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Phlebotomy Today

©2018 Center for Phlebotomy Education, Inc. All rights reserved.                                   


May, 2018


Journal Moderates Ernst-Lippi Tube Labeling Debate

Shutterstock_141660043Should blood collection tubes be labeled before or after filling? What seems like a simple question with a simple answer has been the subject of a raging international debate between two of the industry's most respected authorities and their respective camps. Recently, the debate was moderated in print by the editor of Annals of Blood.

Taking the pre-collection labeling side are Dr.s Giuseppe Lippi and Mario Plebani, two of the most prolific researchers in the world of preanalytics, both based in Italy and members of the International Federation of Clinical Chemistry and Laboratory Medicine's Working Group on Laboratory Errors and Patient Safety (WG-LEPS).

Arguing for post-collection labeling only are three equally prolific authors: international lecturer and Director of the Center for Phlebotomy Education Dennis J. Ernst MT(ASCP), NCPT(NCCT), George Fritsma, MS, MLS, purveyor of the Fritsma Factor, Your Interactive Hemostasis Resource, and David McGlasson MS, MLS(ASCP), a clinical research scientist for the United States Air Force.

In the November, 2017 issue of the Annals of Blood, the Lippi team's position was strongly stated, primarily because automated tube-labeling equipment now exists that can only label empty tubes. They also describe automated systems as being effective in reducing blood collection errors. Such devices, they claim, can print the order of draw to be followed on each label, the minimal draw volume for the tests requested, and the appropriate transport temperature. The list three organizations that advocate precollection labeling, the World Health Organization, The Italian Society of Clinical Biochemistry and Clinical Molecular Biology, and the European Federation of Clinical Chemistry and Laboratory Medicine. [Editor's note: read my column for further insight.]

In the February 2018 issue, Ernst et al made their case for post-collection labeling. The major objection for the authors is the potential for a tube to be labeled, but not used. Should the phlebotomist fail to complete the draw due to a fainting patient, withdrawal of consent, or difficult draw, the only thing preventing the tube from being used on another patient is for the phlebotomist to remember to throw it away. The authors argue strongly against adding another error point to an already error-prone procedure. They also hold firmly that when technology is developed that defies the prevailing standard, such as prelabeling instrumentation, the standards are not obligated to change so that the technology can prevail, especially when it introduces threats to patient safety. 

Annals of Blood editor, Dr. Emmanuel Favaloro discussed both positions in the April issue, stating he has no strong feelings one way or the other. He highlights the fact that no study has found either to be more effective in reducing labeling errors, and calls for a double-blind study to assess the respective error rates of each process. However, he observes such a study would be difficult since those involved in each study group would know which process they are participating in by the timing of the label's application to the tube. \

This issue  is likely to remain contested for the foreseeable future. Those who work where CLSI standards dictate the protocol will continue labeling only after the tubes are filled. To do otherwise, and who mislabel a sample, would have a difficult time explaining why the prevailing standard was violated. Likewise for those who work where the protocol is to label before collection. Regardless of the prevailing standard, any discussion on the right or wrong way is irrelevant whenever the tube is labeled correctly.

[Editor's note: read my column, "From the Editor's Desk,"  for further insight into this ongoing debate.]


Workpath: Improving the Phlebotomy ExperienceWorkpathScreenshot

This month's featured sponsor is Workpath.

As phlebotomists, you're at the front line of healthcare. The majority of medical decisions begin with a blood draw. But here's the challenge: some of the most valuable professionals in healthcare are forced to spend more time wrestling with scheduling and communication mishaps than they are delivering the critical skills they offer the medical community.

Healthcare specialists today, beginning with phlebotomists, regularly contend with a patchwork system of communication -- phone tag, email chains, and spreadsheets, just to name a few. Workpath, a healthcare technology company that solves the complexities of mobile workforce management, has created a better way.

"It's time that we say goodbye to outdated and fragmented ways of organizing specimen collection appointments," says Eddie Peloke, CEO of Workpath. "Workpath has built intelligent technology that helps phlebotomists accept available appointments, manage their schedules, and track their draws all on one platform."

Workpath is an all-inclusive platform that phlebotomy groups can use to digitally create appointments, automatically dispatch team members to appointments, and send automated messaging to patients to keep them informed. In addition, Workpath increases a phlebotomy team's efficiency by providing every phlebotomist with their agenda, GPS navigation to appointments, appointment details, and appointment protocols.

