April, 2011

Copyright 2011 Center for Phlebotomy Education, Inc.
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Special Feature: Randolph World Ministries Update

What began in 2000 as a partnership with one Haitian clinic laboratory to improve laboratory services, Randolph World Ministries, Inc. (RWM) continues to expand its mission and outreach through medical missions, disaster relief, education, small business start-ups and evangelism to meet the spiritual and physical needs of the people of Haiti and beyond. Teaching Haitians how to draw blood properly and safely is a very important part of the ministry, but only a small part of their efforts to improve the quality of care Haitians receive.

In the wake of last year’s devastating earthquake, RWM experienced an unprecedented outpouring of support for the people of Haiti. Thanks to its partners including two laboratory suppliers, Infolab, Inc., and Greiner Bio-One, RWM shipped donated goods to Haiti almost every week for months following the quake.

In addition to its ongoing disaster relief efforts, RWM is bolstering the local economies of some communities through small business startups, such as The Lab Supply Company of Haiti, with other businesses under development. RWM is also conducting sickle cell research in Haiti, with the ultimate goal of transforming sickle cell disease in Haiti from a fatal disease that currently claims the lives of 90 percent of its victims before age five.

Earlier this year, RWM announced new projects including “Love a Rwandan Child” child sponsorship program that will provide assistance to over 800 orphans in coordination with local ministry efforts in Rwanda. RWM is also working with individuals in Africa to develop a new ministry called “African Genocide Reconciliation” with the goal of bringing together adversarial African tribes through Christian education. Plans are also underway to reopen the vision correction ministry, which fitted over 750 Haitians with glasses during RWM’s 2009 summer mission trip.

RWM has also partnered with the Saint Louis University Medical School and its Coe Service Program. Interested SLU medical students may apply to RWM to work in one of three areas: research, mobile clinics, and the free mass screening program. Selected students will log service hours in the U.S. to develop their respective program and then participate on two RWM teams to implement what they helped plan.
Other objectives in the planning stages include:

  • Creating and shipping a water treatment system and nutrition plan for individuals living in tent villages;
  • Establishing sickle cell treatment centers;
  • Expanding RWM’s medical mission ministry to Africa;
  • Developing a Christian Medical University;
  • Seeking dentists as partners to develop a dental ministry.

Currently, Randolph World Ministries has a list of urgent requests posted on its website, including prayer support, various medical and laboratory supplies, basic medicines and toiletries, and non-perishable food. The most important needs that the phlebotomy community can fill (in order of priority) are below:

  • EDTA tubes; 
  • Phlebotomists on mission teams; 
  • Pediatric styrofoam tube racks; 
  • Lancets; 
  • Styrofoam tube racks for 5mL tubes; 
  • Clot tubes (no other tube types are needed).

To learn more about this ministry and how you can help, visit www.randolphworldministries.org.


Wishing you a happy and healthy
National Medical Laboratory Professionals Week!

April 24–30, 2011

From all of us at the Center for Phlebotomy Education


CDC Reports on Contaminated Alcohol Prep Pads

Last month, the Centers for Disease Control and Prevention reported on the investigation by a Colorado children’s hospital into two cases of pediatric sepsis involving Bacillus cereus. As part of the investigation, alcohol prep pads used in the treatment of both patients were obtained from various locations within the hospital and cultured. Forty of the 60 pads representing eight different manufacturing lots, grew B. cereus or Bacillus spp.

All of the alcohol prep pads tested were supplied by a single manufacturer and were not labeled as either sterile or non-sterile on the outside of the individual package or on the box in which the prep pads were contained. Alcohol prep pads are commercially available as sterile and non-sterile products. Sterile products are labeled as such and should not be interchanged with non-sterile products.

B. cereus group and Bacillus species are resistant to killing by alcohol and have been previously linked to healthcare-associated outbreaks and product contamination. Healthcare facilities and users of alcohol prep pads should know if the pads they stock are sterile or non-sterile, and assess the risk for iatrogenic infection among their patients if non-sterile alcohol prep pads are used.

