Top Ten Ways to Injure a Patient, Part 3
In March, we began our countdown of the top ten ways to injure a patient. Could your technique stand up to scrutiny should a patient be injured and seek compensation? Could your lab's procedure manual? The answers to these and other questions will determine your potential, and that of your facility, to inflict a phlebotomy-related injury that could lead to litigation. But avoiding lawsuits should not be the driving force to ensure standards are met; preventing injury should. No injury, no litigation.
Let's finish our countdown starting where we left off last month with #4.
4. Disregard shooting pain
The "reasonable and prudent phlebotomist" (legalese for one who applies the standards every time she draws blood) knows that shooting, electric-like pain indicates a nerve has been provoked, and will remove the needle immediately. Those who disregard the patient in excruciating pain risk making a minor injury severe, and a temporary injury permanently disabling. If you are performing within the standard of care, you're removing the needle whenever the patient expresses unusual or extreme pain, tingling or numbness in the fingers or hand, and any electrical, shooting-pain sensation.
3. Stick the first vein you find
First come, first served works well for a soup kitchen, but it doesn't apply to veins that present themselves for venipuncture. Just because a large basilic vein is the most obvious one when you tighten up the tourniquet doesn't mean you should stick it without looking around some more. The standards urge us to prioritize the veins for safety. This requires us to perform a thorough survey of both arms (if available and accessible) for the presence of a vein that is least likely to be near nerves and the brachial artery. That means avoiding the basilic vein and any other vein that lies on the inside (medial) aspect of the antecubital area. In other words, give priority to the center and outside (lateral) aspect, i.e., the median or cephalic veins. If you're not confident either can be successfully accessed, you can attempt to draw from a basilic vein, but not until the safer veins of both antecubital areas have been ruled out.
Nobody likes to admit defeat. In some arenas that's an admirable quality. However, failing to surrender to a missed vein can lead to probing around until blood is obtained. Sooner or later, those who do seem to end up injuring patients. Nerves and the brachial artery can be easily injured when the collector probes for a basilic vein (in the medial aspect of the antecubital area) that was missed upon initial insertion. The reasonable and prudent phlebotomist recognizes this risk, and removes the needle instead of giving into temptation to salvage the draw.
When the medial or cephalic veins are missed, there's more leeway for a calculated relocation, but never probing. These veins are not associated with frequent injury to underlying structures. Make sure you know it's beneath the standard of care to relocate the needle when you miss the basilic vein.
This has to be the number one way to injure a patient during venipuncture, doesn't it? Every year we hear of transfusion-related deaths because someone failed to follow the established standard for specimen collection. Do you ask patients to state their full name and birth date as a way to confirm the arm bracelet is correct? Do you require them to spell their first and last names? The standards require it. Patients can suffer serious complications and death when an arm bracelet is all that is relied upon to establish a patient's identity.
Do you rely on arm bracelets that are not attached to the patient? You shouldn't. An identification bracelet that is taped to the bedrail identifies the bedrail; nothing else. When a bride and groom leave the altar, they are united as one. Labels and specimens should be the same way when they leave the patient's side. Make sure your procedure manual clearly spells out that all specimens must be labeled at the patient's side after the draw (not before) without exception. If you're a supervisor or manager, be sure to discipline infractions. It's that important.
There are many more than ten ways to harm a patient during venipuncture. But the ten discussed in this series are likely to be the most common. To immunize your specimen collection staff from inflicting an injury during a venipuncture and the legal firestorm that can follow, make sure they know the standards for the procedure, and that your manuals reflect them. When fully galvanized to the standards in policy and practice, your facility could likely find itself on a different kind of list: Top Ten Safest Labs to Draw Your Blood.
If you missed Parts 1 & 2 of this series, access them here: Part 1; Part 2.
Is Your Venipuncture DVD Up-to-Date?
What's Wrong Here?
What's wrong with this picture (left)? We guarantee something isn't as it should be. The answer will be in next month's issue. (Click image to enlarge.)
