So far in this countdown of the Top Ten Ways to Injure a Patient during venipuncture, we've discussed:

10. reinventing the procedure

9. draw from unorthodox sit

8. seat the patient anywhere

7. turn your back on the patient

6. draw from an artery

5. bandage in a hurry

4. disregard shooting pain

Let's wrap it up with the final Top Three in our countdown:

3. Stick the first vein you find

First come, first served does not 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. 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 the vein that is least likely to be near nerves and the brachial artery: the medial or cephalic veins. In the absence of a medial or cephalic vein that brings the confidence it can be successfully accessed, one can attempt to draw from a basilic vein. But not until the safer veins of the antecubital area have been ruled out.

2. Probe

Nobody likes to admit defeat. In some arenas that’s an admirable quality. However, failing to surrender to a missed vein can cause the unwary to probe around until blood is obtained. Sooner or later, those who do end up injuring a patient. Nerves and the brachial artery can be easily injured when the collector probes for a basilic vein (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 your staff knows it’s beneath the standard of care to relocate the needle when they miss the basilic vein.

1. Misidentify/mislabel

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 only because someone failed to follow the established standard for specimen collection. Does your staff ask patients to state their name as a way to confirm the arm bracelet is correct? Even though Joint Commission doesn’t require this step, the CLSI standards do. Patients can suffer serious complications and death when an arm bracelet is all that is relied upon to establish a patient’s identity.
Does your staff rely on arm bracelets that are not attached to the patient? They 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 without exception, and be sure to discipline infractions. It’s that important.

There are many more than ten ways to harm a patient during venipuncture. But these ten 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.

Part 1 in the series

Part 2 in the series