Here We Go Again...
Another personal experience where phlebotomy was not done correctly.
by Shanise Keith • May 11, 2022
Technical, Professionalism, Editor's Desk
A few days ago, I spent some time in the emergency room with my sister because she was having severe chest and abdominal pain to the point where she had trouble breathing and speaking. Once I heard the news that she was headed to the ER, I jumped in my car and raced to meet her and her husband at the hospital. By the time they got there, her pain had subsided quite a bit, and she actually wanted to head back home, thinking whatever it was must have passed. We talked her out of that, thankfully, because the symptoms she was having were clearly serious, and she needed to get checked out.
They got her back to a room fairly quickly and began the workup. Her nurse entered the room to start an IV and draw some blood. Here is where the trouble started, and you can probably guess some of the issues I am going to describe. The nurse started looking for a vein in her right AC, and she immediately found the basilic vein. My sister used to be a phlebotomist and medical assistant years ago. She is familiar with her own veins, and she is pretty aware of the standards - plus, being related to me, she has to be.
She told the nurse that she would prefer it that she didn't use the basilic vein because it tended to roll and didn't work very well for IVs, AND it always hurt a lot. You would think with those three reasons the nurse would have listened and looked for another vein. She did not. She said, "Well, I think we'll give it a try anyway. It should be fine." My sister pointed out a beautiful median cephalic vein popping up on the same arm that would have been a great alternative instead of the basilic, but the nurse didn't want to use it, even after she requested it. These choices were the first in a long list of things that were done incorrectly and led to complications for my sister.
She cleaned the site with an alcohol wipe, and then immediately wiped the alcohol off with a gauze square. Then she attempted to insert the IV. She hit the vein on the first try, which was good, but as she tried to advance the catheter, she was unable to insert it very far, likely due to a valve. She then pulled the catheter back onto the needle, which is terrible and should never ever be done. She probed forward with the needle, and then tried to advance the catheter once more. Again it didn't work. She removed the needle and then messed with the catheter, pulling it out a little and then trying to advance it back in, and in the meantime there was a nasty hematoma building that was visible from where I was sitting across the room. I included a picture taken of it after a few days.
I was internally screaming at this point, arguing with myself about whether I should say anything. The nurse had already proved that she wasn't open to suggestions, and I worried that anything I said would make the situation worse. My dear sister sat there patiently while all this was happening, both of us aware that it wasn't working and that she would have to stick again. The nurse finally quit messing with the catheter, removed it, and taped a piece of gauze over the hematoma, not taking time to apply pressure and stop the bleeding. My sister asked if she could use the other vein in her right AC that she had pointed out at the beginning, but the nurse said it was really small and wouldn't work - which simply was not true.
The nurse switched to the other arm, once again looking at the basilic vein, but my sister pointed out a really great median vein that was even better on her left arm than her right. This time she used the median vein instead of the basilic, and the IV went in smoothly. Hooray. Next up, blood collection... She began to fill up the tubes in the wrong order of draw. First, she filled up the green tube, next the red tube, then the lavender tube. She flushed the line and left the room, clearly irritated. My sister applied pressure to her hematoma, trying to help distribute the swelling.
Her pain began to increase again, and we waited for the nurse to return with something to help. An ECG was done, and then an ultrasound of her upper abdomen. Finally, the nurse came back, and at this point, my sister could barely tolerate the pain she was experiencing, telling us it was worse than the pain she felt with Pitocin when she was in labor. The nurse told us that the doctor had ordered another blood test that she didn't expect, and she would need to collect one more vial of blood. She popped a red tube onto the IV to use as a waste to clear the saline from the line, and then she put on a light blue tube - and here is where I couldn't keep quiet anymore. I knew the chance of altered test results would be really high with the additive from the red tube passing to the light blue tube. I asked the nurse to collect one more light blue tube to hopefully secure an accurate sample.
My mother has a rare blood clotting disorder that can be genetic. She had a heart attack from a blood clot when she was in her thirties, my sister is not much younger than my mom was when her heart stopped, and she collapsed in front of us in the backyard. She is fine now, but it took a long time for doctors to figure out what caused the clotting, and we (my sister and I) were warned to avoid things like hormonal birth control because our risk of clots was higher. The additive in the red tube makes blood clot, and the light blue tube tests for blood clots. Do you see the problem here? I'm sure you do, but the nurse did not.
I grabbed another light blue tube from the tray and handed it to the nurse, trying to quickly explain that I knew she was using that red tube as a discard to clear the line, but that the additive could still carry-over to the blue tube, and that she needed to draw another one to have a chance at some accurate test results. The nurse was silent, but took the tube from me and applied it. She finished the blood collection, and then administered morphine to my sister. After she left the room, my brother-in-law told me that she applied that second light blue tube for about one second, and then took it off. She didn't let it fill up. She put it on for just a moment to appease me, but clearly had no intention of actually sending it to the lab. I didn't see that, or I would have said something.