Centers for Disease Control and Prevention. Notes from the Field: Contamination of Alcohol Prep Pads with Bacillus cereus Group and Bacillus Species --- Colorado, 2010. MMWR March 25, 2011/60(11);347 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6011a5.htm?s_cid=mm6011a5_e&source=govdelivery. Accessed 3/31/11.


Ernst Interviewed by ADVANCE for MLP

Executive Director Dennis J. Ernst, MT(ASCP) shares personal insights regarding his career path and passion for phlebotomy education in his recent interview with ADVANCE for Medical Laboratory Professionals.

Executive Director Dennis J. Ernst, MT(ASCP), interviewed for Lab Leaders column in ADVANCE for Medical Laboratory Professionals.

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Featured Product
NEW CE Offering! To the Point® Volume 3 Download

The To the Point® Volume 3 Download provides accurate and affordable phlebotomy continuing education that is easy to use. A single download of five articles on various phlebotomy topics with corresponding test questions, the To the Point® Volume 3 Download allows users to earn up to 6.0 contact hours of P.A.C.E.® continuing education credit.*  

Highly researched and regularly updated, all material provided is current and consistent with the latest CLSI standards and OSHA guidelines. Article titles included in the download are:

  1. Mastering Pediatric Phlebotomy (1.0 contact hour)
  2. How Phlebotomists Can Alter Potassium Results (1.0 contact hour)
  3. What Every Phlebotomist MUST Know (1.0 contact hour)
  4. Risks to Phlebotomists: Allergies, Ergonomics, & Needlesticks (1.5 contact hours)
  5. Handling Patients with Needle Phobia (1.5 contact hours)

Users simply read all five articles, record their answers to the corresponding test questions and lesson evaluations, and submit the completed form for processing.

*To earn a total of 6.0 contact hours of P.A.C.E.® credit, a test score of 70% or higher for each article is required.

Click here to order and download.


This Month in Phlebotomy Today

Here’s what subscribers to Phlebotomy Today, the Center for Phlebotomy Education’s paid-subscription newsletter currently in its 12th year of publication, are reading about this month:

  • Feature Article: How to Become a Better Phlebotomist, Part IV: Conquering the Difficult Draw (geriatrics & cognitively impaired patients)
  • ASCP Publishes 2010 Wage Survey
  • Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in March including these stories:
    • NY Bill Makes Reckless Patient Safety Violations a Felony
    • Psychiatric Center Notifies 229 Patients of Possible HBV Exposure
    • Sucrose More Effective than Lidocaine for Reducing Newborn Venipuncture Pain
    • Phlebotomist among Jurors Seated for Barry Bonds’ Trial
    • Micro Sample Technology to Improve Efficiency, Reduce QNS
    • iPads in the Clinical Setting: You’ll Need an App for That
  • According to the Standards: Transporting Coags
  • Tip of the Month: I'm a Phlebotomist
  • CE questions (institutional version only).

Buy this issue for only $9.95.

For subscription rates and to subscribe to Phlebotomy Today, click here. The current month’s issue will be emailed to you immediately upon subscribing.


Featured FAQ
Preventing hematoma formation

Q: I drew blood from an elderly woman using a 22g needle and a tube holder. I needed two gold tops and one purple top. The first gold top filled fine, but when I switched tubes, a hematoma was forming and I had to take the needle out. Why do hematomas form during a blood draw? Would it have helped to use a butterfly instead of a 22-gauge needle? Is it possible that during the switching of tubes in the holder that I moved the needle out of position causing the hematoma? What can I do to prevent this from happening in the future?

A: The hematoma was likely a result of two things: the age of the patient and needle movement during tube exchange. Elderly patients are more prone to hematoma formation than younger patients. That's because when you puncture a vein of a younger patient, the vein is more elastic and constricts around the needle when it is inserted. In older patients, the elasticity is gone and the blood readily oozes from the vein where the needle passes through its upper wall. Should the needle be disrupted during tube exchange, as is likely in your case, the space around the needle increases and the hematoma forms.

