May, 2010

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Winning the Battle of the Butterfly

Is the Battle of the Butterfly being waged in your facility? Not the pretty kind of butterfly that flits around from flower to flower, but the kind in your draw stations and on your phlebotomy tray for drawing blood. Some patients insist you use them; most managers wish you wouldn't.... at least not so many. Stuck in the middle is you.

When the Battle of the Butterfly wages on in your facility, it can be a very polarizing issue. Some phlebotomists love 'em; some are indifferent. If it weren't for the fact that they can cost up to ten times as much as a syringe or tube-holder assembly, we wouldn't be having this conversation. But they do, and we must.

What do you do when a patient requests a butterfly when it's not necessary? Why do managers discourage their use? Whose side should you be on? Answering these questions requires a long, hard look at the good and the bad of the most controversial—and useful—blood collection device ever invented.

The good
Butterfly sets, or winged-blood collection sets, sound harmless enough. In fact, the name alone likely contributes in no small degree to their popularity with patients, especially pediatrics. Named for the "wings" that are held during use, butterfly devices are lightweight, maneuverable, and ideal for difficult veins. Patients for whom they are well-suited include those with fragile or delicate veins like geriatric, oncology, and neonatal patients. Because they are lightweight and have a simple construction, they can be inserted at a low angle and held lightly throughout the procedure without disrupting the needle.

The addition of an adapter on the non-patient end of the tubing allows them to be used in conjunction with either a tube holder or a syringe. Patients who prefer them sense they are less painful (after all, a "butterfly" would never hurt you!), and after one successful butterfly experience, tend to insist on their use for every future venipuncture, effectively positioning themselves on the front lines of the Battle of the Butterfly wherever they go for lab work.

The bad
Would you insist your dentist use a certain drill bit on your molar? Of course not. You trust your dentist to use the combination of equipment he or she finds most useful, successful, and does the best job in achieving the desired result. Why, then, would you allow patients to select the device you will use to draw their blood? Especially when the device they select is more likely to lead to an accidental needlestick than another device you are just as proficient with?

Compared to a needle/tube-holder assembly, butterfly devices have been associated with an inordinately high rate of accidental needlesticks for as long as records have been kept. (Figure 1.)

Figure 1. EPINet statistics on needlestick exposure (1)
Year Percentage of needlesticks sustained
while using tube-holder assemblies
Percentage of needlesticks sustained
while using winged needles
2007 1.7 5.5
2006 2.9 5.6
2005 1.4 6.7
2004 2.1 6.2
2003 3.8 7.6
2002 3 7
1998 6 8
1997 6 7

Therefore, allowing patients to select the device is allowing patients to increase the risk of an exposure. Given the potential, such requests must be weighed heavily.

The cost per butterfly set has the potential to makes overuse extremely costly to the facility. A survey of one laboratory supply company's online catalog shows multi-sample needles for tube holders cost 14 cents each compared to $2 a piece for butterfly sets. Because laboratories are under intense pressure to do more and more with less and less, uncontrolled butterfly usage can put a significant strain on a lab's resources. A recent online survey conducted by the Center for Phlebotomy Education asked respondents if their facility puts a monthly limit on the number of winged collection (butterfly) sets specimen collection personnel can use. Twenty-six percent said they did. The limits ranged from one box per phlebotomist per month to one box for the entire staff (size of staff not indicated).

A winning strategy
Every healthcare professional who draws blood samples is part of a team. Team players do what's best for that team, while preserving their own well-being. That means walking the tightrope of customer service, needlestick prevention, and cost containment. When patients request butterfly sets be used even though their circumstances don't require it, it takes a tact and diplomacy to reclaim authority over the procedure without upsetting some patients. Explaining that you have better success, and/or are more comfortable, with another device might be all it takes. After all, few patients will allow their own preferences to force the discomfort of multiple venipunctures upon themselves. For patients who demand butterfly use where not needed despite gentle persuasion toward a safer device, a policy should be in place and uniformly implemented on how the staff is to react.

When budgets are tight, as they always are, the use of the most expensive device must be reserved only for situations that require them. Phlebotomists and other healthcare professionals with blood collection responsibilities who use butterflies exclusively are allowing their own skills to erode.

It could also be argued that when budgets are tight, facilities can't afford to alienate patients. However, exchanging both your safety against accidental needlesticks and your employer's financial wellness for a satisfied customer may not be a logical tradeoff. (Accidental needlesticks have been found to cost the average facility around $4000 for immediate care, loss of productivity, and follow-up care and counseling.(2) If an infection is acquired, the cost to the employer skyrockets.)