Last month's image (right) depicted a patient bending his arm up after the draw. This goes against the CLSI standards because merely bending the arm up is not an adequate substitute for pressure. Hematomas can result due to inadequate pressure against the puncture to the vein. Instead, the phlebotomist or patient should apply direct pressure. If the patient is unable to provide adequate pressure, the healthcare professional should assume the responsibility.
How can you tell if pressure is enough? One trick is to observe the nail beds of the finger applying pressure. If they blanch white, it indicates pressure is sufficient. If the nail beds remain pink, pressure may not be enough to prevent blood from leaking into the tissue.
What Should We Do?: Risky technique for VBGs
Dear Center for Phlebotomy Education:
I recently became aware that when our phlebotomists draw venous blood gases along with routine labs they use a regular 10-20 cc syringe. First they evacuate the syringe into whatever tubes are required for the routine labs with a safety transfer device, then they fill the blood gas syringe also using the transfer device. I do not think this is best practice, but am not able to find documentation to support my position. As a matter of fact, there is woefully little information regarding collection of venous blood gas specimens, their place in the order of draw, etc. What should we do?
You are right to be concerned about this practice. It does sound unorthodox and contrived.
If we understand you correctly, they must be forcing blood from the regular syringe, through the safety transfer device and into the blood gas syringe by pushing on the plunger of the regular syringe. The only way to accomplish this is for the interior needle of the safety transfer device to be inserted into the blood gas syringe, and the two syringes pushed forcefully together for a tight seal as the blood is pushed from one syringe to the other. The safety transfer device is not intended for that purpose. Because the connection between the blood gas syringe and the safety transfer device is dangerous and ineffective, it sounds like it's begging for a blood exposure.
The better approach would be to draw the blood with a butterfly set that has a clamp. After the puncture is performed, attach a small syringe to remove the air in the tubing. A 3 cc or 5 cc syringe would be fine, but even a TB syringe would suffice. After removing the air from the line, clamp it off, attach the ABG syringe, open the clamp and withdraw the sample. Then close the clamp, remove and cap the syringe, attach a regular syringe, open the clamp and complete the draw for the remaining tubes. A tube holder adapter could be added instead of the syringe to fill the tubes.
We've heard of phlebotomists drawing blood gases (venous and arterial) into heparinized tubes instead of blood gas syringes. Make sure your creative phlebotomists don't make this mistake, too. The heparin in tubes is not the proper formulation of heparin, and the vacuum in the tubes subjects the sample to subatmospheric pressure, which can alter results.
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.)
Center's YouTube Channel on Steroids
The Center for Phlebotomy Education's YouTube channel is on steroids. We're up to 37 short clips on a wide variety of phlebotomy topics, all available for free. Over 12,000 subscribers strong, it has become YouTube's go-to channel for quick lessons and inspiration for all who draw blood samples for clinical testing. Here's just a partial list of the current titles available:
- Nightmare on Phlebotomy Street
- Update from our northern Michigan studio
- Why the standards matter
- The order of draw: why you MUST follow it.
- Mixing a blood sample
- Why physicians order blood cultures
- The revised venipuncture standard: will I see you in court?
- Pumping the fist: a really bad idea
- Getting hired as a phlebotomist without experience
- Did I just see you rip that safety shield off?
- The First Commandment of Phlebotomy
- Preventing hemolysis in the blood samples you draw
- Line draws and potassium results: mutually incompatible?
- Positioning pediatric patients
- Preventing iatrogenic anemia
- What impressions are you giving your patients?
- Is that tube full?
- How to prevent newborn screening cards from being rejected by the lab.
- How to draw blood using a tube holder
- How to perform a venipuncture using a syringe
- Performing a venipuncture using a butterfly needle
- How to perform a Modified Allen Test
- Proper patient identification: make no exceptions!
- Preanalytical Errors Real People Real Suffering.
Subscribe to the Center's YouTube channel.
