood from a vein. The person having the responsibility for the performance of the venipuncture may be a phlebotomist who is a part of the laboratory staff, or he/she may be another health care professional that has been trained to perform this duty. In this course, we will refer to the person performing the venipuncture as the phlebotomist.

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Explore the Possibilities!

The antecubital area of the arm is usually the first choice for routine venipuncture. This area contains the three vessels primarily used by the phlebotomist to obtain venous blood specimens: the median cubital, the cephalic and the basilic veins.Although the veins located in the antecubital area should be considered first for vein selection, there are alternate sites available for venipuncture. These include the top of the hand, the side of the wrist, and the forearm. These sites should only be considered after determining that the veins of the antecubital area cannot be accessed or cannot be used. Vein Location Reason for Choice Placement Direction Median Cubital Mid antecubital fossa Vertical to diagonal Musculature assists in stabilizing vein; very often largest; ease of access Cephalic Thumb side of antecubital fossa Vertical Ease of access; few nerves and tendons in area Basilic Body side of antecubital fossa Vertical to diagonal More difficult to access; proximity of artery, nerves and tendons. Use this vein only as the final alternative.

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Proper Patient Identification

In order to prevent errors that affect specimen quality, the phlebotomist must pay close attention to detail during the entire venipuncture process. All steps of the phlebotomy procedure must be included for every venipuncture. This will help to maintain specimen integrity during the collection, transport, and handling of blood specimensProperly identify the patient every timeThe phlebotomist is responsible for correctly identifying the patient using two unique patient identifiers that include the patient's complete first and last name, medical record or hospital number, and/or date of birth. The patient location or room number, bed tag and chart are not reliable forms of identification and should not be used for patient identification. Every patient must verbalize his/her name to the phlebotomist, if able to do so. It is unacceptable for the phlebotomist to ask the patient to confirm his/her name that was verbalized by the phlebotomist. For example, the phlebotomist should say, "Would you please tell me (or spell) your name and birthdate. " The phlebotomist should NOT say, "Are you Sally Brown, and is your birthdate June 1, 1925?" If this is a hospital inpatient, check the information on the patient's wristband and confirm that the name and hospital number or medical record number matches the patient information on the test order. Never rely on identification attached to a bed, chart or door. NEVER draw a patient whose identity is not established or is in conflict. If there is a discrepancy, the phlebotomist must STOP and seek assistance to have the discrepancy resolved before proceeding with the venipuncture. If this is an outpatient that does not have a wristband, ask the patient (or guardian/caregiver) to state the patient's date of birth. A picture ID, such as a driver's license, can also be used for positive patient identification.

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What is a Hidden Error?

Hidden errors are those that cannot be detected or corrected by the laboratory analyst prior to testing. Most often these errors can be prevented by the phlebotomist following correct venipuncture procedure for every procedure, every time.Hidden errors include hemoconcentration, incorrect order of draw, and (the most serious of all errors) misidentification of patient or specimens. Because these errors often are unknown, the analyst may inadvertently report erroneous patient results which could be harmful to the safety and well-being of the patient. Condition What is it? How does it happen? What is the Result? Hemoconcentration Blood pools at site of venipuncture Tourniquet is applied for a prolonged period of time Test results may be inaccurate because blood components move between blood and tissues Pouring Blood between tubes Mixing contents of two or more tubes Removing top of tube to combine contents of one tube with another Inaccurate test results due to over or under dilution or incorrect anticoagulant Clots form due to lack of mixing Patient may have to be redrawn Incorrect patient identification and incorrect specimen labeling Using the wrong name to label a specimen Failure to positively identify EVERY patient using 2 unique identifiers BEFORE beginning venipuncture Failure to label EVERY specimen in the presence of the patient Failure to concentrate fully on the task Results reported to caregiver for wrong patient Compromises patient care; may be life-threatening

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Labeling Specimens

All specimens must be labeled in the presence of the patient at the time of collection. Inaccurate or incomplete labeling may result in rejection of the specimen by the laboratory. Unlabeled specimens will automatically be rejected by the laboratory. When labeling a specimen for the laboratory, the following information must be included: Patient's first name and last name Hospital medical record number, date of birth or alternate unique patient number Collector's ID Time the specimen was collected Date the specimen was collectedA phlebotomist must NEVER pre-label specimen containers. This can result in specimen mix-up and potentially disastrous consequences for the patient.

