February, 2009

Copyright 2009 Center for Phlebotomy Education, Inc.
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Patient Identification Errors May be Added to Medicare’s No-Pay List

Last fall the federal Centers for Medicare & Medicaid Services (CMS) announced it would no longer reimburse healthcare providers for care stemming from nosocomial infections and incompatible blood transfusions. According to an article in the Dark Daily , the agency is considering adding three more categories of medical mistakes to the list. The latest so-called “never events” include:

  • Wrong surgical or other invasive procedures performed on a patient;
  • Surgical or other invasive procedures performed on the wrong body part; and
  • Surgical or other invasive procedures performed on the wrong patient.

The CMS web site recites the National Quality Forum’s (NQF) definition of never events as “errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.”  To be included on NQF’s list of never events, an event had to have been characterized as: 

  • Unambiguous—clearly identifiable and measurable, and thus feasible to include in a reporting system;
  • Usually preventable—recognizing that some events are not always avoidable, given the complexity of health care;
  • Serious—resulting in death or loss of a body part, disability, or more than transient loss of a body function; and
  • Any of the following:
    • Adverse and/or,
    • Indicative of a problem in a health care facility’s safety systems and/or,
    • Important for public credibility or public accountability.

Other insurers have followed the agency’s lead, implementing nonpayment policies of their own for never events. What’s unclear is whether or not the agency will consider venipunctures to be an invasive procedure. But the specter of non-payment alone provides phlebotomists and their employers reason enough to further reinforce proper protocol and adherence to the standards in their facilities.


Just Write for Lab Week: Order of Draw Pens

Managers and trainers looking for an inexpensive but uniquely educational gift for their students and staff can keep the recommended order of tube collection right at their fingertips. Just in time for National Medical Laboratory Professionals Week (April 19-25), the Order of Draw pen is comfortable and attractive with the order of draw illustrated in full color on the barrel for easy reference.

Many studies have proven that when blood collection tubes are filled in the wrong order, test results can vary, sometimes wildly, from the patient’s actual condition. Those who follow the prescribed order of draw collect specimens that are less likely to yield misleading test results that impact how the patient is diagnosed, medicated, and managed.

Reinforce the importance of the order of draw with phlebotomists, nursing personnel, medical assistants, the ED staff, and all those who draw blood specimens in your facility by putting this constant reminder in every pocket. The pens are available for immediate delivery in packs of 12 for $19.95.

For more information or to order, click here.


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This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 9th year of publication, are reading about this month:

  • Feature Article: Accuracy in GTT Collections
  • Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in January including these stories:
    • Phlebotomist Pleads Guilty to Fraud
    • Florida Near-Worst for ED Wait Times
    • Infection Control Failures Prompt Hepatitis Testing for 60,000 Patients
  • According to the Standards: Fingerstick site and wiping the first-drop
  • Tip of the Month: Spotting a Winner
  • CEU questions (institutional version only).

Buy this issue for only $9.95.

For subscription rates and to subscribe to Phlebotomy Today, visit www.phlebotomy.com/PhlebotomyToday.html. The current month’s issue will be emailed to you immediately upon subscribing.


Featured FAQ: Revised order of draw for emergencies

Q: Our written venipuncture procedure states the order of draw as: citrate, SST/clot, heparin, EDTA. Our Emergency Preparedness Plan currently states that when a trauma alert (i.e., disaster) is called, the order of draw changes to: EDTA (for BB/hematology purposes), citrate, heparin, and then the clot tube. I understand the need for BB/hematology to take priority in this kind of situation, but how does this revised order square with the risk of anticoagulant cross-contamination?

A: There’s no support in the literature for such a modification. It sounds as if the person behind this revision lacks an understanding of the rationale behind the order of draw. It’s difficult to understand why an emergency would demand a revised order of draw. Will there be someone standing by during every venipuncture to rush each tube to the laboratory as soon as it’s filled? You should vigorously discourage attempts to reinvent such a well-established procedure.

Each month, PT--STAT! will publish one of the hundreds of phlebotomy FAQs in the growing database of questions and answers available in Phlebotomy Central, the members-only section of the Center for Phlebotomy Education's web site. For information on joining Phlebotomy Central, visit www.phlebotomy.com/PhlebotomyCentral.html.