Fortunately, my sister felt much better after receiving some morphine, and proceeded to quote random old movies and show off her $90 Italian leather shoes to everyone that entered the room. She refused to take them off and wore them the entire time while lying in a hospital bed. I mean, they're cute sandals, but I think the morphine made my sister a little more "extra" than normal because I have never heard someone talk about $90 shoes so much. It was great entertainment, and I was very glad she was feeling better. I had never seen her in so much pain.
After a couple of hours, the doctor came in and told my sister that the ultrasound showed she had gall stones, and he believed she was having a gallbladder attack. He said he would have thought that was the only issue, except that one of her test results was abnormal. Her D-dimer was slightly elevated, and because of that result, combined with our family history, he was considering doing a chest CT to rule out a blood clot in the lungs. I had been upset with the nurse before, but now I was really frustrated. How could we know if the D-dimer was actually elevated or if it was altered because it was drawn incorrectly? There was no way to know unless we redid the blood test, or went through with the chest CT. Both of those options would increase the time and money needed for the ER visit, and no one wants the radiation from a CT scan if they can avoid it.
I told the doctor what the nurse had done, and that I wasn't sure that the D-dimer was correct. He agreed that it was possible that it was falsely elevated, and that would make more sense than a blood clot based on her symptoms. She had classic symptoms of a gallbladder attack, and none for a blood clot besides pain and some trouble breathing when the symptoms first started, which are also normally present with gallbladder attacks. She decided to skip the CT scan, and she was discharged not long afterward.
Here is an extra fun fact for you as well. The ER that my sister went to is the same one that I worked at when I was younger. I drew blood and started IVs there every day for years. I know what the rules are, and what the training is like for nurses who work there. I know exactly what it's like to have a patient tell you how to do your job, or tell you that you are doing something wrong. I know how aggravating it can be to have a patient's family member think that they know best when they are clearly wrong. HOWEVER, I also know that even if you don't agree with what they are saying, you still need to listen. Don't automatically disregard everything just because it's a patient or a family member saying it. Listen respectfully, and if you don't agree, you can do so kindly and strategically, possibly providing some correcting education if what they are saying is against protocols or best practices.
That nurse had no idea that I'm the Director of the Center for Phlebotomy Education, and that because of my sisters experience there I would be writing about it and filing a complaint. If she had taken just a couple of minutes and opened herself to the possibility that she doesn't know everything, much of the stress of our experience could have been avoided. There was an attitude of dismissal and annoyance from her every time my sister or I said or requested something from her. By the time she left the room after I asked her to draw the extra light blue tube I was half expecting her to tell me to meet her in the parking lot so we could fight. To which I might have actually said yes, because I was very frustrated with the situation.
I am in no way saying that this nurse is a bad nurse. I just think she is a poor phlebotomist, which largely, is not her fault. Phlebotomy is not something that is taught to nurses, so how are they supposed to know what is right or wrong? They learn bad habits and practices from watching others and learning on the job. I am sure that my sister's nurse is incredible and talented in many ways, and I am grateful that she has chosen to work in healthcare during such a difficult time, but her phlebotomy skills could use some touching up, and so could her bedside manner when it comes to situations like ours.
It just makes you think, how many mistakes like these are happening on a daily basis? How many are much worse and possibly life-threatening for the patients who have to be treated based on inaccuracies from simple things like incorrect order of draw? How many patients are at risk from just one nurse who isn't aware of current standards? Unfortunately, most nurses suffer from the same shortcomings related to their phlebotomy knowledge, which means many patients are at risk.
This is something that I know phlebotomists everywhere struggle to overcome. It's a common theme that phlebotomists feel dismissed and unimportant when dealing with nurses because of a general attitude that "phlebotomy is easy, and anyone can do it." - which is just not true. Situations like this are proof that phlebotomists are crucial and irreplaceable, and that many nurses need more education if they are expected to perform phlebotomy. Hopefully, that is something that we can all work together to change in the future.
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basilic blue top healthcare nurses nursing personnel order of draw professionalism research sample
Well written, and unfortunately not uncommon occurrence I suspect
Eesh, what an awful experience. I recently had a similar experience with both a family member, and to a lesser degree when I had my blood drawn at a national lab's draw site last week. Shame some people are too proud, or arrogant, listen to simple, polite, well informed suggestions from those who know.
FYI - Excellent writing style, Dennis has taught you well!
Glen Fine, 05/11/2022 09:19:51
Stop the Madness
When are we as a whole going to stop the madness and stop allowing others to do our jobs? Where I work there is now an initiative to train the CNAs to collect blood. I have been raked over the coals because I asked what is the training and is anyone in the lab involved? Guess what the training is - a 4 hour class and 20 sticks. THAT IS IT! I am helpless here and really scared for our patients. The madness needs to end. We need to do SOMETHING to end just accepting blood collected from anyone just because they work at a hospital!
Sheila, 05/11/2022 09:20:23
Here we go again
Thank you for this article. I too have experienced seeing this.
Joy Culp, 05/11/2022 09:30:32
Where are the comments?
