As many of you have also probably witnessed at some point in your time in healthcare, I’ve watched a phlebotomist sit for three full minutes, moving the needle around under the skin, searching blindly for a vein while the patient gritted their teeth in pain. The result? A massive hematoma, and a traumatized patient.

I’ve also watched a phlebotomist give up immediately after missing the vein by a millimeter—when the patient was willing and a simple adjustment would have fixed the problem. The phlebotomist missed again on the second stick and also refused to relocate the needle. This patient had large, but very rolly veins.

Both are wrong.

Redirection is a necessary skill in phlebotomy. Rolling veins are real. Sometimes a vein moves at the last second. Sometimes you need to make a small adjustment. But there’s a world of difference between a purposeful, anatomically informed redirection and painful, blind fishing.

Let’s talk about how to know the difference—and how to do it safely.

What is Redirection vs. Fishing?

Redirection is a controlled, purposeful needle adjustment based on precise knowledge of where the vein is located. It’s minimal, calculated, and ideally painless.

Fishing is blind probing—moving the needle around under the skin, searching for a vein without clear knowledge of its location. It’s painful, traumatic, and dangerous.

The difference comes down to three things: anatomical knowledge, intention, and patient response.

If you know exactly where the vein is and you’re making one small adjustment to reach it—that’s redirection. If you’re moving the needle around hoping to stumble into something—that’s fishing, and you need to stop immediately.

The Anatomy You MUST Know

Before you ever attempt to redirect a needle, you must have a mental map of the antecubital fossa anatomy. Not a vague idea—precise knowledge.

The median cubital vein typically runs across the middle of the antecubital fossa. It’s usually the safest target because it’s relatively superficial and away from major nerves and arteries. It also tends to be more well-anchored, and less likely to roll.

The cephalic vein runs on the lateral/outside (thumb) side. It’s generally a safe area for venipuncture.

The basilic vein runs on the medial/inner (pinky) side. And this is where things get dangerous. Remember that the basilic vein is the last choice for venipuncture, and should only be used if no other options are available.

The medial (inner portion) of the antecubital fossa is a danger zone. Running alongside and beneath the basilic vein are the brachial artery and the median nerve. These structures are close to the surface. Too close. Close enough that any venipuncture or needle movement in this area carries significant risk.

I’ve reviewed several legal cases where phlebotomists caused permanent nerve damage or arterial punctures from manipulating needles in the basilic vein area. In fact most of my cases arise from injuries from accessing (or attempting to access) the basilic vein. Based on those cases, my recommendation is stronger than CLSI’s (description farther down): do not attempt any redirection in the medial (inner area) of antecubital fossa. Not lateral, not forward, not backward. If you miss in that area, pull out and try somewhere else.

The risk is simply too high.

When Redirection is Appropriate

Redirection should only be attempted when specific conditions are met, and you are in an acceptable vein location:

• You felt the vein clearly during palpation and know exactly where it is
• You entered the skin but advanced past the vein or stopped just short
• The vein rolled slightly during insertion but you can feel where it moved
• The first attempt was minimally painful and the patient is willing
• You’re not in the medial antecubital fossa (basilic vein)
• You have a clear plan for what adjustment you’re making and why

If you’re not absolutely certain where the vein is, don’t redirect. Pull out and reassess.

Acceptable Redirection Techniques

Forward and Backward Movement (Safest and Most Common)

This is your primary redirection technique. If you’ve inserted the needle but don’t have blood return:

• If you think you went through the vein: Slowly withdraw the needle (without coming out of the skin) while maintaining the same angle. Often you’ll get a flash as the bevel re-enters the vein from the other side. Plus, even if this doesn’t work you are now in position to perform a redirect.
• If you think you stopped short: Advance slightly deeper along the same trajectory. This works when you felt the vein but didn’t quite reach it.

Keep these movements small—we’re talking millimeters, not centimeters.

According to CLSI PRE02 (formerly GP41): To perform a calculated relocation, the healthcare professional must release the vacuum applied to the vein by removing the tube from the interior needle of the tube holder or discontinue pulling the plunger of the syringe. The healthcare professional must withdraw the needle until it is just beneath the dermis, re-anchor the vein, reorient the needle towards the perceived position of the vein, and advance the needle. The healthcare professional must reapply the tube or withdraw the plunger.

