Venipuncture Information and Courses from MediaLab, Inc.

Venous BloodVenous blood is deoxygenated blood that flows from tiny capillary blood vessels within the tissues into progressively larger veins to the right side of the heart. Venous blood is the specimen of choice for most routine laboratory tests. The blood is obtained by direct puncture to a vein, most often located in the antecubital area of the arm or the back (top) of the hand. At times, venous blood may be obtained using a vascular access device (VAD) such as a central venous pressure line or Hickmann Catheter or an IV start. Most laboratory reference ranges for blood analytes are based on venous blood.Arterial BloodDeoxygenated blood is pumped from the right side of the heart to the lungs where it takes up oxygen. The now oxygenated blood is pumped through the left side of the heart via arteries.The most common reason for collection of arterial blood is the evaluation of arterial blood gases. Arterial blood may be obtained directly from the artery (most commonly, the radial artery) by personnel who are trained to perform this procedure and are knowledgeable about the complications that could occur as a result of this procedure. Arterial blood may also be obtained from a vascular access device (VAD) inserted in an artery such as a femoral arterial line or Swan-Gantz catheter. Capillary BloodCapillary blood is obtained from capillary beds that consist of the smallest veins (venules) and arteries (arterioles) of the circulatory system. The venules and arterioles join together in capillary beds forming a mixture of venous and arterial blood. The specimen from a dermal puncture will therefore be a mixture of arterial and venous blood along with interstitial and intracellular fluids.Capillary blood is often the specimen of choice for infants, very young children, elderly patients with fragile veins, and severely burned patients. Point-of-care testing is often performed using a capillary blood specimen. Specimen Type Method of Collection Common Use Venous Direct puncture of vein by venipuncture; vascular access device Routine laboratory tests Arterial Direct puncture of artery; vascular access device Arterial blood gases Capillary Dermal puncture of fingertip or heel Infants and young children Elderly patients with fragile veins Severly burned patients Point-of-care testing

There are some instances where a dermal puncture is prohibited or not recommended.Mastectomy patientsAs a general rule, a dermal puncture, or a venipuncture, should not be performed on the side affected by a mastectomy. The body's ability to fight infection is compromised if lymph nodes were removed. A physician's permission must be obtained before performing a blood collection procedure on the same side as a mastectomy. Edematous siteDermal punctures should not be performed on previously punctured sites or swollen sites. Excess tissue fluid may contaminate the specimen.Dehydrated patientIf the patient is dehydrated or has poor circulation, it may be impossible to get a quality specimen. Fingerstick on a newborn or young infant Dermal punctures must never be performed on the fingers of a newborn or very young infant (usually defined as under 12-months-old). There is very little distance between the skin and the bone. Therefore, the bone could be easily pierced during the puncture, causing injury to the bone, infection, or gangrene.

Pre-analytical variables are those that affect the specimen before the actual testing begins. Some of the pre-analytical variables to consider with molecular testing include those that are applicable to all clinical specimens but should be emphasized when discussing molecular methodologies. Some of these include but are not limited to:Receipt of valid orderProper patient identificationProper venipuncture procedure for blood collection Use of correct anticoagulant Collection of correct specimen type (eg - plasma, serum, whole blood)Order of drawProper storage Proper transportProcedures if there is a delay in testing and/or transport

A technologist performs a venipuncture for glucose testing on the wrong patient. This medical error leads to the patient receiving an incorrect dose of insulin and the patient goes into a coma--this medical error led to an adverse event. Analysis without RCA: Determines the technologist should have checked the patient's wristband (the immediate reaction). Questions why the technologist did not also verbally identify the patient (the subsequent reaction). Restates these reactions (in the internal follow-up review). Misses causes discoverable by a detailed and open investigation.Analysis with RCA: Includes descriptions of events leading up to a "wrong person procedure" in its reports. Describes 17 separate errors identified in the follow-up investigation. Recommends actions that should avoid reoccurrence of the error.

Excessive bleeding after a venipuncture can occur as a preventable or an unpreventable adverse event. Laboratory professionals might or might not have control over this situation because of the factors involved. For example: Bleeding due to failure to apply immediately pressure on the venipuncture site is a preventable adverse event. Bleeding due to later injury to the venipuncture site is an unpreventable event. Circumstances that cause the bleeding determine whether it is a preventable or unpreventable adverse event.