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Correct Fill

Fill blood collection tubes completely (until vacuum is exhausted) to ensure the correct blood to anticoagulant ratio necessary for accurate patient results. Specimens may be rejected by the laboratory if the tube is short-filled or over-filled. To avoid short-filling of tubes, the phlebotomist must ensure that the blood flow stops completely before removing the tube from the needle. When using a winged device (butterfly) to collect blood for coagulation studies (e.g., protime, aPTT), the phlebotomist must draw a light blue top "waste" tube before attaching another light blue top tube for testing. If the air in the tubing of the winged device is not displaced into a waste tube and is drawn into the tube used for testing, the tube used for testing will short-fill. The laboratory may reject the specimen because of invalid blood to anticoagulant ratio.

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Do Not Tamper With the Specimens

A phlebotomist should not uncap a blood tube and pour blood between tubes or combine two partially filled tubes of blood into one. This may lead to over-fill of tubes and more importantly, invalid patient results. Combining two tubes with the same additive into one tube will alter the blood to anticoagulant ratio by doubling the amount of anticoagulant in the tube. When blood is being transferred from a syringe to a tube, the phlebotomist must not apply pressure to the plunger to force blood into the tube. This may cause over-filling of the tube and hemolysis of blood cells. With the aid of a transfer device, the tube will draw the amount of blood required to fill the tube based on the amount of vacuum in the tube.

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Avoid Prolonged Tourniquet Time

A prolonged tourniquet time may lead to blood pooling at the venipuncture site, a condition called hemoconcentration. Hemoconcentration can cause falsely elevated results for glucose, potassium, and protein-based analytes such as cholesterol.Ideally, the tourniquet should be in place no longer than one minute to prevent hemoconcentration. If the phlebotomist takes longer than one minute to assess and locate vein of choice for venipuncture, it is best practice to release the tourniquet, assemble supplies and reapply tourniquet immediately before needle insertion.

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Importance of Using the Correct Blood Collection Tube

Specific anticoagulants must be used for each test that requires plasma or whole blood. If the blood is drawn into a tube with the wrong additive, patient results may be adversely affected. For example, the test for lithium usually requires a serum sample. If instead of a serum tube, the phlebotomist used a tube that contained lithium heparin, the lithium result for the patient would be falsely elevated. It is imperative that the phlebotomist use the tube with the correct additive to avoid erroneous patient results.

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Ideally, a tourniquet should remain tightened for no longer than what amount of time before releasing it?View Page
Protect Yourself

The safety of both the phlebotomist and patient is of utmost concern at all times. In the unfortunate event of an accidental needlestick or if you get blood or other potentially infectious materials in your eyes, nose, mouth, or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. Report this immediately to your employer and seek immediate medical attention. It is imperative that the phlebotomist follow facility protocol for reporting the incident. This ensures prompt treatment for the injury. The facility procedure must be followed whether the accidental puncture was from a clean or contaminated needle.The single most important element to prevent an accidental needlestick is for the phlebotomist to fully concentrate during every procedure. Keeping your mind on the task at hand contributes to a successful and safe result.

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Needles - What's the Point?

Needles that are used for venipuncture are available in a variety of lengths and diameters. The diameter of the needle is referred to as the needle gauge; the larger the diameter of the needle, the smaller the gauge number. The image on this page illustrates the relative gauges of needles that are available for venipuncture. Needles that are routinely used for venipuncture are available in 3/4 inch, 1 inch, and 1 1/2 inch lengths. The phlebotomist determines the gauge and length of the needle to use for a venipuncture after assessing the vein.

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Blood Collection Systems and Devices

The phlebotomist has a choice of several blood collection systems. Three that are commonly used are discussed on the following pages. Evacuated Tube SystemThe primary choice for a routine venipuncture that will be performed on an adult or an older child is a blood collection system that consists of a holder (or adapter), a needle that is pointed on both ends, and evacuated blood collection tubes. One end of the needle will pierce the vein and the other end will pierce the stopper of the evacuated tube so that blood will flow into the tube to fill the vacuum. A safety device is required on either the holder or the needle to comply with current standards for needle safety. Two examples of needle holders equipped with safety devices are shown on this page.

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Syringe

The syringe and needle combination should be the last equipment option that is considered; it is not as safe a choice as the self-contained blood collection systems because it involves more manipulation. However, the phlebotomist may choose to use a syringe to prevent vein collapse if the phlebotomist thinks that the vein is too fragile to withstand the pressure exerted by the vacuum as it pulls blood into the collection tube. A transfer device aids in the safe transfer of blood from the syringe into blood collection tubes. During blood transfer, do not manually push plunger as this may cause hemolysis of the specimen.