What does this mean? To perform a needle relocation, pull the needle backwards until only the bevel is in the skin, and then pivot towards the vein (reorient the needle position), then advance the needle. The tubes should not be applied while performing a redirection. The continued suction can pull tissue towards the bevel and worsen damage to the area, and make a clean redirect more difficult.

When this is performed it needs to be reasonable. No 90 degree pivots towards a vein that lies at a difficult angle.

Angle Adjustments

Sometimes the angle is the problem, not the depth.

• If you went too deep: Flatten your angle slightly by lowering the hub of the needle closer to the skin. This can help you enter a vein that’s more superficial than you anticipated.
• If you’re too shallow: Slightly increase your angle. But be cautious—this can quickly become dangerous if you’re near nerves or arteries.
• Remember that the angle of the needle should never exceed 30 degrees. Low angles are more appropriate and safer.

Calculated Lateral Adjustments (Very Limited Use)

In some circumstances, a small lateral adjustment may be attempted—but only if:

• You have precise knowledge of the vein’s location
• You’re in a safe anatomical area (not the basilic vein or medial antecubital fossa area)
• The movement is minimal (we’re talking a millimeter or two)
• You can feel resistance/structure through the needle bevel

This technique takes practice. If you’re not completely confident, stick with forward/backward adjustments.

CLSI PRE02 (formerly GP41) states: A calculated lateral relocation in some areas may be attempted only if precise location has been determined. However, sideways needle relation, even calculated, must not be attempted in the medial (inner) aspect of the antecubital fossa where nerves and the brachial artery are most vulnerable to injury.

So how is this different from the first CLSI description above about reorienting or pivoting the needle? When we are talking about lateral redirection, typically it means we want to avoid dragging the needle from side to side while it’s deeper in the tissue. When the bevel is the only part of the needle that remains within the skin we are limiting the amount of damage we are causing. Pivoting a needle that has not been pulled back will slice through any tissue it encounters, worsening the damage that is being caused.

An example of when these conditions might be met: A vein has rolled, but upon re-palpation you can confirm it’s within 1-2mm of your current needle position and you’re in a safe anatomical area. In this specific scenario, a minimal lateral movement may be appropriate rather than backing up completely and reinserting.”

What makes all of this tricky is that it is up to the phlebotomist in the moment to determine what to do. Having the knowledge of what the standard of care is, what the risks are anatomically, and paying close attention to the demeanor of the patient is critical in determining if a redirection is acceptable in that moment. If it seems tricky or questionable it should not happen.

The Non-Negotiable Rules

Rule #1: Pain is Your Stop Signal

A good redirection should be minimally painful—ideally painless. The patient might feel pressure or slight discomfort, but they shouldn’t be wincing, tensing up, or pulling away.

If your redirection causes significant pain, stop immediately. Pain means you’re hitting something you shouldn’t be—possibly a nerve. Remove the needle and try a different site.

Rule #2: One Redirection Attempt

You get one redirection attempt on a typical patient.

CLSI PRE02 states: When a cautious and calculated relocation has failed, the tourniquet and needle must be removed, the safety device activated, and pressure applied to the puncture site. Any additional attempts at specimen collection must be started from the beginning of the procedure, preferably at the other arm or another part of the body. The same needle must never be used for additional subsequent punctures.

While the standard’s language states one redirection attempt, realistically, a second attempt may occasionally be warranted if the first was completely painless, the patient is willing, and you have clear anatomical knowledge of what adjustment is needed. Sometimes you may be trying to redirect on the only vein you had access to, or they are a highly difficult stick due to other reasons (chemo, burns, multiple IV’s etc.). However, two attempts is the absolute maximum - anything beyond that causes unnecessary trauma and violates the spirit of the standard. After that, you’re done. Remove the needle and try again.

I don’t care how close you think you are to the vein. I don’t care how confident you feel. One, maybe two attempts, then stop. Every additional movement increases the risk of trauma, hematoma formation, and nerve injury.

It’s ALWAYS better to err on the side of caution rather than inflict pain and damage on your patient.

Rule #3: Never Blind Probe

Every needle movement must be purposeful and based on anatomical knowledge. You should be able to explain exactly what you’re doing and why. I once entered a room to see a coworker fishing around on a patient’s arm. After watching for a moment, I asked them if they needed help with their stick, and they said “No, I know it was around here somewhere.” That type of mindset is unacceptable and incredibly dangerous.