Center for Phlebotomy Education Opens Phlebotomy School

The Center for Phlebotomy Education has been developing educational materials for schools and healthcare facilities around the world since 1998. This month, they open their own school.

The School of Phlebotomy will provide students in the Louisville, Kentucky/Southern Indiana area with a valuable, marketable skill in healthcare, while creating a steady stream of qualified applicants for local hospitals and other healthcare providers.

“Phlebotomists have always been in high demand,” says the Center’s Director Dennis J. Ernst MT(ASCP). “Hospitals, laboratories, clinics, and other healthcare providers are always looking for good phlebotomists, not just locally, but across the country. Every healthcare facility we’ve talked to is anxious for us to start producing quality applicants to fill their vacancies.”

According to Ernst, the program is open to adult students of all ages. “Whether an applicant is just out of high school, a stay-at-home mom who wants to contribute to the family income, or someone who just lost their job, we can give a marketable skill to anyone who wants to develop professionally in an industry that weathers economic downturns better than most.”

The School of Phlebotomy is a certificate program that will prepare students to take a national certification exam, and then enter the workforce as valuable members of the healthcare team.  It offers 96 hours of classroom training followed by clinical experience at local hospitals where students are required to successfully complete 100 venipunctures and 25 skin punctures. The School of Phlebotomy, a newly formed division of the Center for Phlebotomy Education, will be seeking NAACLS program approval. Classes started February 2.


Survey Says

In last month’s issue we asked Phlebotomy Today STAT! readers
Do you have ammonia inhalants on your collection trays or in your outpatient drawing areas?”

Yes: 19%
No: 81%

Most of those who commented reflected a thorough understanding of the risk ammonia inhalants pose, especially to asthma patients. Because it is a respiratory irritant and asthmatics don’t identify themselves as such when presenting for lab work, the potential exists that a fainting patient who is given whiffs of ammonia can go into respiratory distress. The Clinical and Laboratory Standards Institute’s venipuncture standard (Document H3) has cautioned against the use of ammonia inhalants since 2003.

This month’s survey question: What mnemonic do you use to remember or teach the proper order of draw? (example: "Studious Boys Rarely Get Low Grades" = Sterile, blue, red, green, lavender, gray.)
Click here to participate in the survey.

Featured Product: Manager's Toolbox

Do physicians question the accuracy of your potassium results?

Is your laboratory plagued with hemolyzed samples from the emergency department?

Do you need an assessment tool for evaluating venipuncture competency of your staff?

Not sure if a specimen is too old to add on another test?

Would you like something to give your patients explaining post-venipuncture care?

If you responded “yes” to one or more of these questions, then the Center for Phlebotomy Education’s latest download is written with you in mind. “The Manager’s Toolbox” consists of five documents in PDF format including:

  • Analyte Stability Chart—lists what the current literature says about the stability of over 40 commonly tested analytes to help you and your staff know when adding on a test to a previously collected specimen is not appropriate.
  • Hemolysis and IV Starts—a summary of eight journal articles published between 1996 and 2008 comparing hemolysis rates of specimens drawn during IV starts versus venipuncture, ED draws versus lab draws, syringes versus tube holders attached to vascular-access devices, and more.
  • Potassium Troubleshooting Checklist—lists over 40 preanalytical causes of falsely elevated potassium levels (pseudohyperkalemia) including medications, disease states, and specimen collection and processing variables with full references to allow managers to troubleshoot the causes of spurious potassium results. Also includes a chart with 14 causes of hemolysis, which also falsely elevates potassium levels.
  • Venipuncture Competency Checklist—outlines the key steps of the venipuncture procedure according to CLSI standards to aid in the assessment by observation of a routine venipuncture. Also includes an exam that can be administered orally or on paper to assess the collector's knowledge of the procedure in regards to concepts that aren’t assessed in an observed venipuncture.
  • Post-Venipuncture Care card—a template created in Microsoft Word that managers can customize and hand to their patients instructing them on the care of their venipuncture site with contact information should they have any questions or complications after the draw.
Eleven pages of highly researched and referenced data in all, the “Manager’s Toolbox” gives access to documents previously only available to subscribers to Phlebotomy Central, the Center’s online comprehensive knowledgebase of specimen collection materials.

Click here to order Manager's Toolbox.