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Winged Device

The winged device is another popular choice for the phlebotomist. This may be chosen for pediatric venipuncture, small delicate veins on adults (particularly geriatric patients), or hand veins. The device can be used with a needle holder and evacuated tube or a syringe. A needle safety device is incorporated into the design of the winged device to prevent needlestick injury.

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Tourniquets, Alcohol, and Gauze

A tourniquet is used by the phlebotomist to assess and determine the location of a suitable vein for venipuncture. Single-use, latex-free tourniquets are preferred but reusable tourniquets are acceptable. However, if the reusable tourniquet becomes contaminated with blood or body fluid, it must be discarded immediately to avoid the spread of harmful contaminants to other patients. Follow the guidelines established by your facility for cleaning reusable tourniquets.Proper application of a tourniquet will partially impede venous blood flow back toward the heart and cause the blood to temporarily pool in the vein so the vein is more prominent and the blood is more easily obtained. The tourniquet is applied three to four inches above the needle insertion point and should remain in place no longer than one minute to prevent hemoconcentration. If the tourniquet is used during preliminary vein selection, it is best to release the tourniquet after assessing the vein and while you are assembling your supplies. Reapply the tourniquet just before starting the venipuncture; it should then be released soon after the needle has been inserted into the vein and the blood flows into the first tube. If collecting multiple tubes, the tourniquet may remain in place until blood enters the last tube.

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Vein Palpation

A skilled phlebotomist relies more on touch or feel than on sight when determining a vein suitable for venipuncture. Palpation is used to assess the depth, width, direction and health (resilience) of a vein. Use the index or middle finger to palpate the vein following this procedure: Align your finger in the direction of the vein Press on top of the vein with enough pressure to depress the skin Keep your finger in contact with the skin so that you may feel the "bounce back" of a resilient, healthy vein. Assessing a vein by palpation before attempting a venipuncture increases the possibility of a successful venipuncture.The image on the following page illustrates the considerations for vein assessment.

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When to Use Hand Veins to Obtain Blood

Sometimes the phlebotomist may decide that the antecubital area is not the best site for venipuncture. Reasons for this decision may include: Extensive bruising (hematomas) in the antecubital area Inability to "feel" a vein suitable for puncture Presence of an intravascular line (IV) or vascular access device Physical condition of the patientWhen the veins in the antecubital area cannot be used, the phlebotomist may choose to use a vein on the top of a hand. The veins in the hand are very near the surface and often very small and thin so the procedure must be performed carefully and cautiously. .

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Handle With Care

Equipment: To successfully enter a hand vein, the phlebotomist must choose equipment that will allow needle entry at a very small angle. A winged device with a small gauged needle of 3/4 inch length is most often used to obtain blood from a hand vein. A syringe is usually attached to the end of the tubing of this device. By using a syringe, the phlebotomist can control the amount of pressure on the vein and avoid vein collapse. Evacuated tubes may collapse a vein by exerting too much pressure on the delicate vein. If available, smaller tubes containing less vacuum may be used.Insertion angle: The angle at which the needle is inserted into a hand vein is smaller compared to the angle of needle insertion into veins of the antecubital area. When drawing from a hand, the needle should be inserted into the vein at approximately a 15 degree angle to allow easier access of the surface hand veins. By inserting the needle at this angle, the risk of the needle going "through" the vein and puncturing the bony structures underneath is reduced.

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Tips for Successful Venipuncture When Using Hand Veins

Hand position: When collecting blood from a hand vein, it is best practice to position the patient's hand slightly downward with the top of the hand facing you. The fingers of the patient's hand should be rolled underneath, forming a loose fist. Use your thumb to pull back gently on the surface of the skin, making the skin taut. The vein should be anchored adequately to proceed with venipuncture. The hand veins will be more prominent if the patient grips a pillow or a rolled up washcloth.Tourniquet Position: The tourniquet should always be applied 3 - 4 inches above the needle insertion point. Therefore, when assessing for a usable vein in a hand, apply the tourniquet 1 - 2 inches above the wrist. If the tourniquet is on longer than one minute, release and reapply prior to venipuncture to avoid hemoconcentration.Cautions:Choose a straight section of the hand vein-- avoid the "intersection" or "V" where a vein branches into another vein. This juncture may contain a valve and could be damaged if punctured. Only use the top of a hand or thumb-side of the wrist for puncture. Avoid the fingers or the underside of the wrist. This will prevent the inadvertent puncture of hidden arteries, tendons or nerves in the area.