"Workpath not only improves the back-office process and support for a phlebotomy company, but proactively tackles customer support to ensure that patients have the best possible experience," says Peloke.

The Workpath API integrates with existing systems, like EHRs and other internal technology platforms, to create a seamless workfow for phlebotomists, phlebotomy labor providers, and other healthcare organizations offering specialized services. As an award-winning healthcare tech company, Workpath is on a mission to make the life of anyone involved in phlebotomy easier and more efficient so they can focus on creating better collection experiences.

For an independent phlebotomist, Workpath offers the ability to manage your schedule on a mobile app, access procedure intelligence to gain insights into the protocols for every specimen collection, and the ability to easily locate your patients at any time. The service request form provided by Workpath serves as a tool to take orders from a doctor, patient, or anyone. Phlebotomists can simply pass their unique link (placed on business cards, a website, etc.) and have orders come directly to their account.

For phlebotomy staffing agencies, Workpath helps dispatch, manage, and track their mobile workforce. The growing platform offers phlebotomy organizations the ability to grow their business through service request forms and to assign phlebotomy appointments with a click, on any device. In addition, phlebotomy businesses can easily manage an entire network and track who's doing what, access finance reports to invoice clients, perform background checks, automate messaging to patients, and keep one concise audit record of all appointments.

Workpath is currently offering one free month to any phlebotomy group or individual phlebotomist who signs up in May and references this Phlebotomy Today article to see firsthand how the platform serves as a competitive advantage and improves patient experience.

Learn more at www.workpath.co, sign up for a free demo, and engage with Workpath to help make specimen collection, and other forms of mobile care services, better for everyone involved.


Standards Update: Circular cleansing

The newly revised venipuncture standard released by the Clinical and Laboratory Standards Institute in April, 2017 is the most comprehensive revision in the document's history. With over 140 new mandates, facilities have a lot of changes to implement. This series discusses one or more substantive changes each month.

CirclularCleansingAlmost every phlebotomy trainer and educator teaches the meticulous practice of cleansing a venipuncture site in concentric circles of increasing diameter. If that includes you, it's time to abandon the practice. The standards no longer require it, not even for blood culture collections.

Where the origins of this technique came from is unclear. Even though the CLSI venipuncture standard has made it a requirement for 38 years, the passage has never been referenced. That's probably because no study has ever proven, or even attempted to prove, that circular cleansing prepares a venipuncture site any better than random, directionless friction. Since it is not an evidence-based practice, the CLSI committee revising the 7th edition of the popular standard removed it as a requirement. 

"We didn't remove it just because it wasn't evidence-based," says committee Chairholder Dennis J. Ernst MT(ASCP), NCPT(NCCT). "We removed it because we found reliable peer-reviewed sources that said back-and-forth friction was more effective." Those sources, referenced in the new standard, include Infection Control Today the Critical Care Nursing Quarterly, and the American Society of Microbiology's Cumitech 1C

GP41_cover_400wThe most common word-of-mouth rationale for concentrically circular cleansing seems to be based on the movement of organisms away from the center of the site towards the periphery. "The prevailing explanation for circular cleansing is that, by starting in the center with the antiseptic and moving outward, the bacteria on the skin is 'pushed away' from the center where the puncture will take place," says Ernst. "Perceptually, the center would then seem to have fewer organisms than the periphery, since the applicator never comes back to the center where the needle will be inserted.

"However, if you think about it, any organism that comes in contact with the antiseptic, whether it's an alcohol pad or chlorhexidine scrub, will be denatured or killed, respectively. It's not the pushing out that prevents site contamination, it's mere contact with the antiseptic, which takes every organism out of the picture no matter what direction you apply it."

The current CLSI venipuncture standard now simply states friction is required when cleansing sites, and calls attention to the studies that have found a back-and-forth pattern to be more effective.

Editor's note: Readers are urged to obtain their own copy of the standard as soon as possible and begin implementing all new provisions immediately. The document, Collection of Diagnostic Venous Blood Specimens (GP41-A7), is the standard to which all facilities will be held if a patient is injured during the procedure or suffers from the consequences of an improperly performed venipuncture. It can be obtained from CLSI or the Center for Phlebotomy Education, Inc.

 


Product Spotlight: Preanalytic Errors & Potassium DVD

PotassiumDVD_900wPotassium is the one laboratory test more effected by preanalytical errors than any other. When your physicians don't trust your potassium results, everything else is called into question. Does your lab have a credibility crisis?