Butterflies have their place. For some patients, they can mean the difference between a successful and an unsuccessful draw. But those who limit their use to those patients and situations that require them not only reduce their risk of exposure, but assist their employers in being able to provide for their employment and the benefits that go with it. If the Battle of the Butterfly is being waged in your facility, remember, the enemy is not the manager or supervisor who wants to limit butterfly use. It's not the patient who demands you use a butterfly. The real enemy is wasted resources and accidental needlesticks. Which side are you on?


  1. Data Reports from the U.S. EPINet Sharps Injury and Blood and Body Fluid Exposure Surveillance Network. International Healthcare Worker Safety Center, University of Virginia Health Systems. http://www.healthsystem.virginia.edu/internet/epinet/SOI/2007-NSI.pdf. Accessed 5/10/10.
  2. Pallatroni, L. Needlesticks: Who pays the price when costs are cut on safety? Adv Med Lab Prof, 1998;30(7).


Featured Product
Webinar on Phlebotomy-Related Lawsuits

The Center for Phlebotomy Education is presenting a webinar titled "Avoiding Phlebotomy-Related Lawsuits" at 1 pm. (ET) (GMT-4:00) on Tuesday, May 25, 2010. This webinar identifies common errors in the performance of venipunctures that cause minor and catastrophic injuries to patients and bring legal action against employers. It outlines policies, procedures and practices that those who perform venipunctures and their managers can implement to minimize their risk of litigation.

The presenter is Dennis J. Ernst MT(ASCP), director of the Center for Phlebotomy Education. Mr. Ernst will use actual cases from his files as an expert witness in phlebotomy-related litigation to illustrate key concepts. At the end of the webinar, attendees are provided with a list of questions to ask themselves or their staff to assess their vulnerability to inflicting a phlebotomy-related injury and the opportunity to pose questions to the presenter.

For more information, go to :

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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 11th year of publication, are reading about this month:

  • Feature Article: Identifying and Correcting Patient and Specimen ID Errors
  • Center Names Program Coordinator
  • Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in April including these stories:
    • CA Phlebotomist a Pain in the Neck
    • UK Nurses in Danger of Sharps Injuries
    • Germ Zapping Plasma Technology for Hand Hygiene
    • Little Improvement Seen in Hospital Infection Rates
    • Research Expanded on MI Newborn Blood Spots
    • Pilot Project Takes Nurses Out of Blood Donor Process
    • CA Phlebotomist a Pain in the Neck
  • According to the Standards: Analyte differences between capillary and venous blood
  • Tip of the Month: Let Your Reality Show
  • CEU 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
Alcohol prep before iodine for blood culture

Q: I teach the phlebotomy class at my local hospital and am currently re-writing my lecture. The CLSI standard says to allow the site to air dry after cleansing with the disinfectant, then remove it from the skin with alcohol. Why we should clean the site with the alcohol after we had already sterilized it with chlorhexidine/povidone-iodine?

Also, do you have to clean the site initially with alcohol? Does it have to be a 2-part scrub at all? In the past we have used either chlorhexidine or povidone-iodine but not both. The kits we use come with a povidone-iodine swab for cleaning the arm. The alcohol wipe is used to clean the top of the collection bottles. Is this a "violation" if we only do a single scrub?

A: You are referring to an older version of the venipuncture standard. The newest version (H3-A6) doesn’t include that reference. Instead, it states to remove iodine compounds from the skin after the procedure is complete to prevent absorption into the bloodstream and allergic reactions. It no longer mentions that it should be removed prior to the procedure. Historically, blood culture site prep has included an alcohol prep/scrub followed by a disinfectant such as iodine or chlorhexidine compounds. Recently a study showed three consecutive scrubs with 70% isopropyl alcohol to be just as effective as iodine in tincture form, povidone iodine, or povidone in combination with 70% ethyl alcohol (1).

Regardless, the preliminary alcohol wipe is not as critical as a good friction scrub (30-60 seconds) to get to the bacteria beneath the dead skin cells on the surface. Nor is it as critical as assuring the antiseptic compound remains in contact with the skin for at least 30 seconds.

If you are using iodine or chlorhexidine compounds, it won’t compromise the collection if the preliminary alcohol prep is left out. Again, the most critical aspect is friction and adequate skin contact with the disinfectant.

I wouldn't worry about "violating" the CLSI passage. But if you find your blood culture contamination rates creeping above 3 percent of all cultures collected, you might have to look at the lack of an alcohol prep step as one of the factors.

1.) Calfee DP, Farr BM. Comparison of four antiseptic preparations for skin in the prevention of contamination of percutaneously drawn blood cultures: a randomized trial. J Clin Microbiol 2002 May;40(5):1660-5.

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, click here.


Survey Says
Shift Change

Last month’s survey asked visitors to our website about the transition that occurs with blood collection personnel in their facilities at shift change.