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Venipuncture Procedure At a Glance

Required Step Description Step #1 Wash your hands. Clean your hands with soap and water or gel cleanser. Step #2 Positively identify patient using unique identifiers. Ask the patient to state his/her first and last name; if the patient is unable to give you this information, ask the patient's caregiver to confirm the patient's name. A second unique identifier must also be used. Step #3 Special test requirements Determine if the test to be obtained has any special requirements. For example, should the patient be fasting? Is this a timed test? If any requirements are not met, consult with the caregiver to determine a course of action. Step #4 Prepare the patient Explain the procedure to the patient and obtain cooperation. Usually the patient will extend an arm. (This is a form of implied consent.) Position the arm for venipuncture; support the arm on a firm surface; the arm should be in a downward position. Step #5 Site determination The patient can make a fist, but should not pump the hand open and closed. Apply tourniquet Palpate the vein. Release the tourniquet and assemble appropriate equipment. Step #6 Aseptic technique Wear gloves that have not been altered in any way. Cleanse site with approved disinfectant. Allow the disinfectant to air-dry to avoid hemolysis of the specimen and discomfort to the patient. Step #7 Specimen collection Re-apply tourniquet about 3-4 inches above puncture site, insert needle, bevel-side up, at about a 30° angle, and collect specimens. Remove needle and immediately activate the safety device. Mix specimens by gentle inversion 5-10 times. Step #8 Patient care Apply direct pressure to stop bleeding at puncture site; do not have patient bend arm as this may cause a hematoma to form. After about 2 minutes, check the puncture site to verify that bleeding has stopped. Apply bandage if appropriate. Thank the patient for his/her cooperation. Step #9 Specimen labeling Label specimen(s) in the presence of the patient including all the information that is required by your facility. Check the labeled tubes a second time against the patient's wristband to verify labeling accuracy. A professional phlebotomist follows the procedure in the same way for every venipuncture. This ensures that none of the vital steps are omitted. The phlebotomist who is consistent in performance and who concentrates fully to obtain a quality specimen is an indispensable part of the healthcare team.

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Don't Compromise Your Safety

An important element of safety is personal protective equipment (PPE). This must be provided to phlebotomists by their facility and may include gloves, lab coats, and protective eyewear. An N95 respirator (shown in the lower image) or other respiratory protection may be required to protect the phlebotomist from Mycobacterium tuberculosis or other airborne infectious agents. Phlebotomists and other healthcare workers must be medically cleared and fit-tested to wear N95 respirators. Gloves are required during every phlebotomy procedure. The gloves must remain totally intact. The gloves cannot be altered in any way as to expose the hand or fingers to potential bloodborne pathogens. Never remove all or part of the finger tip of the glove while performing venipuncture.

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Julie Smith is a recently certified phlebotomist who has been working at Northwood Hospital for several months. As she approaches room 825, she looks at her collection list to verify this is the correct room for her first collection. Julie enters the room to find a middle-aged man who appears to be sleeping. Julie approaches the patient and says, "Good day Mr. Ready. My name is Julie and I am from the lab. I need to draw blood for some tests ordered by your doctor." The man awakens and Julie again states that she is from the lab and needs to draw blood for some tests ordered by the doctor. The patient tells Julie to go ahead and get it done so he can go back to sleep. Julie then proceeds with the venipuncture.What procedure did Julie not follow prior to performing the venipuncture?View Page
Which of the following methods could Julie have used to positively identify the patient?View Page
Scenario Conclusion

When the results on Mr. John Ready were called to the nurse, she was very surprised that the result of his CBC was normal. The nurse explained to the laboratory technologist that Mr. John Ready had a known diagnosis of lower GI bleeding. His hemoglobin had been very low for the past 24 hours because of the internal bleeding, and she thought it was very surprising that his hemoglobin had normalized so quickly without having received a blood transfusion. Mr. Ready's doctor decided the patient should be redrawn to ensure a correct result. The nurse further questioned if the phlebotomist could possibly have drawn the wrong patient because earlier that day Mr. Ready had been moved to room 831, and room 825 was presently occupied by a patient named Walter Redding. If Julie had properly identified the patient by asking him to state his name and then checking the name and identification number on the wristband, she would have realized that the patient in 825 was the wrong patient.