Potassium Results Your Physicians Can Trust, a DVD from the Center for Phlebotomy Education, discusses how this analyte can be (and often is) altered by those who draw and process blood samples. Over a dozen preanalytical errors affecting potassium in the samples labs test, plus a multitude of patient-dependable and drug-induced variables, are discussed in this highly researched video. The objective: to help those who draw blood samples---and their supervisors and educators---to prevent the process of drawing and handling blood samples from changing the result before they're even tested.

Because improperly drawing and handling blood samples can lead physicians to over or under-medicate, misdiagnose and mismanage their patients with disastrous consequences, Potassium Results Your Physicians Can Trust is a must-see for everyone who touches a blood sample. 

"Potassiums altered during sample collection, transport and processing pose a serious threat to the quality of care every patient receives," says Dennis J. Ernst MT(ASCP), NCPT(NCCT) who produced and narrated the video. "Patients with critically low potassium levels get reported out as normal and go untreated while patients with normal levels get treated for falsely elevated values." 

Some of the preanalytical errors discussed in the video include:

  • sample storage and transport temperatures;
  • centrifuging specimens twice;
  • prolonged tourniquet constriction;
  • pouring the contents of EDTA tubes into tubes to be tested for potassium;
  • inadequate centrifugation;
  • fist-pumping;
  • filling tubes in the wrong order.

The 43-minute video includes access to an online exam for in-house use and to obtain P.A.C.E. CE credit.


Watch a preview and get more information.


Phlebotomy Errors and Their Impact on Patient Care

  • PotassiumTile_transparentYou know that you shouldn't leave the tourniquet on longer than one minute, but do you know what can happen to your patient if you do?
  • You know you should draw a discard volume when drawing through an IV line, but do you know how it can affect the care your patient receives?
  • You know you shouldn't underfill tubes, but do you know what it can do to your patient?

 Most phlebotomists and other healthcare professionals with blood collection responsibilities know the do's and don't's of drawing blood, but not everyone knows why the procedure must be followed exactly as they were taught. As a result, there's a disconnect between cause and effect that leads healthcare professionals to underestimate the importance of every standardized detail when drawing blood samples for clinical testing. Without a thorough understanding of why certain details of a venipuncture or skin puncture must be followed, the missing can't prevent a modification that can profoundly impact not only their patient's care and safety, but their own well-being.

You may know the how, but do you know the why?

Take time to review some of the most common blood collection errors in the chart below and the ultimate consequences they can have on patients. By connecting the dots from a self-styled deviation to the potential impact it can have on the patient, you'll gain a better understanding of why you do what you do, and why you shouldn't do what you shouldn't. 

Blood Collection Errors
that Alter Test Results

Potential Consequences to Patient

Failure to properly identify the patient

Transfusion- or medication-related death.

Patient mismanagement due to being treated according to the results of another patient.

  • Failure to properly cleanse site for blood culture collection
  • Repalpating a site cleansed for blood culture collection
  • Failure to allow antiseptic time to take effect prior to blood culture collection.

Unnecessary administration of antibiotic & extended length of hospitalization due to false-positive blood culture.

Prolonged tourniquet application beyond one minute

  • Seizure, death, & patient mismanagement due to falsely elevated potassium* level.
  • Patient mismanagement due to temporary elevation of albumin, calcium, RBC count, hemoglobin, and hematocrit.
  • Patient mismanagement due to temporary decrease in WBC count and differential.
  • Hypovolemia, anemia, and death if hemoconcentration obscures diagnosis and condition goes untreated.

Patient allowed to pump fist

Seizure, death, patient mismanagement. Fist pumping significantly increases potassium* and ionized calcium levels in blood being drawn.

Underfilling coagulation tube

Stroke due to unwarranted decrease in blood thinner dosage necessitated by falsely prolonged coagulation times.

Underfilling EDTA tube

  • Patient mismanagement/misdiagnosis from falsely decreased hematocrit and MCV.
  • Unnecessary transfusion.

Underfilling heparin tube

Patient mismanagement/misdiagnosis from altered potassium, sodium, ALT, AST, amylase, and lipase results.

Underfilling blood culture bottles

Death from septicemia due to false-negative result.

Failure to properly mix tubes

Patient mismanagement due to delays when anticoagulated tubes contain clots and must be recollected.