You can minimize the oozing of blood around the needle by keeping the needle as stationary as possible during the transfer. Keep the backs of your fingers holding the syringe or tube holder firmly on the patient's forearm and make sure you use the flared extensions of the device to push on and pull off the tubes.

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 website. For information on joining Phlebotomy Central, click here.


Survey Says
Drawing from Unorthodox Sites

Last month, visitors to our website were asked when performing phlebotomy procedures if they ever feel pressured to draw from unorthodox sites. For those who do, we asked they identify the most common source of the pressure encountered, and if they have ever actually drawn from an unorthodox site.

When performing phlebotomy procedures, do you ever feel pressured to draw from unorthodox sites?

    • Yes: 39%
    • No: 61%

Sample Comments:

  • “…we are the professionals and if you are confident in your knowledge and skills, there should be no reason to feel any type of pressure to draw from unorthodox sites.”
  • “If by unorthodox you mean the wrist area, no matter how good the vein looks, it is too dangerous.”
  • “Always say it is against our protocols.”
  • “…I want to get good specimens, so I will not draw from any places that are not called for in phlebotomy guidelines.”

Those who affirmed feeling pressured identified the top three sources as the patient (30%), followed by nursing (26%) and the Emergency Department (22%). Attending physicians and parents of pediatric patients tied at nine percent, with the laboratory at four percent (see Figure 1).

Sample Comments:

  • “Several patients have told me that they have been stuck in the palmar side of the wrist, and they expect me to do the same.”
  • “I work in the ER but was trained in the lab… nurses constantly point to inappropriate sites for me to draw from.”
  •  “Occasionally the patient will request a site. I always educate them as to why I cannot draw there and provide options.”
  • “When the physician says ‘just get the blood however and wherever you can’, you just do it.”
  • “I work with children… parents are my major issue!”
  • “Drug users have asked me to draw from very unusual sites, e.g., top of leg.”
  • “Most often the physician just wants the blood and is not particularly interested in what it costs the patient or the phlebotomist to get it.”

When asked if they had ever drawn from an unorthodox site, almost two-thirds (64.4%) of survey participants responded that they had. Interestingly, over half of this group (52.6%) indicated that they did not feel pressured by outside sources to do so.  

Sample Comments:

  • “If the patient is really, really sick and there is no other site, I do… but this is rare.”
  • “When nothing else is available.”
  • “Only with an MD supervising the draw.”
  • “…I have drawn from veins up and down the arms and legs and feet. My oddest site was a vein on top of the great toe…”
  • “In a rare case when even the RN couldn’t get an IV in the patient, I drew from the wrist area, which is frowned upon at our facility.”
  • “I have had to draw blood from large surface veins in the shoulder/upper chest area on obese patients with severe edema. Doctors and nurses both have asked me to draw there on patients…”
  • “Emergency department needs the blood stat because the patient is going to the operating room due to a trauma.”
  • “…the blood test had to be done and no doctor was around for advice…”
  • “If you call the foot or the wrist an unorthodox site, I have done that.”
  • “As supervisor, I have found others who try to use the wrist area. If I can prove it, disciplinary action is started.”
  • “I have been a phlebotomist for almost 20 years and had a really strict instructor who not only taught us not to draw from these sites but also gave us the why’s of not allowing yourself to be tempted into it.”

According to CLSI’s venipuncture standard (H3-A6), veins on the underside of the wrist must not be used due to the close proximity of nerves and tendons to the skin’s surface. In addition, alternative sites such as ankles or lower extremities must not be used without physician permission due to the risk of serious complications.

In difficult draw situations, the phlebotomist can escape liability if the physician provides permission, ideally in writing. Collectors should also keep in mind that obtaining the patient’s permission to draw from an orthodox site may not be sufficient to protect them from liability should an injury or complication occur, since the patient may not fully comprehend the risk.