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Bobby Jones, a phlebotomist at Community Hospital, enters the room of Mrs. Mary Grayson with a physician's order for blood tests. After greeting Mrs. Grayson, identifying himself, and properly identifying the patient, using two methods of identification, Bobby prepares for the venipuncture.As he approaches the patient's bed, he notices a sign posted above the bed that reads: "Restricted left arm use. Do not use left arm for venipuncture." Bobby prepares to use the patient's right arm and notices an intravenous (IV) line in Mrs. Grayson's right arm positioned in a vein slightly above her wrist on the dorsum (top) of her forearm.Which site should Bobby choose for the venipuncture?View Page
A phlebotomist was collecting a STAT prothrombin time (PT) and complete blood count (CBC) on a patient when blood flow unexpectedly stopped. The lavender top tube being drawn at the time was less than one-third full. The light-blue top tube had already been drawn for the prothrombin time.Before resorting to a second venipuncture, which of the following procedures should be attempted in order to adequately fill the lavender top tube?View Page

Special Topics in Phlebotomy
What To Do if the Patient Feels Faint

Fainting does sometimes occur as a result of venipuncture. A patient may experience a feeling of weakness or light-headedness or in severe cases, the loss of consciousness at any time during the venipuncture procedure. Before the procedureIf a patient is aware that he/she gets light-headed, or has in the past fainted while having blood collected, the patient may alert the phlebotomist. The phlebotomist must then take appropriate measures to safeguard the patient during the procedure. For example, the phlebotomist may instruct the patient to lie down instead of sitting upright during the procedure. This practice may lessen the risk of patient fainting and eliminate the possibility of patient injury due to falling or sliding out of a draw chair. During the procedureIf a patient faints during the venipuncture, immediately abort the procedure by gently removing the tourniquet and needle from the patients arm, apply gauze and pressure to the skin puncture site and call for assistance. If the patient is seated, place the patient's head between his/her knees. A cold compress applied to the back of the neck may help to revive the patient more quickly. The use of an ammonia inhalant (smelling salts) to rouse the patient is considered an unsafe practice. The inhalant may cause irritation and/or anaphylactic shock in some patients. A typical fainting spell is self-limited and usually the patient comes around fairly quickly. However, the phlebotomist should stay with the patient for at least 15-30 minutes to ensure the patient has fully recovered from the fainting episode. After the procedureIf the patient states that he/she feels dizzy after the blood collection is completed, again, as stated above, place the patient's head between his/her knees and apply a cold compress to the back of the neck. The phlebotomist should never direct the patient to an alternate location while the patient is experiencing dizziness. There is a great likelihood that the patient will faint while walking and be injured. It is never advisable for the phlebotomist to allow the patient to leave after the procedure until the patient is safely able to do so. It is important to review your facility's specific procedures and know how to react appropriately if a patient experiences dizziness or faints during a blood collection.

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Hematoma

A hematoma is another name for a bruise. A hematoma or bruise is a collection of blood beneath the skin. Hematomas are the most common adverse reaction to venipuncture. There are many factors that can contribute to the formation of a bruise. Venipuncture techniqueIf the phlebotomist pushes the needle too far into and through the vein, blood leaks out of that opening and into the surrounding tissue. The appearance of a blue or purple discoloration at the venipuncture site indicates the presence of a hematoma. This discoloration at the site may occur immediately or some time after the venipuncture is completed. A bruise may cause slight discomfort for the patient, but the mere sight of a bruise may generate undue anxiety and discontent for some patients. A patient may associate a bruise with a negative venipuncture experience and be hesitant to have blood tests in the future. It is not advisable for the phlebotomist to perform a venipuncture at the site of a recent bruise as this may cause discomfort for the patient and may also affect the quality of the blood sample. Bleeding disorders and anticoagulant medications:A hematoma may also form after a venipuncture, if the patient has a medical condition that impairs clot formation. A patient who is on anticoagulant therapy will experience a delay in clot formation. If the phlebotomist is aware of the condition, he/she can reduce the incidence of bruising by applying pressure to the venipuncture site for a longer than normal period of time. Also, it is best to inform the patient that bruising is likely. Communication is important to relieve patient anxiety if a hematoma appears.

