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The Dark Side of Phlebotomy
Last month we published a letter from a student about her phlebotomy clinical experiences. The techniques and lack of professionalism she experienced were appalling. So we wanted Phlebotomy Today—STAT! readers to share their horror stories, too. The response was overwhelming.
The most common observations of unacceptable phlebotomy practices include:
- Tearing the tip off the gloved finger
- Combining the contents of two tubes
- Using the same needle for multiple attempts on the same patient
- Disregarding the order of draw
Here are just a few anonymous accounts of life on the front lines of phlebotomy today.
“I have been asked by physicians and nurses to ignore lab protocols regarding identification and or specimen suitability. As a lab supervisor, I am responsible for teaching students and new employees about the proper procedures and following policies. I am horrified by the letter published, I would hope no one here could ever write an account like this about our facility. I do have to admit that there is gossip in the workplace, and this letter brought home how a new employee or student would think about that gossip. We can do better.”
“Fish the clots out of the EDTA tube used for a CBC.”
“I once worked in a small hospital where a phlebotomist told her supervisor that the SSTs were expired. The supervisor (also the supervisor of the chemistry dept.) told her to make sure the patient label covered up the expiration date.”
“I am happy to report that here in our facility that each of the staff treat each specimen as if it were our own family member. Excellent Care Every Patient Every Time.”
“No gloves, ripped-off glove tips, not wiping with alcohol enough or using circular motion, probing, not inverting tubes, pouring off anticoagulated blood into ‘serum’ tubes, you name it, we see it, and it is commonplace.
“An ER nurse called on nights saying he had drawn some blood for me and asked me to come to the department to get it. When I arrived he was sitting at the desk, mixing an unlabeled 20 mL syringe by inversion.”
“The patient needed a CBC, coags, and chemistries. It had been about six minutes since he had drawn the sample. He was not happy when I insisted the patient had to be redrawn, because, after all, he had been mixing it the whole time!”
“I have been told by a nurse that I have to draw from an IV arm with the saline still running. What was worse was that the patient was refusing to be drawn, but the nurses were attempting to hold him down against his will. I refused to do the draw.”
“On my first day as a trainee, my trainers were in such a rush to get all the rounds done that they ignored precautions for isolation patients. I brought this to the attention of my superiors, and I was told you don’t need to follow that protocol.”
“I was at our local hospital with my mother. The phlebotomist who tried to draw her blood gave up. She then left the room to go and get someone else without removing the tourniquet from my mother’s arm. I waited about 2 minutes then took it off. When she finally did return I told her that she had left the tourniquet on. She said, ‘Oh, I know. I was going to see if something popped up on her.’ I told her that it was unacceptable practice to EVER leave the tourniquet on a patient’s arm if she was not standing next to the patient. She just gave me a funny look and walked out.”
“In the beginning stages of my phlebotomy career, I was being trained at a new facility by a phlebotomist who had been at the facility for about a year. After we had left a patients room, I was asked to turn my back while she poured off from a SST tube to a lavender-top tube because she forgot to draw a CBC. It wasn’t a difficult decision to bring this to the supervisors attention for me, because I have always felt that my integrity is worth far more than popularity!”
“I have witnessed some phlebotomists drawing full SST tubes by fingerstick.”
“Phlebotomist not turning on lights in room to do early am draws. Wrist sticks and palm sticks regularly, even some foot sticks. Not ID-ing the patient until after the draw. Probing and leaving the tourniquet on too long. Arterial sticks when no other veins work. Covering for each other when a mistake is made. This was at a very nice suburban hospital, and management was aware of the shenanigans that went on. They just chose to look the other way because the phlebotomists had worked there a long time and if they took action their management satisfactions for bonuses might suffer. Disgusting!”
“1. Pouring two short-draw EDTA specimens together to make it look like enough sample 2. Pouring off the plasma from a PT tube so the testing personnel can’t tell it was a short-draw 3. Using wooden sticks to remove fibrin clots from SST tubes, then respinning the original tube to clear the serum 4. Labeling specimens after the patient has left the lab area 5. Performing a 2nd stick on a patient with the same needle apparatus used for the initial stick.”
“One of our senior phlebs at our hospital yells at everyone in the lab whether they’re students or employees for really no reason. People have quit/cried over her and they still keep her.”