“Searching” for a vein with the needle inserted is never acceptable. If you don’t know where the vein is, the needle doesn’t belong in the patient’s arm.

Rule #4: No Redirection in the Basilic Vein Area, or ANY Vein in the Medial Antecubital Fossa (Inner Area of the AC)

This bears repeating because it’s critical: if you miss a vein in the medial area of the antecubital fossa, do not attempt to redirect. Remove the needle and select a different site.

The proximity of the brachial artery and median nerve makes any needle movement in this area too risky. I’ve seen the consequences of ignoring this rule, and they’re devastating—permanent nerve damage, complex regional pain syndrome, career-ending injuries.

It’s not worth it. Move to a safer site.

Reading the Feedback

Your patient and your equipment will tell you whether a redirection is working.

Successful redirection feels like:

• A subtle “pop” as the bevel enters the vein
• Immediate blood flash in the hub or tube
• Smooth, effortless blood flow
• Patient relaxes

Unsuccessful redirection feels like:

• Resistance or a “wall” feeling
• No blood return despite advancement
• Patient reports increased pain or discomfort
• You’re guessing rather than feeling confident

When in doubt, pull out. A second stick is better than tissue trauma from excessive probing.

The Two Extremes (And Why Both Are Wrong)

The Excessive Fisher

This phlebotomist refuses to admit failure. They’ll sit for minutes, moving the needle in multiple directions, causing visible trauma and pain. The patient is tensing, sweating, or asking them to stop—but they’re determined to “get it.”

This isn’t skill. It’s ego.

Excessive fishing causes hematomas, nerve injuries, and destroys patient trust. I’ve reviewed cases where this behavior led to permanent injuries and malpractice lawsuits. If you recognize yourself in this description, please hear me: your pride is not worth your patient’s safety.

The Immediate Quitter

On the other end, this type of phlebotomist won’t attempt even the most basic adjustment. They miss by a millimeter, the patient is willing, and a simple backwards pull or advancement would work—but they immediately give up and stick again.

The result? Patients who look like pincushions. Multiple unnecessary sticks. And an inability to develop redirection skills because they won’t practice the technique.

Neither extreme serves patients well.

Special Situations Where Redirection Skills Matter

Redirection isn’t about being stubborn—it’s about being skilled enough to prevent unnecessary additional sticks.

Rolling veins (especially common in elderly, and those with connective tissue disorders such as Ehlers-Danlos syndrome) often require slight adjustments as veins move during insertion. Knowing how to follow the vein’s movement can mean the difference between one stick and five.

Patients with limited available sites (cancer patients, dialysis patients, those with lymphedema) can’t afford multiple sticks in different locations. A skillful redirect might save their few remaining viable veins.

Deep or fragile veins sometimes require angle adjustments mid-insertion. This is legitimate technique when done correctly.

The goal is to balance minimizing sticks while respecting safety limits.

Developing This Skill Responsibly

Like any technical skill, proper redirection takes practice—but it must be practiced responsibly.

Start with supervision. Practice on clear, stable veins before attempting on difficult anatomy.

Develop your sense of feel. Learn to detect vein walls, resistance, and position through the needle. This comes with experience.

Build mental mapping skills. Train yourself to create a 3D image of vein location before insertion.

Communicate with patients. Let them know you might make a small adjustment. Get their consent. Stop if they ask you to. Many patients will not tolerate redirections due to poor past experiences, and that is okay. Respect their wishes and show them you will listen.

Know your limits. If you’re out of your depth, ask for help. There’s no shame in requesting a more experienced colleague.

In Summary

Redirection is a necessary skill in phlebotomy. But it requires anatomical knowledge, technical proficiency, honest self-assessment, and putting patient safety above your ego.

The goal isn’t zero redirections—rolling veins are real, and sometimes a small adjustment prevents additional sticks. The goal is purposeful, safe, minimal redirection that serves the patient.

So practice the skill. Learn the anatomy. Know when to try and when to stop.

And remember: sometimes the most skilled thing you can do is recognize when it’s time to pull out and try somewhere safer.

Your patient will thank you for it.

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