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Phlebotomy Today

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February, 2020

Is There a Bully in the House? (Part 2)

[Editor's Note: This month we continue our series on effective communication and the negative impact of workplace bullying on patient care and teamwork with a discussion of malpractice risk, The Joint Commission Standards, and strategies for organizations and individuals in addressing intimidating and disruptive behaviors.]

Bradley noticed how the new kid at school was withdrawn, quiet, and reclusive. Sensing an easy target, he set out to establish himself as a force to be reckoned with. When nobody was looking, he roughed up Preston, another fifth-grader, with menacing words and physical intimidation. Thirty years later, Bradley was roughing people up on another playground: the hospital laboratory. The new phlebotomist was quiet, withdrawn, reclusive... an easy target.

Whether it's on the playground or at work, bullying is bullying. It's dispiriting, demotivating, and demoralizing. It's not just intimidation, it's an assault against human dignity that burdens its victims whether the bully is physically present or not. Bullies intimidate even when they're not there.

Healthcare managers and employees who recognize and eradicate bullying immediately preserve the spirit of cooperation necessary to deliver the quality of care patients deserve. Facilities that ignore bullying behaviors not only fail to deliver quality care, but expose themselves to legal action from patients and employees.1 Gerald B. Hickson, MD, director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tennessee says any behavior that impairs the healthcare team's ability to function well risks malpractice litigation.1

Not only that, but openly hostile and passive-aggressive actions chase away good employees. "High performers don't thrive in hostile environments," says Catherine Ernst, RN, PBT(ASCP) with the Center for Phlebotomy Education. "They'll recognize it immediately and go to a competing hospital that recognizes the importance of top performers. Thoroughbreds don't want to run with donkeys. That's why facilities that tolerate bullying to any degree have scant hope of ever building a well-functioning team. Instead, they settle for employees who are just there for the paycheck, most of them unhappy." 

Lack of Reporting

Based on the results of a recent survey on workplace bullying conducted by the Center for Phlebotomy Education, 87 percent of participants admitted to having been bullied at work, while 85 percent have witnessed bullying. The problem is most people don't report it for a number of reasons including:1

  • Fear of revenge;
  • Fear over being branded a troublemaker;
  • Reluctance to confront a bully;
  • The belief that bullying by powerful, profit-generating physicians is excused.

Gary Namie, PhD, Workplace Bullying Institute cofounder, reports that not only do most employees fail to report workplace bullying, when they do, their managers don't take it seriously.2 Could it be that victims lack confidence their managers will discipline bullies effectively and consistently? Probably so. According to one study, 62 percent of cases in which employers were made aware of bullying behavior, employees thought their managers either worsened the situation or simply did nothing.

Facilities that fail to formally address unprofessional behavior are indirectly promoting it.1

As for consistency, over one-third of those surveyed (39%) agreed that "physicians in my organization who generate high amounts of revenue are treated more leniently when it comes to behavior problems than those who bring in less revenue."1 The article "Behaviors that Undermine a Culture of Safety" suggests facilities that fail to formally address unprofessional behavior are indirectly promoting it.1

Joint Commission Standards

The Joint Commission warns of a distressing decline in trust among hospital employees and, with it, a decline in the quality of medical outcomes.3 In 2008, TJC issued a standard on unprofessional conduct in the workplace, citing concerns about patient care:4

Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Addressing the Issue

First and foremost, there must be a commitment to a zero-tolerance policy.

So how should conscientious managers address bullying when it is brought to their attention? First and foremost, there must be a commitment to a zero-tolerance policy.

The Joint Commission provides some helpful tips on how organizations should address this issue, including:1

  • Promote the organization's code of conduct and enforce it consistently and fairly at all levels. The code and education should emphasize respect.

  • Include training in basic business etiquette (particularly phone skills) and people skills.

  • Emphasize the organization's zero tolerance for intimidating and disruptive behavior.

  • Establish policies and processes that encourage reporting of intimidating/disruptive behavior.

  • Hold team members at all levels of the organization accountable for modeling desirable behaviors regardless of seniority or clinical discipline.

  • Respond to patients and/or family members who are involved or witness bullying behavior. The response should include hearing and understanding their concerns, thanking them for sharing those concerns, and apologizing.

  • Educate staff on conflict resolution and how to respond to intimidating and/or disruptive behavior.

  • Encourage discussions across professional and departmental lines as way of addressing ongoing conflicts, overcoming them, and moving forward.