“Interns especially using the same needle repeatedly when they miss the vein; tourniquets being left on for five mins. while staff look for things they didn’t prepare earlier; talking to other staff like the patient isn’t even there; not using gloves at all; staff having disputes in earshot of waiting patients; the list is horrifying and it goes on and I work in a major government-funded teaching hospital!”
“It is not unusual in establishments employing large numbers of phlebotomists to find a ‘bad apple’. To find as many as reported in the letter in one place indicates to me a situation of gross negligence on the part of the person responsible for employing and monitoring the performance of these people. It seems that bad practice is endemic in the establishment in question. I know that in my place of employment, any such behaviour would very quickly be brought to the attention of the supervisor/collections manager. I do believe that the behaviour as reported is rare. The report of the person assisting with ‘the kid’ should never happen. Where I work, (Sydney, Australia) only those assessed as competent to work with paediatrics are allowed to perform venepuncture. It seems that in the establishment from which the report came, serious investigation throughout the Pathology department and the sample collection department is needed urgently. One ‘bad apple’ ...possible. A whole bunch...management negligence! My advice for what it’s worth: get rid of the lot of them and make sure that they never work in this field again. Then get rid of the managers and get some who care enough to perform their jobs correctly.”
“I have witnessed a phlebotomist use the same needle, repeatedly, on re-sticks on the same patient. Also doesn’t use a hub when drawing with a butterfly. Another doesn’t label specimens right away, lines them up with the paperwork and labels ALL tubes ‘when there is time.’”
“I have been told to use 22g needles on patient’s hand because butterflies are too expensive. Some phlebs are very unprofessional on floors in front of patients. Fights with nursing staff are commonplace . Probing for veins is a common practice.”
“I have seen people combine tubes of the same color (i.e. two blue tops, pouring from a SST into lavender). Worst thing I ever saw: a tech used the same needle and repeatedly stuck a patient. She would find a spot, not get blood, take the needle out and move to the next spot. I was a newly graduated MLT and in shock when I saw this.”
Editor’s note: by reading these testimonials, one might think poor technique and unprofessional behavior is the norm. We beg to differ. We regularly encounter individuals and facilities that uphold high standards and are passionately dedicated to sample quality and world-class patient care. If you’re among them, now it’s your turn to tell us your story.
You’ve just read about the dark side of phlebotomy, now show us the bright side. What practices or behaviors related to blood collection have you witnessed that made you proud, lifted you up, or impressed you? We’d love to hear your story. We’re not interested in your name or facility affiliation, just your story.
Complete our anonymous survey about practices you have experienced that make you proud of your facility and/or coworkers. Depending on the responses, we may share them with our readers in a future issue of Phlebotomy Today or Phlebotomy Today—STAT! or otherwise used for educational purposes. No names, no identifiers, just your story.
Tell us your story.
Ernst Presenting Full Day of Lectures
The Center for Phlebotomy Education’s Executive Director is giving a full day of lectures this month at the annual collaborative meeting of the Indiana chapters of the Clinical Laboratory Management Association (CLMA) and the American Society for Clinical Laboratory Sciences (ASCLS).
The event takes place Thursday, August 23 at the Ritz Charles Conference Center in Carmel, Indiana. Ernst will give the following presentations:
- Controlling Blood Culture Contamination Rates
- Mastering Pediatric Phlebotomy
- Case Studies: What Would You Do?
- Industry Update Affecting the Preanalytical World
A promotional video for the event can be viewed on the Center for Phlebotomy Education’s YouTube page. For more information, contact Joy Bergeron at 800-296-5954 or by email at firstname.lastname@example.org.
Whether you teach a phlebotomy course or train your staff, the Center for Phlebotomy Education has bundled two of our most popular training resources and added free extras. For a limited time, buy any three titles in our popular Applied Phlebotomy DVD series and an Advanced Venipuncture Training Aid at their regular price, and we’ll throw in a free carrying case for the training aid at no extra charge (priced at $49.99) and free shipping.
The Advanced Venipuncture Training Aid is what we consider to be the best line of venipuncture training aids on the market at a fraction of the price of anatomical arms. It contains visible and/or palpable veins of varying size and depth embedded in latex-free, tissue-like material providing a life-like experience for those learning how to draw blood. A realistic “flashback” of simulated blood confirms proper needle placement. Durability using 22-G needles is estimated at 5,400 sticks.