Incorrect order of draw

  • Seizure and death from potassium carrying over from EDTA into tube to be tested for K+.*
  • Medication errors when additives carry over into coag tubes, falsely lengthening coagulation times and leading to unwarranted and life-threatening medication adjustments.
  • Unnecessary antibiotic administration and prolonged hospitalization due to contaminated blood cultures.
  • Vigorous mixing samples
  • "Milking" the site of a capillary puncture
  • Improper needle placement
  • Pulling excessively on the plunger of a syringe
  • Line draws
  • Prolonged tourniquet application
  • "Rimming" clot tubes during processing            

Seizure, death, medication errors, and patient mismanagement should these practices hemolyze samples causing the contents of red cells to be released into serum/plasma. Hemolysis falsely lengthens prothrombin times and elevates the reported levels of potassium,* LDH, AST, ALT, phosphorous, magnesium, and ammonia. Hemolysis falsely shortens aPTT times and decreases RBC counts, fibrinogen, and hematocrit.

Specimen drawn above IV

Death, medication errors, & patient mismanagement due to contamination by IV fluids of samples tested.

Inadequate discard volume drawn when collecting blood through vascular access device

  • Stroke/hemorrhage due to modification of blood thinner dosage based on inaccurate coagulation results.
  • Medication errors due to contamination.
  • Patient mismanagement from altered results.

Failure to properly label the specimen

Transfusion- or medication-related death, and patient mismanagement due to being treated or transfused according to the results obtained from another patient's blood.

Failure to label the specimen at the patient's side

Transfusion- or medication-related death, and patient mismanagement due to being treated or transfused according to the results obtained from another patient's blood.

Pouring contents of one tube into another

Patient mismanagement/misdiagnosis & medication errors based on altered results, especially potassium.* Stroke/hemorrhage due to unwarranted modification to blood thinner dosage.

Drawing timed specimens at the wrong time

Patient mismanagement/misdiagnosis & medication errors.

Delays in drawing blood cultures based on fever spike

Septicemia, death. Since fever spikes  ?? 30 minutes after bacterial shedding into the bloodstream, any delay in fever-based blood culture collections limits the ability of the laboratory to grow and identify the causative organism in a timely manner.

Chilling/refrigerating samples to be tested for potassium prior to centrifugation

Seizure, death, patient mismanagement due to falsely elevated potassium level.*

  • Tubes not centrifuged properly;
  • Gel tubes centrifuged twice;
  • Centrifuging tubes with stoppers removed.

Seizure, death, patient mismanagement due to falsely elevated potassium levels from platelets and/or red cells remaining in serum or plasma.* 

Delay in transporting/testing coagulation specimens

Stroke caused by unwarranted modification to blood thinner dosage based on inaccurate aPTT result.

Transporting sodium citrate tubes on ice

Hemorrhage, death, medication errors. Cold activation of Factor VII causes a falsely shortened prothrombin time, which may mislead the physician into increasing blood thinner dosage.

Delay in centrifuging samples to separate serum from cells

Seizure, death, patient mismanagement. Prolonged serum/cell contact causes a falsely elevated potassium level to be reported.* Other analytes affected include glucose, LD, phosphorous, creatinine, folate, vitamin B-12, ALT, AST, and ionized calcium.

Specimen not protected from light

Newborn suffers irreversible brain damage because bilirubin deterioration leads to falsely lower result, which prevents physician from ordering phototherapy.

*Patients whose reported potassium levels are falsely elevated (pseudohyperkalemia) are at risk whether their reported value is in the normal range or elevated. Actual potassium levels that are below normal (hypokalemic) but falsely elevated into the normal range by collection errors may be inappropriately cleared for surgery due to the "normalizing" of their potassium. Such patients are at risk for seizures and other complications when subjected to anesthesia. Other hypokalemic patients whose potassium levels are falsely elevated into the normal range may require rapid intervention, but go untreated. Such patients are at risk for developing cardiac arrhythmia. Patients whose potassium levels are actually normal but reported as elevated (hyperkalemic) due to collection errors may be treated for a high potassium level unnecessarily.

  Center for Phlebotomy Education. All rights reserved

 

[Editor's note: The Center for Phlebotomy Education has developed Blood Collection Errors and Their Impact on Patients, a 20" x 28" laminated poster containing this and much more information for managers to display in their facilities to facilitate their staff's understanding of the impact preanalytical errors have on patient care.]


Preanalytical Summit Taking Early-bird Registrations

 

Summit_2018_framed


From the Editor's DeskDE_grayscale_411w

I had the distinct pleasure recently of leading a small team of high-profile lab leaders---real movers and shakers in the laboratory industry---to write an opinion piece for the Annals of Blood. The issue: when should blood samples be labeled, before or after they are filled? I've summarized the arguments earlier in this month's issue, but I think you'd enjoy hearing the back story.

