October, 2011

Copyright 2011 Center for Phlebotomy Education, Inc.
 All rights reserved. View our copyright policy.


Is the Order of Draw a Tough Sell in Your Facility?

Have you witnessed others with blood specimen collection responsibilities drawing additive tubes in the wrong sequence? Have you been preaching the Order of Draw in your facility and found that winning converts is an uphill battle?

If your message on correct tube filling isn’t sticking with those who perform the task, perhaps we can help. It is well documented that the Order of Draw is necessary. It's a subject the Center for Phlebotomy Education knows a great deal about and has written on extensively.

The Clinical and Laboratory Standards Institute (CLSI) in its venipuncture standard (H3-A6) states that the following order of draw is recommended to avoid possible test result error due to additive carryover:(1)

  1. Blood culture tube/vial
  2. Coagulation tube (eg, blue stopper)
  3. Serum tube with or without clot activator, with or without gel (eg, red stopper)
  4. Heparin tube with or without gel plasma separator (eg, green stopper)
  5. EDTA tube with or without gel separator (eg, lavender or pearl stopper)
  6. Glycolytic inhibitor ( eg, gray stopper)

To help you get this point across, we’ve provided the following links to free articles either authored or co-authored by our Executive Director, Dennis J. Ernst MT (ASCP), on the Order of Draw. One or more of these cites an article that first appeared in the literature in 1977 showing result differences when additive tubes are drawn in a random order:

We also have a video clip on YouTube.com about the Order of Draw for venipunctures that provides some explanation as to why it’s so important. http://www.youtube.com/watch?v=P5pcmqPuSDo

To help reinforce the concept with new and existing staff, we offer the following Order of Draw items for purchase on our website:

Order of Draw Products™, a California-based online company founded by phlebotomist Pam VandeDrink, is another resource for Order of Draw items including bracelets, watches, badges, t-shirts, and much more.


  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.

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Featured Product
Center Announces 2011-2012 Webinar Schedule

The Center for Phlebotomy Education announces its 2011-2012 Phlebotomy Best Practices webinar series beginning in November. The series, consisting of four webinars, each one hour in length, will cover a wide variety of preanalytical topics and is developed for phlebotomists and all other healthcare professionals with blood collection responsibilities. The 2011-2012 schedule is as follows:

November 17, 2011
Safety Survey: How Vulnerable Are You to a Needlestick?

December 13, 2011
Preanalytical Benchmarks: How Does Your Lab Compare?

January 17, 2012
Ten Commandments of Phlebotomy

February 14, 2012
Seizing Control of Blood Culture Contamination Rates

All webinars begin at 1pm, Eastern Standard (Daylight) Time - GMT-5 on the dates listed.

All content reflects the standards and guidelines of the Clinical and Laboratory Standards Institute (CLSI), and is presented by a faculty of national and international speakers including Dennis J. Ernst MT(ASCP), the Center's Executive Director, and Lisa O. Ballance BS, MT(ASCP), CLC(AMT), the Center's Director of Online Education. The Center has been providing educational materials and resources to healthcare professions since 1998.

Registrations are being accepted for individual events or for the entire series at a discounted rate, and are priced per login. For more information, contact the Center through our website, or call toll free 866-657-9857.

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 X: Leadership roles
  • Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in September including these stories:
    • Improper Glucose Monitoring Practices Growing Concern for CD
    • HHS Rule to Give Patients Direct Access to Lab Results
    • Crocs Footwear Banned by NHS
    • PA Phlebotomist Finds Niche in Healthcare
    • Offering Topical Anesthetic Improves Odds of Blood Donation
    • MA Phlebotomist Found Not Guilty of Patient Assault
    • Study Finds Skin Disorders among HCWs Linked to Work Stress
  • According to the Standards: "Windows" technique
  • Tip of the Month: The Path of Least Resistance
  • 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.

Follow us on...
Our Facebook PageOur Facebook Page

Last Month on Facebook

During the month of September, fans and visitors to our Facebook page shared their thoughts on the following topics:

  • Acquiring phlebotomy experience
  • Tips for new phlebotomy students
  • Sources of phlebotomy continuing education
  • Crocs™ footwear in healthcare settings
  • Drawing a patient with a fistula in each arm
  • Tourni-tie tourniquet coupling device
  • Privacy curtains as a source of contamination
  • Following the Order of Draw
  • Easing patient anxiety

Looking for an online community to post questions or to simply satisfy your hunger for phlebotomy talk between newsletter issues? Visit and “Like” our Facebook page and you’ll never miss out on another discussion. Your peers need your input, and you need theirs. www.facebook.com/CPEInc


On a Personal Note...

A few months ago, my "From the Editor's Desk" column in Phlebotomy Today talked about an incident that took place after I conducted a phlebotomy workshop in Austria. But there's more to the story. ….If you have a moment, follow me.


Featured FAQ
Drawing from triple lumen catheters

Q: With a triple lumen catheter, there is one port that is used to draw blood. Do all other ports need to be shut off for a certain amount of time before collecting the specimen, and should there be a volume discarded before withdrawing blood to be tested?