  • Document all efforts to address intimidating and disruptive behaviors.

For addressing conflict with staff one-on-one in a constructive way, Barbara Linney, vice president of career development at the American College of Physician Executives, Tampa, FL suggests the following:5

  • Avoid teasing the individual, as this makes you an equal in bad behavior.

  • Avoid emotional outbursts and defensiveness, which can escalate the problem.

  • Be mindful of your body language, since it constitutes 55% of what we communicate. The tone of our voice is 38% of what we impart to others, with only 7% of what we convey coming from the words we use.

  • Listen to what the employee has to say, restating concerns and asking questions to improve your understanding.

  • If you are at fault, admit it. If not, explain your point of view to help resolve the situation.

When bullying occurs, facing the bully and reporting the behavior is the first step toward fixing the problem. However, according to executive coach Robin Samora, it's best not to react in the moment. Instead, she suggests "building a bubble around yourself" to protect your self-esteem and work performance while addressing the issue. Samora also recommends communicating by email, so that you have a documentation trail to back you up, or keeping a notebook that lists the date, time and details of the incident. Be sure to note if another employee witnessed the event. This is important in case things worsen and you have to go to your human resources department or take legal action.

If you seek help from human resources, documentation of the incident along with a description of the bully's impact on the organization gives HR information to work with on your behalf. It's not just a matter of the bully hurting your feelings. Their bad behavior can sabotage the reputation of your employer, staff productivity, and the health and welfare of your patients.6 In the United States, there isn't a law against workplace bullying. However, over 20 states have introduced some form of anti-bullying legislation known as The Healthy Workplace Bill.7

In Summary

Ineffective communication due to bullying among healthcare team members can be harmful on many levels. Bullying in a healthcare environment can potentially:8

  • contribute to medical errors

  • negatively impact safe and effective care

  • result in poor patient outcomes

  • impact patient satisfaction

  • lower productivity and morale

  • increase staff turnover and absenteeism

  • increase healthcare costs

  • diminish the organization's image

  • increase the risk of employee retaliation and violence

Conversely, the building blocks of effective communication that contribute to team satisfaction also contribute to quality patient care. Phlebotomists and laboratory personnel are motivated to do their best work and fulfill their role in providing exceptional patient care when they feel supported both in the job and interpersonally, are respected, valued, listened to, have a clear understanding of their role, and are fairly treated in work and pay.

When nobody was looking, Bradley roughed up the new phlebotomist with words and physical intimidation. The next day Bradley was suspended, assigned to counseling sessions with the human resources department conducted by Preston, an HR professional who remembered Bradley from fifth grade. For bullies like Bradley, the Day of Reckoning may not be swift, but it is inevitable.


  1. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert. Issue 40, July 9, 2008. http://www.jointcommission.org/assets/1/18/SEA_40.PDF. Accessed 2/3/2020.
  2. Workplace Bullying Institute & Zogby International. U.S. Workplace Bullying Survey. September 2007. http://workplacebullying.org/multi/pdf/WBIsurvey2007.pdf. Accessed 2/3/2020.
  3. Workplace Bullying Institute. Physician, Heel Thyself. http://www.workplacebullying.org/2011/05/10/physician-heel-thyself/#more-4295. Accessed 2/3/2020.
  4. Yamada D. Workplace bullying in healthcare 1: The Joint Commission Standards. Minding the Workplace (blog). December 15, 2009. http://newworkplace.wordpress.com/2009/12/15/workplace-bullying-in-healthcare-i-the-joint-commission-standards/. Accessed 2/3/2020.
  5. Hernandez, JS. Confronting Conflict in the Lab. How Managers Can Curb the Effects of Disruptive Behavior. Clin Lab News. July, 2011; 16–17.
  6. http://humanresources.about.com/od/difficultpeople/qt/work_bully.htm
  7. Healthy Workplace Bill. http://www.healthyworkplacebill.org/. Accessed 2/3/2020.
  8. Workplace Bullying Institute. Yamada: Workplace Bullying Is Bad For Business. http://www.workplacebullying.org/2012/01/09/yamada-2/. Accessed 2/3/2020.

The Whole Phlebotomy Enchilada


For years, the Center for Phlebotomy Education has put everything we've ever created into two subscription-based online platforms: The Phlebotomy Channel and Phlebotomy Central. What's the difference? 