I'm no stranger to this dispute. As chairholder of the CLSI committee that recently revised the standard by which blood should be drawn for clinical testing, my committee was challenged to allow for tubes to be labeled prior to filling, breaking 27 years of precedent. It seemed healthcare professionals in some European countries routinely label tubes before they are filled as a matter of national policy (Sweden) or tradition (Germany). Since the standard my committee was revising was a global standard, it was a reasonable request.

At the end of the day, my committee's decision was unanimous: blood tubes must only be labeled after they are filled. 

While all this was playing out, the European Federation of Clinical Chemistry and Laboratory Medicine's Working Group on Preanalytics (EFLM-WGP) published a "call for harmonization" on the issue. I have engaged in a passionate but respectful discourse with EFLM-WGP representatives on the topic over the years; we've agreed to disagree. So I've heard all the arguments, which is why I embraced the opportunity to lead coagulation gurus George Fritsma and David McGlasson in writing the post-collection labeling position for Annals of Blood

Our first draft presented a compelling and passionate argument with plenty of references to back up our claims. I was more than a little stunned when it came back from the editor with a request: Revise it without the passion.

Without the passion? This is an opinion piece! I might be able to have a dispassionate opinion about my favorite flavor of ice cream (blue moon), but we're talking about a change in a medical procedure here that can precipitate serious medical mistakes. Mistakes that can even lead to patient death. Anyone who can write an opinion on such a matter without passion has no business writing it in the first place. Passion is required on such things. I was totally flummoxed.

But I got over it. We removed most of our "passion," but we admit it wasn't easy. After submitting a toned-down article, my coauthors and I all agreed it was a solid, albeit emotionless, position paper. The editor accepted it, and we all awaited the publication of the opposing view. It was released in November, equally devoid of passion. Not surprisingly, the authors misinterpreted the World Health Organization's Guidelines for Drawing Blood: Best Practices in Phlebotomy, Those who favor pre-collection labeling do so routinely. But if you look at page 19 in the WHO guideline, its step-by-step instructions on drawing blood from adults for laboratory testing shows the tube-labeling step as coming after the tube is filled. The sequence is repeated on Page 39 for pediatric draws, solidifying proof of the WHO's position. Only for blood donor draws does the WHO (oddly) suggest labeling tubes prior to filling. Therefore, if one were to say the WHO favors pre-collection labeling, they would be technically correct, but misleading, since the organization does not hold that position for diagnostic sampling. So we were not terribly surprised when our Annals counterparts claimed the WHO agrees with their position. But we were surprised the moderator let them slide.

Those who argue for pre-collection labeling also often claim the support of  two other European organizations: the European Federation of Clinical Chemistry and Laboratory Medicine, and the Italian Society of Clinical Biochemistry and Clinical Molecular Biology. That sounds pretty impressive until you scratch the surface and find those who are making the claim typically hold positions of significant influence with the same organizations. In reality, no scientific organization on the face of the earth thinks pre-collection labeling is a good idea.unless they have ties to those who claim their support.

I only call these things to your attention because this issue will not likely ever be resolved. In a world where it seems increasingly acceptable to package half-truths, and sometimes blatant misrepresentations, in hopes they will become blindly accepted by the masses as fact, I feel I need to call it out when I see it. My readers depend on the Center for Phlebotomy Education  to provide accurate information in all regards. To filter through the body of knowledge and present verifiable facts on all aspects of phlebotomy and preanalytic science. Whenever I can enlighten my readers as to the whole and complete picture, I feel it is my duty to do so.

The world will continue to label tubes differently and publications will continue to require careful reading and critical thinking. Since no study has shown precollection labeling reduces labeling errors or is safer for the patient, the rational to change a practice that has been the prevailing standard for nearly 30 years has to be beyond opinion. Even mine.

 

Respectfully,

Dennis J. Ernst MT(ASCP), NCPT(NCCT)
Editor


The Empowered Healthcare ManagerEmpoweredManagerWelcomeScreenShot_500w

Every month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager. 

Make Me Want to Work Here

Every time someone comes to you about a personal issue with another employee, it's a request for you to make her want to continue working for you.  It's easy to brush it off and go back to putting out other fires, but fatal to your workforce.

However petty, every interpersonal dispute brought to your attention is a thinly veiled plea for help. Your staff wants you to make their workplace a pleasant place to spend half (or less) of their waking hours every day. They want to be long-term employees, but desperately need your intervention. 