At the bottom of your article (and all the others), it says “3 Comments s.” Where are they, and how can I read them? There is no link. Clicking on “3 Comments” goes nowhere, as it isn’t a link. Please show us the comments.
LP, 05/11/2022 09:46:32
Where are the comments???
??, 05/11/2022 09:55:25
Comments have to be approved.
Hello! To answer one commenters questions, any comments are hidden until they are approved by myself. We get a lot of spam and bot comments after a while, so we keep them censored to make sure only relevant content is visible.
Also... 4 hours and 20 sticks to 'certify' CNAs as phlebotomists?!? That is terrifying, and should not be happening. It is only a matter of time until an injury occurs and a lawsuit ensues. Good luck!
Shanise Keith, 05/11/2022 10:06:17
another argument for certification
This is another supporting argument for required certification. Phlebotomy should not be a "lawless land" for education or skill. Physicians base 70% of their decision making for care based on lab results. If we have people collecting less than ideal samples then how are we to expect accurate results
Stephanie Jackson, 05/11/2022 16:27:13
Clinical Lab Assistant
Again , another excellent article , full of paramount information ! I just love this and since I do train new employees ( used to teach as well and met Dennis here in Denver ), this is crucial information to emphasize to all those who draw blood ! Thank you very much ! Maryam
Jagoda Maryam Arnaut , 05/11/2022 20:17:37
I believe that there are times when it is necessary to fully assert our legal rights as patients, "Patient Rights." We have the right to say, "No"; We have the "right to refuse." In this instance, a patient has the right to refuse a blood draw from a nurse that is clearly not listening, causing injury, and with the potential of causing more injury physically and financially... I'm so sorry this happened.
Christie Hitchcock, 05/12/2022 11:55:23
Blood Draw on early morning hours
Hospitalized some years ago a member of the vascular team came in my hospital room to draw blood she stuck me more times than I want to think about using the same butterfly needle I very nicely released the tourniquet and asked her to leave before I found the strength to punch her I was bruised for a month as a result of this and yes I reported her.
Vivian Fields, 05/12/2022 15:16:54
I think people's embarrassment takes over their logic or humility and they haven't been taught how to react.
Husband was in the ED a few years ago for kidney stones and I kept my mouth shut for the terrible draw (off the IV start, ofc), but when she grabbed the unlabeled tubes and began to walk out, I said sorry, but could she label them at the bedside. From busy but friendly to icy and just radiating anger. Why??
I will never keep my mouth shut about this kind of thing again.
LR, 05/12/2022 20:00:21
This is unfortunate for your sister and family what happened this night. It has happened more than we would like. The last two paragraphs I absolutely love and agree with so much!! This article is so good! Great job. Sad story!
Amber Maginot, 05/12/2022 22:29:31
Hi there, I am very sorry that you had a terrible experience in the ED. It is never great to have any problems on top of what a patient is going through! I did want to point out that if the nurse did use a Red top and not a Red SST (usually has a yellow ring with it) that it does not in fact hold any additives. The clot activator is only present in the red SST, so using a red before the blue top is pretty standard protocol. I hope this helps!
Jess, 05/15/2022 21:22:42
Response to Jess
Thanks for your comment, but plastic red tubes are coated with a clot activator, which is why they are always second in the order of draw. Only the old glass ones were considered non-additive tubes. Red plastic ones now must come after the light blue tube. Here is a link to BD's tubes and additives: https://www.bd.com/resource.aspx?IDX=11068
And here is a link to Greiners tubes and additives: https://shop.gbo.com/en/usa/products/preanalytics/venous-blood-collection/vacuette-tube/serum/cat-serum-clot-activator/
They all have clot activators added.
Shanise Keith, 05/16/2022 18:36:25
This is a very good article, with a lot knowledges. I felt sorry the patient. This article would make me improve more my skill....
Francisca Aitchedji, 05/16/2022 19:21:28
Hello! Yes, the order of draw can mess up quite a few lab tests when not done correctly. Agreed Shanise, the blue should never go after the red or gold since both of these tubes contain a clot activator. Given the fact that though that you mentioned you have a family history with a clotting disorder, it could be that the result was elevated due to that and not because of the wrong order of draw, but unfortunately, we will never know. At that point, I guess I would have suggested they do a redraw (other than the one they pretended they did) if indeed they truly thought there could be a clotting problem as well in addition to what else was going on with her. At the very least, blood should never be drawn from an existing indwelling line if the IV have been started. This can only be done if the IV line is placed and they use a transfer device piggy backed on the IV port (before fluids are started) to draw the labs, which is sometimes done to save the patient another stick particularly if they are a hard stick. Amazing how many different interpretations there are to this 5 minute procedure??
Terri McElhattan, 05/17/2022 17:20:19
Response to Terry
Terri! I loved your comment, and you are absolutely correct. There are SO MANY different variables that went into this situation that could have altered her test results. Nothing was performed at the highest standard of care. Fortunately, she is following up with her own Dr. to get things double checked.
Shanise Keith, 05/17/2022 17:45:28