  • The Phlebotomy Channel---A library of 17 training and inspirational videos streamed to any computer with a high-speed Internet connection.

  • Phlebotomy Central---This online membership section provides access to just about everything we've ever written, published and produced... except videos.

Now you can get both for the price of one! Effective immediately, all new subscribers to an All-access Pass to the Phlebotomy Channel  get a free one-year subscription to Phlebotomy Central.

This offer is for new Phlebotomy Channel All-Access-Pass subscribers only and ends February 29,2020.

So, if you're not already a Phlebotomy Channel All-Access subscriber, for the rest of the year you and your staff and students can have the  the whole phlebotomy enchilada. That's both subscription-based platforms for the price of one. Whether you're a reader or a watcher, this much is for sure: you'll be infinitely more knowledgeable about blood specimen collection and handling at the end of the year than you are now... unless, of course, you already subscribe to both. 

Simply add both to your shopping cart and the discount will be applied immediately. Subscribe or for more information.


Ernst Tapped for CLSI Board of Directors

CLSIDelegates of the Clinical and Laboratory Standards Institute (CLSI) recently elected Center for Phlebotomy Education Director Dennis J. Ernst MT(ASCP), NCPT(NCT) to the organization's Board of Directors. In his notification letter, CLSI President Carl Mottram congratulated Ernst stating "I am confident that your support and contributions will be most valuable in ensuring that CLSI maintains its growth and outstanding reputation."

Ernst first became involved with CLSI as a conference attendee at an event in Raleigh, NC in 2000, then served on his first document development committee revising the venipuncture standard, H3-A5. Since then he's participated in 10 more committees developing a wide variety of preexamination standards and guidelines, chairing six of them.
   "Being selected as a member of the board is the greatest honor of my profession," he says. "When I drove my rickety old pickup 11 hours to attend a Raleigh, NC event in 2000, it was such an amazing experience. I knew I had to be involved in these standards and this organization. To be offered a seat at this level of the organization is both humbling and exciting." 

Ernst encourages all Phlebotomy Today readers to become a CLSI volunteer. "It's the most appreciative organization you'll ever find and the most passionate professionals you'll ever work with."

Interested subscribers can learn more about all the volunteer options on the CLSI volunteer web page.


Product Spotlight: Order of Draw Pens, free Tips cards



Study Details Affect of Hemolysis on Test Results

HemolysisScandinavian researchers set out to examine the impact of hemolysis on 25 commonly performed chemistry tests. Samples from 17 patients were purposefully hemolyzed by freezing and thawing so that four levels of hemolysis were obtained on each sample. All samples were tested on the Beckman Coulter AU480 analyzer.

Analytes that were not affected at even the highest level of hemolysis include calcium, chloride, creatinine, C-reactive protein (CRP), glucose and sodium. 

Clinically significant interference was found for LD at 1+ hemolysis, CK-MB at 2+, AST and potassium at 3+ and total bilirubin at 4+.

The following analytes were affected by hemolysis, but not to a clinically significant degree: alpha-amylase, alkaline phosphatase (ALP), aspartate aminotransferase (AST), total and conjugated bilirubin, creatine kinase (CK), CK-MB, ?-glutamyltransferase (GGT), iron, lactate dehydrogenase (LD), magnesium, potassium, total protein and uric acid at HI=(1+); alanine aminotransferase (ALT) and phosphate at HI=(2+); urea at HI=(3+); albumin and cholinesterase at HI=(4+). 

Read the abstract.


From the Editor's Desk

SanFrancisco2007 skyFriends,

Last week my professional life came full-circle in a truly profound and meaningful way... one I would never have predicted. 

The circle began 40 years ago in Saginaw, Michigan when I landed my first job as a medical technologist. I was still a student, not yet even certified, when I was offered a part-time position at the laboratory at Saginaw Medical Center. I will tell you I was like a deer in the headlights, new in the field, and clueless about working in the trenches of healthcare. All I had was book-sense and no world-view whatsoever.

I remember how good it felt to have a marketable skill at last. Four years of fits and starts trying to settle on a major and career, and now it was all behind me. Someone actually wanted my services as a laboratory professional. Wow. 

