Each year, specimen collection personnel who deviate from the standard for the procedure injure hundreds if not thousands of patients. Do you know the standard to which you will be held accountable? Do your coworkers? Does your staff or trainees? Could your procedure manual stand up to scrutiny should a patient be injured and seek compensation? The answers to these and other questions will determine your vulnerability to a phlebotomy-related lawsuit.

To assess your potential to inflict injury on a patient during phlebotomy---and that of those you manage or teach, size-up the expertise where you work or teach against this top-ten list.

10. Reinvent the procedure

When an established procedure is tinkered with, things go wrong. Over the years, myriad homespun innovations have attempted to modify a standard that was first introduced in 1980. Such “field modifications” we have heard of include:

• Using two tourniquets, one above the antecubital and one at the wrist;
• Routinely drawing from an artery instead of a vein;
• Allowing blood to openly drip into the collection tube from the hub of an inserted needle;
• Applying petroleum jelly or hand lotion to a skin puncture site prior to the puncture so that the blood “beads up” as it emerges;
• Tying a tourniquet around the elbow to hold the gauze in place as a substitute for direct pressure prior to bandaging;
• Forcibly bending a needle into a 45-degree angle before use “to establish a lower angle of insertion”;
• Plunging serum tubes into ice immediately after filling “to expedite clotting”;
• Combining the contents of two tubes (of either the same type or different) into one until a full tube can be submitted for testing;
• Applying a tourniquet under the armpit instead of several inches above the antecubital area;
• Entering the vein at a 90-degree angle.

Crazy? You bet. If you're wondering "who would do such a thing?", so are we. But we've heard of these very techniques being used on patients by healthcare professionals who should know better.

Such “homemade phlebotomy” only serves to increase one’s vulnerability to liability should an injury and/or complications occur. It is imperative that all laboratory procedure manuals reflect the prevailing standard of care as established in the literature and CLSI standards and guidelines, and that any attempt to modify the procedure is disciplined. Failure to enforce the standardized procedure for venipunctures can be seen by a jury as falling beneath the standard of care.

9. Draw from unorthodox sites

Not all veins are fair game. The acceptable sites include the veins of the antecubital area, the back of the hand and the foot and ankle. According to the CLSI standards, veins to the front of the wrist (palm side) or lateral wrists (thumb side) must not be used for venipuncture due the presence of nerves and tendons close to the surface. Veins to the feet and ankles should only be used with physician’s permission. Drawing from veins in sites other than these may subject patients to injury to nerves, arteries, tendon and bone. Regardless of the site of the venipuncture, whenever one is about to insert a needle into a patient’s flesh, one must have a thorough knowledge of the anatomy of that area in order to adequately assess the risk.

8. Seat the patient anywhere

Gravity happens. If it happens to your patient who has just passed out, the consequences can translate into injury and liability if you didn’t position him properly. According to the standards, patients must be recumbent or seated in a chair with arm rests for support in case the patient loses consciousness. This means chairs without arm rests are not acceptable for venipuncture; nor are exam tables unless the patient is recumbent. The standards also require patients with a history of fainting during blood collection procedures to be recumbent.
     Patients have suffered disabling injuries---even spinal fractures and paralysis---after losing consciousness and falling out of chairs without arm rests. Make sure your procedure manuals include this restriction and you are less likely to be subjected to the pain and anxiety that can come from being liable for injuries that result from improper positioning.

Next month, we'll continue our countdown in Part 2 of Top Ten Ways to Injure a Patient.