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Clean Up Your Act

During a blood collection, bacteria that is present on the skin surface may adhere to the outside of the needle as it enters into the vein. This can allow bacteria to infect the puncture site. A serious infection of the blood (septicemia) or of the tissue (cellulitis) may result. To avoid an infection, it is imperative that the phlebotomist uses a technique that thoroughly cleanses the skin at the site prior to venipuncture.Once the phlebotomist locates a suitable vein for venipuncture, the site of the vein that will be punctured is cleaned with a pre-packaged wipe saturated with 70% isopropyl alcohol.The site is cleansed using a "target" motion beginning at the center of the site and moving outward in concentric circles applying enough pressure to move surface bacteria away from the puncture point. (This is demonstrated in the image on the right). It is not recommended to use a scrubbing back and forth motion to clean the site since you may drag bacteria from a dirty area back into the clean area. Allow alcohol to air dry for effective disinfection of the site. Never use non-sterile gauze to wipe dry the alcohol as this will contaminate the site.During the remainder of the procedure, the site must NOT be touched by anything that has not been cleaned in an identical manner. The phlebotomist should avoid retouching the site after cleaning. If it is absolutely necessary to re-palpate, the phlebotomist MUST clean the gloved finger in a manner identical to the above procedure. Make certain that no other piece of equipment touches the site. This includes ends of the tourniquet and gauze. If you suspect that your needle has touched the site before entry, dispose of the needle, re-clean the site and repeat the procedure using a new needle. If a patient complains that there is redness or pain at the puncture site, even hours or days after the procedure, immediately refer the patient to his/her physician for evaluation.

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Case Study Two

Stop and Think !An 18-year-old male has come to the outpatient clinic for blood work. He tells you that he has not been feeling well for several days, which is obvious from his skin pallor. He also mentions being weak and fatigued. If you are the phlebotomist, what would you do?Consider how you would handle this or a similar situation before proceeding to read the suggested solution on the following page.

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Case Study Two: Discussion

Case study:An 18-year-old male has come to the outpatient clinic for blood work. He tells you that he has not been feeling well for several days, which is obvious from his skin pallor. He also mentions being weak and fatigued. If you are the phlebotomist, what would you do?Suggested plan of action: It is important to observe and listen to the patient and assess the situation to avoid a potential adverse event. In this case, because the patient is in a weakened condition, it would be best to have him lie down for the venipuncture as a safety precaution.

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Effective Communication

Effective communication is a key component of successful phlebotomy procedures. It is important to prepare the patient adequately for the blood collection procedure, not just physically, but also mentally. Educating the patient about the process is respectful to the patient and will improve sample integrity. Allow time:For patients to ask questionsTo share information that is important to the sample collection processTo describe post-venipuncture self-care information Use simple vocabulary and not complex medical terms when explaining procedures or answering patients' questions.If an error does occur during the venipuncture procedure and is realized by the phlebotomist, the appropriate actions should be taken. For example, if a blood tube was not collected for a particular test, the phlebotomist should explain the error to the patient and perform a second venipuncture to collect the required tube. Ignoring an error or taking inappropriate actions can put a patient at risk.

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Introduction

Patient-centered health care is care that is delivered in a manner that is "respectful of and responsive to individual's preferences, needs, and values."*Great health care for every patient involves a team approach. All team members contribute in a unique way to ensure successful patient outcomes. The phlebotomist is a key member of the health care team and the team relies on the phlebotomist to obtain quality specimens. Patient diagnosis and treatment is often dependent on laboratory test results. The accuracy and reliability of these results are contingent on a quality specimen. It is easy to see how the phlebotomist directly affects the care of the patient. As members of a professional health care team, phlebotomists should exhibit professional behaviors. Simple things, such as appropriate dress and grooming, reflect a professional image. Language and conversation should also show that you value yourself, your employer, and the patient. Work habits demonstrate to the rest of the team that you provide an invaluable service.*Reference: Committee on Quality of Health Care in America. Crossing the Quality Chasm, A New Health System for the 21st Century. Washington, DC: National Academy Press. 2001.

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Screening for Diabetes Mellitus and Gestational Diabetes

Glucose tolerance tests are used to help diagnose diabetes mellitus or gestational diabetes, which occurs during pregnancy. The procedure basically consists of these steps:Confirm that the patient has been fasting.Collect a fasting blood glucose specimen. Have the patient drink the dose of glucose solution required by the procedure.Collect blood at standard timed intervals. Blood, or blood and urine specimens, are then checked for glucose levels. The patient should be instructed to remain in the facility and remain seated between blood collections. The phlebotomist should check on the patient periodically between blood collections, especially during the first hour. For some patients, the glucose solution may cause nausea and vomiting and the test may need to be terminated.

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Collection and Communication

The laboratory plays an important role in monitoring the level of therapeutic drugs. Communication with clinical personnel is critical. Blood specimens are collected at specific time intervals to determine the trough level and peak levels of the drug. The pharmacist uses these trough and peak values to adjust the dose of the drugs appropriately.It is the responsibility of the phlebotomist to obtain the specimen at the precise time ordered for the specific peak or trough drug level. With some drugs, altering the draw time by even 15 minutes can have an adverse affect on adjusting and administering the next drug dose.Obtain the specimen at the requested time. If the time is missed, ask the clinical staff if the test should still be obtained or if another draw time is desired. If the clinical staff still wants a specimen collected, make a note of the time the drug was administered in relation to when the specimen was collected.Failure to communicate could have an adverse effect on the patient who may be given too little or too much medication based on an erroneous test result.