Manager's Toolbox



The January issue of PT-STAT! incorrectly stated that aPTTs from patients on unfractionated heparin must be tested within one hour. According to the CLSI standards (H21), such specimens must be centrifuged and the plasma separated from the cells within one hour, but testing can be completed in four hours. We regret this oversight, and appreciate our astute readers who have brought this to our attention.


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What Would You Do?

Each month, What Would You Do? presents a different case study, then asks readers to contribute their ideas as to how each situation would best be handled. The following month, selected responses will be chosen by the editor and published (sender will be identified by first name and state only). The most accurate, well written response will receive a free "Accurate Results Begin With Me!® t-shirt. The exercise will conclude with a review of the selected submissions and a discussion of the standards pertinent to the case study


Last Month’s Case Study:
A Standard Deviation

You’re drawing blood from the finger of an 18-month old outpatient being held on his mother’s lap. The collection went smoothly; you’ve mixed the specimens, and completed the tube labeling. You remove the gauze from the finger and see that the bleeding has stopped. Your facility policy reflects the CLSI standards about not bandaging fingersticks on infants less than two years of age, so you thank the mother and tell her they’re free to go. The mother insists you put a bandage on the infant’s finger.
What would you do?


Those who responded to this month’s case study showed a wide diversity in tactics. Ten percent suggested applying gauze or a cotton ball to the site instead of a bandage. Although such a substitute may seem to skirt the standards, the suggestion that gauze is less of a choking risk than a bandage seems hard to swallow.

Another ten percent suggested the collector have his/her supervisor handle the situation, while fully one-third of those who responded said they’d comply if the parent insists. Among those who favored this approach, some suggested the incident should be documented. From a customer service standpoint, this approach is likely to result in the most satisfaction, albeit the greater risk. Before adopting this policy facilities should weigh heavily the likelihood of being exonerated from liability when they allow a parent to insist they deviate from the standard of care.

Fifty-five percent provided the most diplomatic and least risky response: that of explaining the policy to insistent parents, then handing over the bandage for them to apply if they so choose. Presumably, the intent is for this action to transfer liability for choking to the parent…. at least in theory. Whatever the facility’s policy is, it should be carefully drafted with the input from the facility’s risk manager and/or legal counsel. One respondent suggested having a witness observe the handing over of the bandage to the parent. Should a witness not be available, the parent should sign a consent document. Such a strategy sounds prudent and crafted with an abundance of caution, the necessity of which should be asked of a legal representative.

Several articulate and appropriate responses made the selection of this month’s winner difficult. We considered it a four-way tie, and had to randomly select from the best of the best. This month’s chosen recipient of the Accurate Results Begin With Me!® t-shirt goes to Lois B. of Pennsylvania. Congratulations, Lois.


This Month’s Case Study:
Identity Crisis

You’re summoned to the emergency room to draw stat lab work on an
unresponsive patient with a ruptured aneurism. There’s a whirlwind
of activity, and the trauma team is urging
you to hurry so they can rush him into surgery.
You check his wrists and ankles for an identification bracelet, but he has none.
What would you do?

Tell us what you'd do in this case. Submit your response by the 20 th of the month and send it to this address and this address only: WWYD@phlebotomy.com. Submissions sent to any other address will not be considered. Keep your suggested solutions less than 100 words. Although you don’t have to be an English scholar to be considered for inclusion, submission with proper grammar and punctuation will be given priority. If you’re not sure of the appropriate solution, check your facility’s procedure manual or ask your manager. Who knows, you might be presented with the very same dilemma tomorrow.




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PT STAT! is a free, monthly educational service provided by the Center for Phlebotomy Education, Inc., the most respected authority in phlebotomy. For a complete company profile and product list for all healthcare professionals who perform, teach or manage specimen collection procedures, visit us on the Internet at: http://www.phlebotomy.com.
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Copyright 2009, Center for Phlebotomy Education, Inc. All rights reserved. Newsletters may contain links to sites on the Internet owned and operated by third parties. The Center for Phlebotomy Education, Inc. is not responsible for the availability of, or the content located on or through, any such third-party site. Information in this document is provided "as is," without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability, fitness for a particular purpose and freedom from infringement. The user assumes the entire risk as to the accuracy and the use of this document. We will not be liable for any damages of any kind arising from the use of this information, including, but not limited to direct, indirect, incidental, punitive, and consequential damages.