As first jobs go, it was as good as it gets for someone as wet behind the ears as I was. After graduation and certification, though, I was lured away by a higher wage and spent the next 3 years at a blood donor center testing donor units and making components like platelets, fresh frozen plasma, and cryoprecipitate. I always knew teaching was where I was headed, though I didn't know how or where. All I knew is that I needed real-world experiences if I were to ever educate effectively and was certain they didn't exist in Michigan. Call it garden-variety wanderlust or just bona fide naiveté, I left Saginaw three years later and called Southern Indiana home for the next 36 years, working in  a variety of labs in Indiana and Kentucky, ultimately starting the Center for Phlebotomy Education. 

Fast forward to last week.

I've been back in Michigan two years now, hanging the Center's shingle in downtown Cheboygan. This year's top priority is to produce the 3rd edition of our Preventing Preanalytical Errors video. But the problem is finding a location to film it. I don't have the connections up here that I established in "Kentuckiana' for filming... or did I? Though I severed it 40 years ago after only a few months of employment, I could think of no lab more fitting than where my career first began. The Saginaw Medical Center laboratory, now part of the Covenant healthcare system, welcomed me back with opened arms. 

When I arrived last week with the film crew, it felt as if I were some kind of celebrity that came home at long last, the city's favorite son, a home-town boy returning victoriously from the war. Of course, the staff is not the same as when I was there. (But then neither am I. Having worked in labs both large and small my world view is far different now and I'm teaching to my heart's content.) I posed for pictures, signed autographs, and was virtually handed the keys to the laboratory. For the next seven hours we filmed one of the industry's most important (and popular) videos in the lab where I once clocked in and out like everyone else, still green as a gourd and dripping-wet behind the ears. My 40-year circle was complete.

CovenantFilming_500wThe staff and management were incredibly tolerant of our imposition on their workflow, and it progressed like clockwork. Not because I was so prepared and the crew was so skillful (though they were), but because the staff, specifically Alison, the lab educator, was so organized. If it weren't for her dedication and organizational skills, it'd have taken twice as long. By the end of the day we filmed no fewer than 36 scenes depicting various aspects of sample collection, centrifugation, processing, handling, and more. That's about five per hour without breaks. 

It should come as no surprise that everything flowed so smoothly last week. Whenever the stars line up like they have for this project, there's a certain harmony that makes everything fall together with perfection. While we are nowhere near done (we still have narration to film and editing all the footage), the hardest part is over. I think you'll be quite pleased with the finished product, and if the rest goes this smoothly we hope to make it available to you in DVD and streaming in June or July. 

It took 40 years for me to come back to the beginning of my professional career, a career whose path I neither scripted nor conceived, but one that unfolded as it was preordained and with me to only discover. That I came home to such a humbling reception was magical, but unearned. If it weren't for the itch to be from Michigan and not a resident of it 40 years ago, I'd likely had stayed at Covenant. Would I have ever gotten that world view I thought I needed in order to teach effectively? Would there even be a Center for Phlebotomy Education today? Who knows. All that I'm sure of is this: everyone eventually ends up where they're supposed to be as long as they follow the good urgings of their heart and walk through the open doors. For me and Covenant, the good urgings and open doors, even the name of the system, have added a certain poetry to this video production, and to my walk through life.


Dennis J. Ernst, editor


What Should We Do?: How tight is too tight?

Tourniquet_thinkingDear Center for Phlebotomy Education:

We have a phlebotomist that routinely ties tourniquets too tight. She trains new employees that way and she also helps teach the phlebotomy class at the local community college. As her supervisor I've talked to her about it and it doesn't seem to help. Her response is "I'm going to do what I have to do to get the blood I need." One of her students actually ripped a tourniquet trying to tie it as tight as she's been instructed to tie it. I was just wondering if you had any suggestions on how to handle this. I know that she is getting blood, but how accurate is it? What should we do?

Our response:

This is an interesting question. A tourniquet really doesn't have to be as tight as you described. It sounds as if she could be constricting the artery as well.

There is no standard metric on what constitutes the proper amount of constriction. But the CLSI venipuncture standard (GP41) says constriction must not be excessive or uncomfortable. If you deem her constriction to be either, she's in violation of the standards. You should put that passage in your procedure manual so that you're on firmer ground to correct and discipline her.

Nor is there much information in the peer-reviewed journals on what constituents of the blood may be altered due to excessive constriction. It seems logical to assume the same analytes would be affected as for prolonged constriction, but that's just an educated guess.