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Special Tests May Mean Special Collections

Some laboratory tests are so specialized that they require the use of special collection tubes to prevent erroneous results.Some examples of special requirements include:Laboratory TestConsiderationsHeavy metalsBlood collection container material must be free of heavy metalsTissue typingSample may need to be collected in preservative solutionBlood culturesSpecimens must be collected in bottles containing nutrient media to promote growth of bacteria within the bottle. Genetic studiesSpecial tubes may be needed to preserve DNA and/or RNA It is the responsibility of the phlebotomist to be aware of special requirements for certain tests. If the correct collection tube is not known then the phlebotomist MUST refer to the specimen collection manual or ask the appropriate laboratory worker to obtain the information. It is also imperative that the phlebotomist obtain and use only the correct equipment and not substitute something that is "close". This could affect the test results and the safety of the patient.

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Intravenous Line

Blood specimens should not be collected from an arm into which intravenous (IV) fluid is being administered. If at all possible, the phlebotomist should draw blood from the opposite arm or hand. If an IV line is delivering fluid into the patient's vein and the specimen is drawn from that vein, the specimen may be contaminated and diluted by the IV fluid; the blood test results could then be erroneous.If the arm or hand opposite of the arm that contains the IV line is not accessible or cannot be used for another reason, a capillary collection may be an option, if only a small amount of specimen is needed. However, if a venipuncture is necessary and the arm that has the IV line in place is the only option, ask the clinical person in charge of the patient's care to turn off the patient's IV. Ensure that the fluid has stopped flowing through the line, and wait at least two minutes before performing the venipuncture. It is imperative that the phlebotomist witness that the IV has physically been turned off by the health care provider and then turned back on after the draw has been completed. A phlebotomist must not turn the IV on or off.

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Geriatric Patients

Patients who are elderly may also require special considerations before, during, and after the venipuncture procedure.Mobility: Some elderly patients have difficulty walking or getting into or out of a chair. Using a chair that is an appropriate height so that the patient can safely get in and out of it will make it easier for the patient. Geriatric patients may also be unsteady on their feet. In such situations, the phlebotomist should react appropriately and walk alongside the patient, if necessary, to ensure patient safety.Veins: The veins of an elderly patient may appear to "roll" when venipuncture is attempted. The vein is not actually moving, but rather the muscles surrounding the vein have lost tone and the vein is not as stable as in a younger patient. Therefore, the phlebotomist must anchor the vein firmly and securely when attempting venipuncture. Skin: Skin may become thin and "papery" with advanced age. The phlebotomist must apply firm and prolonged pressure after venipuncture to prevent bruising. Use a bandage with a gentle adhesive to ensure stoppage of bleeding and promote skin integrity. Health concerns: Some elderly patients take medications that could affect their bleeding or their balance. Be aware that these patients may require extra attention and time. Keep in mind, not all elderly patients experience hearing loss. Thus, the phlebotomist should not assume the patient is hard of hearing and shout at the patient while speaking to them. Most often, the patient will tell you to speak louder if they are unable to hear you.

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Reducing Pain for Pediatric Patients

There are some commercial products available that are designed to alleviate pain from venipuncture.Cream: A topical cream can be applied to numb the venipuncture site. Apply well in advance to be effective. Always refer to manufacturer's instructions before use on patients. Be certain to determine that no allergy exists before using the product on a child.Mechanical device: A mechanical device can be used to stimulate nerves surrounding the venipuncture site to numb the site. This device must be used according to the manufacturer's instructions.Vein Viewer: This device enables the phlebotomist to determine the flow of blood thereby identifying the presence and direction of a vein. This device does not aid during palpation of the vein to determine vein health, diameter or depth.