Titles in the Applied Phlebotomy series include:
- Basic Venipuncture
- Preventing Preanalytical Errors
- Avoiding Phlebotomy-Related Lawsuits
- Skin Punctures & Newborn Screens
- Arterial Blood Gas Collection
Choose any three titles, and your students or staff will have access to the best phlebotomy training videos on the market, and a training aid to practice what they’ve learned. This special expires September 30.
For more information, click here.
This Month in Phlebotomy Today
Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 13th year of publication, are reading about this month:
Fear and Loathing in the Pediatric Phlebotomy Chair
Phlebotomy in the News
A round-up of articles on phlebotomy and phlebotomists who made Internet headlines in July including these stories:
- Industrial Hygiene Group Urges OSHA to Hikes Fines
- NIOSH cautions healthcare workers who work with chemotherapeutic agents
- Phlebotomist Loses Claim in Computer Monitor Injury>
- Popular Psychic Used to be a Phlebotomist
- YouTube: Where Phlebotomy Runs Amok
- Healthcare Jobs a Shining Light in a Dark Economy
When OSHA Comes to Visit
Tip of the Month
Seven Deadly Sins of Customer Service
(Institutional Version Only)
Buy this issue for only $9.95.
For subscription rates and to subscribe to Phlebotomy Today, click here. The current month’s issue will be emailed to you immediately upon subscribing.
On a Personal Note...
Ever since last month’s blog post, “Barge Therapy,” something’s been bothering me.
If you have a moment, follow me...
Our nurses are balking at discarding a calculated volume of blood when drawing specimens from a line. They say it’s not in their standards that way and they want proof. They are saying the same thing for the order of draw, especially in regards to the citrate (blue top) tube. Can you help?
Actually, it is in their standards. Have them refer to those ascribed by the Infusion Nurses Society under “Blood Specimen Collection from Vascular Access Devices.”
Not only that, but those who draw specimens for clinical testing must conform to the standards in effect by the testing facility. The laboratory is responsible for the quality of the specimens it tests (a CLIA ’88 statement). The standard is the same, regardless of the qualifications of the person drawing the specimen, and deviations from standards should be disciplined uniformly.
The pertinent CLSI standards are document H21, Collection, Transport and Processing of Blood Specimens for Coagulation Testing and General Performance of Coagulation Assays and document H3, Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture. The latter is available on the Center for Phlebotomy Education’s website. Each document states that about 5 mL of blood must be discarded whenever drawing through a vascular access device.
As for the order of draw for citrate tubes, document H3 places the citrate tube before the serum tube. Should your nurses place it at the end of the order, they risk carrying over EDTA or (worse) heparin into the coag tube and erroneous results. By placing it at the end of the line, there is a significant potential that the PTT and/or protime result will be erroneously lengthened and an undermedicated patient may appear well within therapeutic range. Risks include thromboembolism, thrombophlebitis, stroke, and worse etc. If a tactful, cooperative approach won’t work, bring in the risk manager.
Finally, laboratory managers who knowingly permit results to be reported from improperly drawn specimens can bring substantial liability on the laboratory, even if a disclaimer accompanies the result.1 Deviating from the standard is a huge liability. You are probably the patient’s last line of defense against medical mistakes that could have catastrophic consequences. First be tactful; then be firm. Your patients are depending on you.
1.) Harty-Golder B. Liability and the lab. MLO 2004;36(9):43.
Each month, PT-STAT! will publish one of the hundreds of phlebotomy FAQs in the growing database of questions and answers available in Phlebotomy Central, the members-only section of the Center for Phlebotomy Education’s website. For information on joining Phlebotomy Central, click here.
The One-Minute Tourniquet Rule
Last month we asked readers and visitors to our web site and Facebook page to complete a survey asking “Do you follow the one-minute rule for tourniquet application?”
It’s no secret the longer a tourniquet is constricted, the more the blood in the veins below it changes due to hemoconcentration. We were impressed that 98% of those who participated in the survey know prolonged tourniquet constriction affects some analytes. Yet we’re puzzled why only 58% admitted they comply with the 1-minute rule every time.
Of the 42% who admit to not complying all the time, the vast majority estimated they comply at least 90% of the time. Here’s the numbers:
How often do you adhere to the one-minute rule?