Product Spotlight: Full-Length Streaming Videos
If you like our YouTube channel, you'll love the Phlebotomy Channel. That's where you'll access 17 full-length videos that go way beyond what the short clips in YouTube are designed to offer. The difference can be compared to that between a snack and a meal. Our YouTube channel offers quick bites; the Phlebotomy Channel is a banquet.
Designed for facilities, academic programs and healthcare systems, the Phlebotomy Channel streams the most current phlebotomy training videos to your staff and students flawlessly wherever there's a high-speed Internet connection. If you're currently assembling trainees in one room to watch a DVD, assign them to watch the streaming version at their convenience, freeing yourself to accomplish your more pressing tasks. That's good time management.
Once you subscribe to the Phlebotomy Channel, you'll not only get more productive, you'll get:
Seventeen of the most popular phlebotomy training videos on the planet;
Instant access anytime anywhere;
The most current versions, even when the industry standards change;
An insanely affordable cost-per-view.
See why schools and hospitals around the world trust the Phlebotomy Channel to flawlessly deliver high-caliber training videos on demand. Plus, with real-time tracking, you'll get a full report on who watched the videos you assigned and when. You'll also be able to assess their comprehension with the CE quiz accompanying every title. Start streaming. You'll be amazed how convenient it is.
From the Editor's Desk
As you might imagine, there isn't much about phlebotomy that escapes my radar. So naturally when I heard about a stage production called The Phlebotomist currently performing to sellout crowds at London's Hempstead Theatre in the UK, I was intrigued.
The play is being described as "a powerfully provocative vision of a dystopian future." The story presents a world where health, wealth and happiness depend on a single blood test, the results of which are used to determine everything from bank loans to dating prospects. Because a person's success is so dependent on obtaining a high genetic profile rating, phlebotomists reign supreme. Everyone's hopes and dreams rise and fall depending on their blood rating. It's called "ratism."
One of the main characters, Char, has two degrees and is on the brink of landing her dream job. Unfortunately, her rating threatens it all. She confronts her friend Bea, a phlebotomist and the play's lead character, to help her fake her own blood test and beat the system. Bea soon becomes a dealer of her own blood samples, helping people obtain high bogus scores for substantial sums of money. When good blood is a commodity, a good phlebotomist is in high demand.
That's quite a compelling storyline, I must admit. But according to some reviews, dark undertones creep into the script, darkness I would not find very entertaining, mostly because they've already crept into the real world. I've been known to walk out of movies, even keynote addresses, when the dialog or content assaults my sensitivities. I suspect that would likely be the case with The Phlebotomist. But I won't discount the production just yet. It depends on how deep the director goes into the darkness. Seeing what comes out of Hollywood lately, though, I'm not optimistic.
Regardless of my own personal aversions, The Phlebotomist could give the profession a boat load of publicity. I would hazard to guess only half of the general population even knows what a phlebotomist does, so a play or movie that defines the profession would surely be a good thing. So what if the main character sells her own blood on the black market. Any publicity is good publicity, right?
Within a year or two, I expect The Phlebotomist to jump the pond to the U.S., receive rave reviews, and find its way to the big screen with big-name Hollywood actors. I do hope the director puts someone on the set who knows what a venipuncture is supposed to look like. If you're a junkie for ER shows like I am, you've seen all kinds of atrocious techniques on series like The Resident and Chicago Med. If you've been junkie as long as I've been, that list includes such classics as St. Elsewhere, ER, Chicago Hope, and probably the best ER show ever: MASH. Not once have I seen a properly performed venipuncture on any of those shows. Although the set designer on The Resident contacted us for permission to use our set of phlebotomy posters on the set, which we granted, of course. At least that's a start.
Therefore, should The Phlebotomist ever become a movie, we're hereby officially offering our expertise to the set. After all, if the main character is going to draw her own blood to sell on the black market, she should at least know the proper order of draw.
Dennis J. Ernst, editor
Test Talk: Renin and aldosterone
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.