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.

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.

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.

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

Two examples of butterfly needles with built-in safety devices are shown.The Punctur-Guard™ (Bioplexus), shown above, uses an internal blunt needle which is activated after blood is drawn. The activated device showing the blunt internal needle is shown in the inset on the upper right. The Angel Wing ™ (Monoject), is activated by sliding a safety shield over the needle after venipuncture.

Multiple draw needles are used with vacuum collection tubes.They allow the collection of blood into multiple vacuum collection tubes during a single venipuncture. They have a retractable sheath over the portion of the needle that penetrates the blood tube.

Use an isopropyl alcohol swab to clean the site.Move the swab in an outward expanding spiral starting with the actual venipuncture site.

Basic equipment must be in close proximity to the venipuncture site for easy access.

You may now hold the patients arm below the venipuncture site.Pull the skin below the vein to anchor it and keep it from rolling.

If possible, use the fourth (ring) finger or the middle finger.Many patients prefer that you use fingers on their nondominant hand. Choose a puncture site near the right or left edge of the finger tip.Clean the site as you would for routine venipuncture.

Clean the venipuncture site with alcohol to remove all the iodine from the patients arm, then apply a bandage.

Rarely, patients will faint during venipuncture.It is therefore important that patients are properly seated or lying in such a way during venipuncture so that if they do faint, they won't hurt themselves.A typical fainting spell is self-limited, and the patient usually "comes-to" in a few minutes or less.

The needle may not be in a vein. Try slightly manipulating the needle. If no blood flows, withdraw the needle and repeat the venipuncture. Never probe the patient's arm with the needle. The bevel of the needle may be compressed against the inside of the vein wall. Slightly manipulating the needle should result in blood flow. The needle may have passed entirely through the vein. Pull it back slightly, and blood should flow.

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.

Collect the blood specimen next, if required.Be sure to use the iodine swab provided in the collection kit to disinfect the venipuncture site.Do not use an alcohol swab, as this might lead to suspicion of a falsely elevated blood alcohol result.

A study that was published in 2002 concluded that 68 - 87% of laboratory errors occur in the preanalytic and postanalytic stages of the testing process with the majority occurring in the preanalytic phase.* Steps in the pre-analytic phase occur both inside and outside the laboratory, and are performed by both laboratory and non-laboratory personnel. While the following list is not exhaustive, some of the most common sources of error in the preanalytic phase include:Patient preparation Patient not told to be fasting; improper or no instruction to patient on proper collection of specimen such as clean catch urine. Patient injured during phlebotomy Development of hematoma resulting in no specimen obtained for testing. Requisition errors Patient information missing, illegible, or on wrong patient; wrong tests ordered. Patient identification Patient incorrectly identified. Labeling of specimen Specimen not labeled or incorrectly labeled. Preparation of specimen Specimen centrifuged too long or not long enough; specimen placed in improper preservative.Storage of specimen Specimen not refrigerated or frozen as required or refrigerated when it should be at ambient temperature. Shipment of specimen Shipped at ambient temperature when it should have been shipped frozen; delay in shipment. Accessioning process including preparation for analysis Sorted into wrong batch; incorrect labeling. Order entry Incorrect data entered during manual entry of a test requisition. Specimen sub-optimal Not enough specimen for testing; visible hemolysis. Contamination Inadequate cleansing of venipuncture site resulting in contamination during blood culture collection. *Reference: Bonini P, Plebani M, Ceriotti F, Rubboli F. Errors in laboratory medicine. Clin Chem. 2002;48:691-698. Available at http://www.clinchem.org/cgi/content/full/48/5/691#T2BAccessed June 23, 2010.

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 healthcare professional that has been trained to perform this duty. In this course, we will refer to the person performing the venipuncture as the phlebotomist.

A key element for successful venipuncture is choosing the best vein. To determine the best vein, use both sight and touch. Remember -- the first vein found is not always the best vein. Take enough time to assess the vein before beginning the venipuncture procedure.

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.

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.

Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays; Approved Guideline. Fourth ed. CLSI document H21-A4. NCCLS. Wayne, PA: 2003.Clinical and Laboratory Standards Institute (CLSI). Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard. Sixth ed. CLSI document H3-A6. NCCLS. Wayne, PA: 2007.Clinical and Laboratory Standards Institute (CLSI). Procedures for the Handling and Processing of Blood Specimens; Approved Guideline. Third Edition. CLSI document H18-A3. NCCLS.Wayne, PA: 2004.Ernst DJ. Applied Phlebotomy. Baltimore, MD: Lippincott Williams & Wilkins: 2005.Lowe B. Reinforcing safety sticklers. Advance for Medical Laboratory Professionals. May 2004; 16:2A-3A.The Joint Commission. National Patient Safety Goals. Available at: http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed July 2, 2012.

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.

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.

Before attempting a venipuncture, the phlebotomist should assess a vein by palpation. Palpating the vein increases the chance of a successful venipuncture. 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. The phlebotomist uses palpation to assess the depth, width, direction and health (resilience) of a vein. When determining a vein suitable for venipuncture, the skilled phlebotomist relies more on touch or feel than on sight. Looking away from the vein while palpating will help the phlebotomist perfect the skill of palpation leading to good vein assessment. The image on the following page illustrates the considerations for vein assessment.

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. .

Check for any special handling requirements. For example, should the specimen be placed on ice or protected from light? Make certain to enclose all specimens in biohazard bags or designated containers if they will be transported.

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.

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.

Clinical and Laboratory Standards Institute (CLSI). Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard. 6th ed. CLSI document H3-A6. Wayne, PA: CLSI: 2007.Clinical and Laboratory Standards Institute (CLSI). Procedures and Devices for the Collection of Diagnostic Capillary Blood Specimens; Approved Standard. 5th ed. CLSI document H4-A5. Wayne, PA: CLSI: 2004. Clinical and Laboratory Standards Institute (CLSI). Procedures for the Handling and Processing of Blood Specimens; Approved Guideline. Third Edition. CLSI document H18-A3. Wayne, PA: CLSI: 2004.Ernst DJ. Applied Phlebotomy. Baltimore, MD: Lippincott Williams & Wilkins: 2005.

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.

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.

Collecting a blood specimen from a pediatric patient can be very challenging. There are several factors that contribute to this challenge. For example:The veins of a young child are typically much smaller than those of an adults. Often a child has never had the procedure before. Fear of the unknown can increase anxiety and cause the child to struggle. Unfortunately, some adults use health care professionals as "threats" for children. This can also increase anxiety. A child may have had a previous bad venipuncture experience and is now combative. Professional phlebotomists have empathy for all patients, but often, knowing that they may be hurting a small child, even slightly, can trigger emotions that interfere with a successful procedure.

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.

Stop and Think ! You work in a large hospital that specializes in pediatrics. The policy of the facility is to encourage the parent or guardian to remain in the room during venipuncture to comfort the child. You have taken steps to prepare the child for the venipuncture, but the child starts to cry and becomes combative. The mother says that she does not want the test done. What should you do?Consider how you would handle this or a similar situation before proceeding to read the suggested solution on the following page.

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.

Possible means of blood component bacterial contamination involve the blood donor, the collection process, the collection pack, and blood processing. Most bacteremic people are symptomatic and would not be accepted as donors. In the United States, a person cannot donate if their temperature is higher than 37oC. Sometimes a donor may be in an incubation period or in the recovery phase of bacterial infection and this may lead to contamination of their blood products. Most of the organisms isolated from platelet concentrates are normal skin flora which entered the bag during venipuncture when skin is not disinfected properly. Some organisms may even remain viable on the skin after disinfection. The donor's skin may also contain unusual pathogens. Clostridium perfringens was linked to a donor who had recently changed a child's diaper. Blood bags can be contaminated on the outer surfaces. The bacteria can enter the unit at the time of blood donation either through suction into the needle or contamination of the phlebotomist's hands and then on the donor's skin. Contamination during blood processing can occur from thawing frozen products in a contaminated water bath. Bacteria can enter the unit through microcracks in the bags or through pooling.