90% of the time: 78%
80% of the time: 12%
10-70% of the time: 7%
Less than 10% of the time: 3%
We also asked “What are your thoughts about releasing the tourniquet within one minute,” to which 51% chose the option “I was taught this, and I adhere to it as often as possible.” Thirty-nine percent chose “I know this is important, and always comply.” Eight percent chose “I know prolonged tourniquet constriction affects test results, but complying with the one-minute rule is not realistic.” Two percent admitted they have “never heard of this practice before.”
A whopping 67% were actually able to list one or more analytes affected by prolonged tourniquet application. (We’d like to think they are all long-time subscribers!) Contrary to what some think, it’s not just speculation that prolonged tourniquet constriction impacts test results. Consider the following conclusions from published studies:
Significantly elevated after one minute: albumin, calcium, potassium, RBC counts, hemoglobin, hematocrit, glucose, triglycerides, total protein, and alkaline phosphatase.1,2,3 If accessing the vein is perceived to take longer than one minute, the tourniquet must be loosened prior to the puncture according to the standards, and blood allowed to circulate through the arm for at least two minutes. If the vein was difficult to find in the first place, before releasing the tourniquet, take note of various skin features that can help you find the vein again when the tourniquet is reapplied. Creases in the skin, freckles, and other landmarks can shorten the time it takes to relocate the vein and prevent hemoconcentration.
- Lippi G, Salvagno G, Montagnana M, Brocco G, Guidi G. Influence of short-term venous stasis on clinical chemistry testing. Br J Biomed Sci. 2008;65(3):132–5.2)
- Lippi G, Salvagno GL, Montagnana M, Franchini M, Guidi GC. Venous stasis and routine hematologic testing. Clin Lab Haematol. 2006;28(5):332–7.
- Lima-Oliveira G, Lippi G, Salvagno GL, Montagnana M, Manguera CL, eta l. New ways to deal with known preanalytical issues: use of transilluminator instead of tourniquet for easing vein access and eliminating stasis on clinical biochemistry. Biochem Med (Zagreb). 2011;21(2):152–9.
This month’s survey question
It’s no secret the laboratory-nursing relationship is among the most strained of all healthcare professions. This month, we’re asking phlebotomists and other laboratory personnel what they would most like nursing personnel to know about them. Then, to be fair, we’re asking nursing personnel what they would most like phlebotomists and other laboratorians to know. We think you’ve been waiting for just such an opportunity. Now’s your chance to start the dialog.
Last Month on Facebook
During the month of June, fans and visitors to our Facebook page shared their thoughts on the following topics:
- Changes to the profession since entering
- Influential mentors
- Topics of interest for future webinars
- Sources of continuing education
Looking for an online community to post questions or to simply satisfy your desire for phlebotomy talk between newsletter issues? Visit and “Like” our Facebook page and you’ll never miss out on another discussion or one of our special Facebook offers. Your peers need your input, and you need theirs. www.facebook.com/CPEInc
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What Should We Do?
What Should We Do? gives you the opportunity to ask our team of technical experts for advice on your most pressing phlebotomy challenges. Whether technical or management in nature, we’ll carefully consider solutions and suggestions based on the industry’s best practices so that you and those in other facilities with the same problem can benefit, all the while maintaining your facility’s anonymity. What Should We Do? is your opportunity to ask us for suggestions on the best way to handle your real-life dilemmas.
This Month’s Case Study
A Minor Case of Confusion
One reader writes
We are having a discussion regarding minors (under the age of 18) coming into the out-patient lab for blood draws without a parent or permission slip that gives us permission to draw their blood. Do you have any information on this subject? We know that minors can get tested for pregnancy or sexually transmitted diseases without a parent’s permission, but what about other labs? Should we draw their blood or insist on parental permission?
Most minors present for laboratory testing with their parents, but that’s not always the case, as our reader attests. Since minors can obtain drivers licenses and transport themselves when blood testing is required, they are not always accompanied by a parent. In some states, Massachusetts, for example, an order submitted by a healthcare provider is considered authorization for lab work regardless of age. Parental authorization for pediatric patients is assumed since they are the ones giving consent to the provider for treatment. Any subsequent work falls under that visit.
In other states, permission is required until the minor reaches 16 years of age. Therefore, every facility must be aware of the provisions for drawing blood from unaccompanied minors as established by their state laws.
Got a challenging phlebotomy situation or work-related question?
Email us your submission at WSWD@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)
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