Dear 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?

My 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.

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