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Hints For Successful Pediatric Venipuncture

While pediatric phlebotomy can be challenging, these guidelines can contribute to success.Communication: Always be honest with the child. Never lie to a child and say that it won't hurt. If asked by the child if it will hurt, you could explain that it may feel like an insect bite or it may sting, but if he/she holds really still, it will be over very soon.Correct hold of child: Ask the parent or guardian to assist. If you have determined that the child's parent is willing and able to assist throughout the procedure, have the child sit on the parent's lap . The parent can gently "hug" the child in a way to limit the child's movement and stabilize the arm that will be used for venipuncture. Alternately, the child can lie on a bed or exam table. If the parent does not choose to help, ask for assistance from a coworker. Correct hold of the child's arm: A health care professional familiar with the procedure should assist by holding the arm that will be used for the blood collection. The holder should face the child and gently position the child's arm so that the arm is straight and palm facing up. Next, the holder should place one hand underneath the child's elbow grasping lightly yet firmly to stabilize the elbow. With the other hand, the holder should hold the child's hand firmly. This hold will help prevent movement of the arm, even if the child is moving his/her body. This hold also allows the phlebotomist easy access to the venipuncture site during the procedure. Distractions: At times, the phlebotomist may employ a technique to distract the child during the procedure. For example, to help the child keep still, tell the child that the only thing he/she can move is his/her eyelashes. This places the child's focus on moving only their eyelashes and before you know it, the procedure is done!

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Patients with Needle Phobia

The phlebotomist should always carefully observe the patient for clues that indicate the patient's mental and physical readiness for the procedure prior to performing a blood collection. This alertness must continue throughout the blood collection process. When the patient expresses needle phobia or a "fear of needles," it may help to offer strategies to help the patient get through the procedure safely. Sometimes, the anticipation of the needlestick may cause anxiety, and sometimes seeing the blood filling the tubes makes a patient uneasy.It may be helpful to engage the patient in conversation during the venipuncture to keep the patient's mind off the procedure. In some instances, the phlebotomist may seek assistance from a qualified associate to distract the patient with conversation or provide comfort and support by offering to hold the patient's hand. If this is an outpatient, your observations and questioning may lead you to conclude that the best solution is to have the patient lie down during the venipuncture procedure. Remember that the patient does have the right to refuse to have blood drawn and the phlebotomist should respect that patient right.

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Mentally and Physically Disabled Patients

The phlebotomist may encounter a patient with special needs due to physical and/or mental limitations. In these situations, the phlebotomist should assess the needs of the patient and employ others to assist if necessary.For patients that do not understand you when you try to explain the procedure, the patient's caregiver can be asked to assist by helping explain the procedure to the patient in terms that the patient will understand. The patient's caregiver is someone who the patient trusts and someone who knows how the patient will react. The phlebotomist should be as non-threatening as possible when communicating with special needs patients.For a patient with physical disabilities, the phlebotomist should try to modify the environment to accommodate the patient's needs. This may include lowering or heightening the draw chair to accommodate patient height and/or size. If the drawing room environment does not sufficiently accommodate the patient's needs, the phlebotomist should seek out a more appropriate location within the facility, if available.

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Language Barriers

Most health care facilities serve a very diverse population of patients. In everyday practice, the phlebotomist may encounter patients whose primary language is not English, who speak no English at all or who are unable to speak at all. A language barrier should not interfere with providing excellent service to the patient.The phlebotomist often has several options to effectively communicate with patients who speak a language other than what the phlebotomist speaks and understands.OptionAdvantageDisadvantageCommentProfessional Medical InterpreterMany healthcare facilities have staff interpreters who are always availableNot all languages/dialects are availableIt is best to use the professional interpreter when availableTelephone language line; telephone with 2 receiversTrained interpreters in any language are available 24/7Telephone must be moved to patient room; must pay for this serviceAny language in the world is available; professional interpretersStaff member fluent in languageFamiliar with medical procedures and facility policyNot always readily available; unable to perform other duties while interpretingFamily memberOften readily availableInaccurate interpretation of information; HIPAA violations possibleIt is not advisable to use family members as interpreters; children may have to inform parents of unfortunate newsThe phlebotomist should be encouraged to use an interpreter rather than point, push or pull a patient for compliance. Many local schools and universities offer specific short courses for medical professionals in languages such as Spanish or American Sign language.The use of a professional service, either in person or via phone, is the preferred choice.

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Cultural Diversity and the Phlebotomist

It is very important for phlebotomists to recognize and respond appropriately to cultural differences they encounter during performance of their job duties. Patient-centered care includes respecting the patient. If necessary, procedures should be adjusted to accommodate cultural customs, keeping in mind that patient safety must be maintained. For example, in some cultures, the male is the spokesperson for the female members of the family. If this is the case, the female patient may not speak directly to a male health care worker. This may pose a challenge to the phlebotomist when positively identifying the patient prior to venipuncture. The male may verbalize answers to all of the phlebotomist's questions but the phlebotomist must adhere to precise identification procedures. The phlebotomist, while respecting the patient's cultural customs, must be sure that accurate patient identity is established.

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