Whether that intervention is a mediation session or just a good scruffing of the offending party (who might even be the one complaining to you), it's a necessary management evil.  Deliver the intervention promptly and you'll find over time you'll have fewer fires to be distracted from. You'll also earn long-term employees. 

Make Me Want to Keep You

We've all heard the management mantra, "if they're worth keeping, they're worth correcting."  Every time you discipline or correct an employee, you are issuing a request: "make me want to keep you." Once issued, it's their decision whether or not to be retained. 

The corollary is just as true: "if they're not worth keeping, they're not worth correcting"... and vice versa.

Unfortunately, too many managers don't correct their staff and keep them anyway.  Choosing not to correct or discipline a member of your staff is giving up on ever leading that person to a better place, to more effective/efficient work, a more valued member of your team.  

Keeping someone you've given up trying to correct is accepting defeat, lowering the bar, and tolerating mediocrity. Would those who manage you do the same with you when they find out?

Subscribe to The Empowered Healthcare Manager blog.

 


What Should We Do?: Patient wants to select the vein

Standard on blocksDear Center for Phlebotomy Education: Since I'm subscribed to the newsletters and bought the Lab Draw book, I've been up to date with the changes in using the wrist area in the CLSI standard. I've had no problems following this change in most of my patients. However, last week a patient came in whose wrist is her best spot. We've never found anything in her antecubital, and she won't allow us to use her hands because of a previous bad experience. The last time she came in I told her I would no longer be able to use her wrist because it is against the standards. She gave me a VERY difficult time.

So I got her to let me draw from her antecubital, and was only successful because of the tips I've gotten from Phlebotomy Today, (prewarming her antecubital and using an alcohol prep pad to point to the vein), and she was singing my praises. However, she's going to push for a wrist draw every time. Throughout the draw, she tried to convince me that she would not sue me or tell on me and that I should draw from her wrist. She said she did her own research and did not find anything about the wrist being unacceptable. She's from Europe and feels that the change in the standards has to do with Americans being litigious, not necessarily what's in the best interests of the patient. I tried reassuring her that I've used many patients' hand veins without problems. 

My lab director doesn't feel as strongly as me about the wrist. He feels the AC is worse than the wrist when it comes to a nerve injury. He supports my right to choose, but also the patient's right to say what's done to her body. What should we do?

Our response: 

First of all, I sincerely appreciate your patient's concerns. She had a bad experience with hand veins. But she could have a bad experience with wrist veins soon if the site continues to be used. I think it's important for you to obtain the standard and show her the passage. The passage also needs to be reflected in your facilities procedure, which you can also show her. 

The passage was not inserted into the standards because the US is so litigious, but to protect patients from injuries. If there is no injury, there is no litigation. That's why there are standards, not to prevent lawsuits, but to prevent injuries. In the standards, my committee cites no fewer than 8 references supporting the passage against wrist veins.

Even though she insists she won't sue, you can't take the risk. People change their minds after they're injured. I can't agree with your manager, though, who said "people have a right about what happens to their bodies." With that logic, if the patient requested a puncture to the jugular vein, is it okay to draw there? Of course not. 

When patients challenge your choice of where to draw them, they are asking you to violate the standard of care. No patient has that right. If your facility allows this as a matter of policy, sooner or later a professional victim will show up, demand you draw from an unacceptable site or in an unacceptable way, and slap you with a lawsuit that is indefensible. Consider drug addicts. They're savvy and have a habit to finance. They know where the best sources of revenue are. Don't think some won't research what the standard says, get someone to deviate from it (like your manager),, fake an injury and cash in. Stranger things have happened.

This is not her right versus your right. She doesn't have the right to choose the site, especially when her choice violates the standards. Nor does your manager. You've done a magnificent job managing the customer service aspect of this without alienating the patient. I think your only path forward here is to continue resisting the wrist, show her documentation as to why it can't be considered, and draw from the AC, even if that means drawing from the basilic. It's not against the standards when there are no other AC veins. At the end of the day, the patient can choose to go somewhere else for her lab draws or allow you to draw from her hands. I think you should bring your risk manager into this discussion. He/she will certainly advise against allowing patients to dictate standards deviations. 

Got a challenging phlebotomy situation or work-related question? Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)  


 

Tip of the Month: Ten Tips for Halting Hematomas

Click here for this month's featured Tip of the Month from our rich library of archived Tips.