Renin is an enzyme that plays an important role in controlling blood pressure and other physiological functions. It is produced by the kidneys and stimulates the adrenal glands, which sit atop each kidney and produce aldosterone, a hormone that controls blood pressure. Because renin and aldosterone act in concert, they are often ordered together to diagnose adrenal insufficiency.
Both aldosterone and renin levels are diurnal, i.e., they vary according to the time of day. Both are highest in the morning. They are also affected by posture, which is why most labs require patients to be upright for at least 15 minutes prior to the draw; some studies suggest two hours. Renin levels are significantly lower on recumbent patients.
Samples for renin and aldosterone are drawn into EDTA tubes, immediately placed in an ice slurry and centrifuged in a refrigerated centrifuge. Plasma from the sample that cannot be tested immediately should be frozen.
Patients who have high blood pressure, especially when it cannot be controlled by blood pressure medication, are suspected as having Conn's Syndrome, or primary aldosteronism. Because primary aldosteronism is a curable form of hypertension, early detection is critical. That's why it's important that all renins and aldosterones are placed at refrigerated temps immediately upon collection before leaving the patient's side, and promptly centrifuged and processed. When these conditions are not satisfied, patients may not be diagnosed in time to prevent complications from undiagnosed Conn's Syndrome.
- LabTestsOnline. American Association for Clinical Chemistry. AACC. https://labtestsonline.org/understanding/analytes/aldosterone/tab/sample/.
- Wu A. Tietz Clinical Guide to Laboratory Tests---Fourth Edition. Elsevier. St. Louis, Missouri. 2006.
- World Health Organization. Use of Anticoagulants in Diagnostic Laboratory Investigations. WHO. Geneva, Switzerland. 2002.
Advice from the OSHA Expert: Chemotherapy drug precautions
Dan the Lab Safety Man
As a phlebotomist, the likelihood of coming into contact with chemotherapy drugs used to treat some cancers does exist. You may need to draw, process, or test samples from a patient receiving chemotherapy, or you may be involved in a medication spill..
Why is this a safety issue? Because many chemotherapy drugs are known as antineoplastics, a class of drug used in healthcare settings that is designed specifically to destroy cancer cells. Direct contact with these toxic medications can cause many significant health effects, such as nausea, vomiting, hair loss, and suppression of bone marrow function. The health risk is influenced by the extent of the exposure and the toxicity of the hazardous drug.
One way for direct contact to occur with antineoplastic agents is an accidental spill event. Medication vials or intravenous poles can be dropped or knocked over. If you are in an area where a spill has occurred, you should leave the area as soon as possible. Only those trained in spill clean-up should use the special chemotherapy spill kits to participate in containment.
The Personal Protective Equipment (PPE) we commonly use while handling laboratory specimens is sufficient to prevent occupational exposure. A fluid-impervious lab coat, gloves, and proper face protection are protective against the amounts of antineoplastic drugs found in such patients' samples. No extra precautions by the phlebotomist are necessary while collecting or handling blood and body fluids from patients taking chemotherapy.
The Centers for Disease Control and Prevention (CDC) provides additional information about antineoplastic drugs on its website. If you collect or process samples from cancer patients receiving chemotherapy, you should be aware of the necessary safety precautions discussed. As always, perform your duties using Standard Precautions, and be prepared to safely handle situations involving antineoplastic drugs.
1. Centers for Disease Control and Prevention (CDC). Hazardous Drug Exposure in Healthcare. http://www.cdc.gov/niosh/topics/antineoplastic/. Accessed 5/1/19.
2. Centers for Disease Control and Prevention (CDC). Preventing Occupational Exposure to Antineoplastic and Other Hazardous Drugs in Health Care Settings. http://www.cdc.gov/niosh/docs/2004-165/pdfs/2004-165.pdf. Accessed 5/1/19.
You can contact Dan Scungio, "Dan the Lab Safety Man" at firstname.lastname@example.org.
Tip of the Month: Rushin' Roulette
Click here for this month's featured Tip of the Month from our rich library of archived Tips.