Dear Center for Phlebotomy Education,

Our Cancer Center made a request that we avoid draws in the antecubital area. They want us to use hand veins exclusively for patients who meet all the following:

• those who will undergo chemotherapy same day
• those who have restrictions on one arm such as previous mastectomy/lumpectomy.
• those who will require venous access for chemo in a median vein.

This is the first time anyone has asked us to completely avoid all draws in the median area. Have you ever heard of this kind of request before? My concern is that if we draw the hand and cause an injury, are we liable because we did not draw from the antecubital? My gut tells me we're not since the request is technically coming from physicians in the cancer center. But still, what should we do?

Our response:  Physicians can't order you to deviate from the standards without putting you at risk of operating beneath the standard of care. Nowhere in the standards does it say "...unless the physician requests otherwise." That said, drawing from a hand vein when an antecubital is available does not go against the standard. But you should know hand veins have been found to be 2.6% less successful, and more likely to be hemolyzed by the same percentage. That said, drawing from hand veins is a low-risk draw. We've never seen a legal case involving a draw from a hand vein. 

Your physicians are not unreasonable in making this request this. Many chemotherapy drugs can cause extravasion, which means if any of the drug leaks out of a prior venipuncture site the patient can experience severe tissue damage. If you have to go this route, make sure your staff doubles their diligence in applying pressure and observing for hematoma. You'll also need to expect that following their request will result in more syringe and butterfly draws, both of which will increase the cost per draw and the risk of needlesticks.

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