If your blood collection staff covers multiple shifts, how would you describe shift change?

  • Smooth/Seamless: 59.3%
  • Confused/Chaotic: 11.1%
  • Quarrelsome/Contentious: 29.8%

With over 40 percent of our survey respondents indicating that shift change in their facilities is less than smooth, there’s a whole lot of unhappy shift changing going on. As illustrated by the survey comments below, attitudes of “it’s not my job” and “leave it for the next guy” combined with ineffective leadership can create a perfect storm of strife.

Sample Comments:

“The staff who is getting close to the end of the shift doesn’t want to draw patients since it may make them run late and the staff coming on feels that the [previous shift] should finish up the draws that were here before the end of the shift.”

“Each shift believes specific things are the other shifts’ responsibility.”

“There is often someone who hides a draw that they don’t want to do under the labels for future draws, i.e., after their own shift is over. This causes frustration and more work for the next shift.”

“Each shift believes that the previous shift leaves too much work behind. It happens on all three shifts!”

“Third shift supervisor creates conflict.”

“Lack of communication and poor leadership by lead team members.”

Another contributing factor to a less-than-seamless transition can be the physical environment within which blood specimen collection personnel have to work. One respondent stated that the confusion that occurs in their facility is due to having approximately 30 people trying to switch out phlebotomy carts in a very small hallway.

The good news is over half (59.3%) of those who participated in our survey seem to have found the secret to an efficient hand-off process. So what can we learn from their successes? One recurrent theme emerges from the additional comments below; the staggering of schedules of blood collection staff to provide a sufficient overlap between shifts. Coupled with clear employee expectations and a defined shift hand-off protocol, such a scheduling strategy makes for a more tranquil transition.

Additional Sample Comments:

“Everyone is assigned to a certain area and number of patients. Therefore, each phlebotomist knows what is expected of him/her.”

“We have shifts that do not start all at the same time. This allows us to make our transitions between shifts seamless and lets us staff appropriately for “peak” draw times.”

“The shifts overlap by 30 minutes. A pending list is generated within the last hour and the departing staff documents the status of the draws for their floor. This way, the oncoming shift does not need to waste time problem-solving the list.”

“Shifts overlap by 15 minutes to allow for the change in staff. Staff leaving come down and clean their trays so they are ready for staff coming on…”

Applying the Golden Rule to the workplace rather than shifting responsibility was another approach shared by one of our survey respondents. “We tell our staff that it’s not day-shift work, afternoon-shift work or midnight-shift work, it’s lab work and it needs to be done and that’s what your job is and that’s why you are coming into work when you do…Shifts do as much as they can in the hours they are here and try to have things cleaned up as best as they can so the next ones coming in can pick up and get going on the workload…They seem to respect that because what goes around comes around… So if you don’t dump on fellow coworkers they won’t dump on you…” Doing unto others as you would have them do unto you. Now there's a shift in thinking that turns a staff into a team.

This month’s survey question:
When you draw blue-top citrate tubes for coag, how do you transport them to the laboratory; on ice, in a chilled container, or at room temperature?

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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 download from the Center for Phlebotomy Education’s library of download articles. 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:
Information Exchange

You notice a recently hired phlebotomist exchanging phone numbers with a patient presenting for outpatient lab work. In a casual conversation, she's admitted to dating other patients she's met in the Emergency Department when drawing their blood. What would you do?


Being friendly is one thing, but the phlebotomist in this case study takes it to an extreme. It shouldn't take a lot of commentary to explain all the levels in which this scenario is inappropriate in a professional setting. But the underlying question concerns the role of a coworker who observes this behavior. Although it may be easier to turn one's head in the other direction and pretend it didn't happen, the right reaction is rarely the easiest.

Healthcare workers who are team players realize that such behaviors by coworkers reflect on the entire staff. Tolerance of inappropriate behavior is justifiably seen as an endorsement. That's why all who responded to this month's case study shared that intervention was required.

One respondent put it succinctly: "I would advise her to stop.  I would remind her of the company policy and let her know she could lose her job."

For her reply, Stephanie from Florida will receive a free download from the Center for Phlebotomy Education’s library of download articles.


This Month’s Case Study:
The Other End of the Needle

Tomorrow you get your appendix taken out in a hospital other than the one in which you work. The phlebotomist comes to your room to draw your pre-op lab work, introduces herself, checks the ID bracelet on your bedrail, finds a vein without using a tourniquet, cleanses the site, removes the sheath from the needle with her teeth, palpates the vein one last time, and is about to insert the needle into your basilic vein. 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. Next month, the best submission selected by our editors will earn the sender a free 5-pack of our Order of Draw pens.

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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