This month’s survey question:
Do you observe the tip of every needle for burrs and defects before use?


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What Should We Do?

[Editor’s Note: "What Should We Do?" gives you the opportunity to ask our team of technical experts for advice on your most pressing phlebotomy challenges. Whether technical or management in nature, we'll carefully consider solutions and suggestions based on the industry's best practices so that you and those in other facilities with the same problem can benefit, all the while maintaining your facility's anonymity. What Should We Do? is your opportunity to ask us for suggestions on the best way to handle your real-life dilemmas.]


This Month’s Case Study:
Issuing Tourniquets


One reader writes: “We are allowed to have one tourniquet when we go about our duties. Primarily, this is a safety measure to prevent a phlebotomist from leaving a tourniquet in the patient's room, or worse, on the patient. The difficulty is that we have to carry this same tourniquet from room to room. To get another, we have to call the lab for one to be sent. This is fine on the evening shift when the work slows and we can afford to wait for materials to reach the floor. However, on the day and night shifts, when a phlebotomist may draw from 30 or more patients in a three- or four-hour period and all samples have to be in the lab by a specific time, waiting for tourniquets to get to the floor is not an option.

How are we to help lower the rates of infection when the tools we use are contaminated and there isn't time to replace them? We have tried using gloves as tourniquets, but for patients that are larger and/or edematous, getting a glove that fits is sometimes a problem. Tying the glove tightly enough to constrict venous blood flow while ensuring that it will be easy to take off immediately after drawing the sample is also a concern. Any alternatives or solutions you are able to offer would be greatly appreciated.”

Our response: Although well intended from a patient safety perspective, the one-tourniquet limit you describe appears to have at least one unintended consequence, that of negatively impacting staff productivity, not to mention the potential to spread nosocomial infections. Clearly, continuing to use a soiled tourniquet is not acceptable. According to CLSI, tourniquets must be discarded immediately when contamination with blood or body fluids is obvious or suspected.(1) When a tourniquet is not available, one option is using a blood pressure cuff inflated to 40 mmHg to distend the patient’s veins.(1)

Regardless, it sounds like it’s time for you to communicate your concerns to your supervisor. If addressed as a patient safety, process improvement, and infection control issue, input from your facility’s risk manager and infection control personnel may be helpful. Because reusable tourniquets are a potential reservoir for bacterial pathogens, and have been known to spread MRSA, some institutions have implemented a single-use tourniquet policy.(2,3)

In terms of your current protocol, there are ways to account for tourniquets without compromising turn-around times and efficiency. For example, each phlebotomist could be issued two tourniquets per shift, with the second tourniquet held in reserve on the phlebotomist’s tray/cart in a zip-closure bag. Should the primary tourniquet become soiled, the phlebotomist could request a replacement from the lab, as is your facility’s current practice. The difference is the phlebotomist could then continue drawing patients in the interim using the second tourniquet. The tourniquet delivered by the lab would then serve as the phlebotomist’s new “reserve” tourniquet. This would ensure that the phlebotomist has only one tourniquet in use at any given time, but makes a replacement tourniquet readily available when needed.

Alternatively, your facility could combine strategies and issue a dedicated tourniquet to each patient upon admission, and designate it as the primary tourniquet. If it disappears, you would still have the one you have been personally allocated as a backup.


  1. CLSI. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture: Approved Standard – Sixth Edition. CLSI document H3-A6. Wayne, PA: Clinical and Laboratory Standards Institute; 2007.
  2. Hensley D, Krauland K, McGlasson D. Acinetobacter baumannii and MRSA Contamination on Reusable Phlebotomy Tourniquets. Clin Lab Sci 2010; 23(3):151-156.
  3. Center for Phlebotomy Education. Tourniquets Tied to MRSA Threat. Phlebotomy Today July 2008; 9(7).


Your most challenging phlebotomy situations and work-related questions.

Send your submission to WSWD@phlebotomy.com and you just might see it as a future case study.



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Copyright 2011, 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.