We have to suspect she's taking quite a few liberties with the standard protocol when nobody's looking. If you have authority over her and she is not following your directive to back off on constriction, that's insubordination. We also have to wonder if she should be training anyone. Her comment that "I'm going to do what I have to do to get the blood" is cringe-worthy. Besides the passage in the standard on tourniquet constriction, there are plenty of other aspects of a venipuncture that do not allow a person to "do whatever I have to." She could be a real liability for your department and the facility.

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


CardinalHealth Sponsors Free Blood Culture Webinar

CardinalHealthLater this month, CardinalHealth is sponsoring a free CE-accredited webinar on controlling blood culture contamination rates. The event is managed by Whitehat Communications.

Three Percent is For Wimps: Achieving and Maintaining Blood Culture Contamination Rates Below 1% takes place Tuesday, February 25, 2020 at 1:00 p.m. EST. The presenter for the event is Phlebotomy Today editor Dennis J. Ernst MT(ASCP), NCPT(NCCT). One hour of P.A.C.E. continuing education credit is available to attendees at no cost.

Ernst's presentation will include discussions on the most commonly committed errors in the collection of blood cultures that lead to contamination and false positives, the impact of contaminated cultures on the patient and the facility, and sustainable strategies to reduce blood culture contamination to one percent or less. Strategies will not only include effectively correcting human error, but effective tracking, staff commitment, and emerging technologies. The webinar is part of Cardinal's popular Lab Briefings webinar series.

Register for the webinar.


What's Wrong Here?

Sharps bucket high resWhat's wrong with the picture to the left? (Click image to enlarge.) We guarantee something isn't as it should be. The answer will be in next month's issue.

No gloves phlebotomyLast month's "What's Wrong Here?" image (right) depicted gloveless phlebotomy. While every country except the U.S. makes glove use during phlebotomy optional, the risk is the same everywhere. Namely, the potential to be infected with one or more of over 20 bloodborne pathogen from breaks in the skin and careless practices when drawing and handling blood.

Many argue that gloves don't prevent accidental needlesticks, which is true. However, studies have found that those who are wearing gloves during an accidental needlestick are less likely to acquire a bloodborne pathogen like HIV or Hepatitis C. That's because the glove material wipes off up to 86 percent of the blood that would otherwise be implanted into their flesh


Test Talk: Ammonia

A column that features a different laboratory test each month, what it measures, why physicians order it, and any collection handling restrictions and requirements that must be met.

BloodTestTextGraphicPhysicians order ammonia levels when they suspect liver disease, especially when the patient has mental changes or lapses into a coma. It's also ordered on newborns who suddenly has vomiting episodes and becomes lethargic, and when children enter a pattern of continuous vomiting after a viral infection, which suggests Reye Syndrome.

When bacteria digest protein, ammonia is a byproduct that enters the blood stream. Under normal conditions, the liver removes it from the blood and breaks it down into urea and glutamine, which the kidneys eliminate. If the liver is diseased, cancerous, or otherwise dysfunctional, ammonia builds up in the blood and enter the brain where it is toxic and can cause patients to become lethargic or comatose. High ammonia levels in the brain can also cause hepatic encephalopathy, which is a cognitive impairment due to a dysfunctional liver. Often, liver function tests are ordered at the same time as an ammonia level.

Ammonia is typically collected in EDTA tubes (lavender tops), although sodium heparin can be a suitable anticoagulant. Ammonia heparin tubes are never acceptable. Results from heparinized tubes are typically higher than with EDTA samples. Stability at room temperature is limited to 15 minutes, but extends to two hours when placed immediately on ice. Because of its instability, improper transportation temperatures and delays in transit can result in a falsely higher values and lead to misdiagnosis. Fist clenching and tourniquet use should be avoided. Some physicians feel arterial ammonia levels are more accurate, but there is not widespread agreement on the ideal blood sample.


  1. LabTestsOnline. American Association for Clinical Chemistry. AACC. Accessed 2/3/2020.
  2. CLSI. Procedures for the Handling and Processing of Blood Specimens for Common Laboratory Tests; Approved Guideline—Fourth Edition. GP44-A4. Clinical and Laboratory Standards Institute. Document GP44-A5 Wayne, Pennsylvania 2010.
  3. Wu A. Tietz Clinical Guide to Laboratory Tests---Fourth Edition. Elsevier. St. Louis, Missouri. 2006.
  4.  World Health Organization. Use of Anticoagulants in Diagnostic Laboratory Investigations. WHO. Geneva, Switzerland. 2002.



Tip of the Month: Slap Happy

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