A: According to the Infusion Nurses Society's Procedures and Policies for Infusion Nursing, the procedure for withdrawing blood from a triple lumen catheter is the same as what the CLSI venipuncture standard says for drawing from any vascular access device. That is, all other ports need to be shut off for at least 2 minutes. The lumen through which the blood is to be drawn should be flushed with 5 cc of saline, and a discard volume withdrawn prior to collecting the specimen. The discard volume should be twice the dead-space volume of the catheter for all labs except coags, which require 6 times the dead-space volume. Five cc is usually sufficient.
 You should confirm this with your facility's policy and make sure the policy squares with the standards.

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
Duties Beyond Phlebotomy

Last month’s survey confirmed what we’ve long suspected: those who draw blood wear a lot of hats and have quite a few job titles. We asked visitors to our website and Facebook page if blood specimen collection was their main duty at work. Nearly two-thirds of survey participants responded that it is.

At your place of employment, is blood specimen collection your primary duty?

  • Yes: 65%
  • No: 35%

Of those who indicated blood specimen collection is their primary duty, 57 percent reported performing five or more additional tasks. Just five percent of this group reported that drawing blood is their only responsibility in the workplace. Figure 1 provides a breakdown of survey responses by job title.

Figure 1

  • Phlebotomists: No 21%; Yes 79%
  • Medical or Lab Assistants: No 42%; Yes 58%
  • Phlebotomy Supervisors or Managers: No 38%; Yes 62%
  • Laboratory Managers: No 67%; Yes 33%
  • Clinical Laboratory Scientists/Medical Technologists: No 67%; Yes 33%
  • Medical Laboratory Technicians: No 50%; Yes 50%

To learn more about the additional duties being performed by those who draw blood, we asked survey participants to identify those tasks and indicate if they felt their training was adequate. Responses are summarized in Table 1 below.

In addition to blood specimen collection procedures, what other tasks do you perform as part of your regular duties? Do you feel that you received adequate training to perform these tasks?

Table 1


Total %
Performing Task/Activity

Adequately Trained?



Specimen processing




Mentoring/training students




Inventory control




Point-of-care testing (POCT)




Patient result reporting








Instrument maintenance




Patient coding/billing




Courier duties




CLIA non-waived testing




Setting up/plating micro specimens




Bleeding times




Making blood smears at the bedside




TB skin tests




With regards to training, the good news is an overwhelming majority of respondents felt it was sufficient for the tasks assigned. Interestingly, the activity with the highest negative response for adequate training was patient coding/billing (27%).

Other work activities mentioned by survey participants not on the list included various clerical duties, patient registration, computer order entry, printing daily reports and pending logs, QA reporting, problem solving, handling physician/patient complaints, urine drug screen collections, N95 fit testing, payroll, health fairs, and therapeutic phlebotomy draws.

Sample Comments:

  • “As the Lead Phlebotomist in a 350+ bed hospital with an outpatient lab that does not require appointments and will not turn any patient away regardless of the hour, I am responsible for 1) preparing, sending, and tracking samples to multiple reference labs; 2) maintaining files for not only the results but ordering requisitions from numerous off-campus facilities; 3) maintaining outpatient Rx's; 4) printing daily reports and pending logs; 5) handling phone calls from all hospital staff with questions pertaining to the laboratory and specimen handling; 6) charting refrig/freezer temps for storage of reference samples and the morgue.”
  • “At our facility, we register patients, order their tests, set up blood and urine cultures, wash pipettes, perform bleeding time tests, do nasal and throat swabs, and centrifuge specimens. We also have a steady stream of students coming through from local colleges and high schools that we have to supervise and educate.” –Medical/Laboratory Assistant
  • “Paperwork, lots of it!” –Phlebotomist
  • “Send-out specimen preparation, urine drug screen collection, alcohol breathalyzer testing, secretarial filing, faxing, outpatient admitting, and special projects for techs.” Phlebotomist
  • “Drug screen collections (DOT and non-DOT), paternity collections, assisting with bone marrow collections (making slides etc.), nursing education for lab-related issues, policies/procedures, competency assessments, safety, monthly reports.” –Phlebotomy Supervisor/Manager

Participants in this survey self-identified as phlebotomists (49%); medical or laboratory assistants (22%); phlebotomy managers or supervisors (15%); medical laboratory technicians (5%); laboratory managers (3.5%); clinical laboratory scientists/ medical technologists (3.5%); and other (2%).

This month’s survey question:
According to your facility's written procedure for blood specimen collection, at what point during the draw are you instructed to don gloves?

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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:
Postural Effect on Hematocrit

One reader writes: There is a discussion going on within our hospital inpatient system regarding hematocrit (HCT) results being low in the early morning. Our medical director has suggested a postural effect. Should there be posture and time-of-draw requirements for HCT?


Our response: According to Tietz Clinical Guide to Laboratory Tests, recumbency can account for decreased HCT results. "Hb, HCT and RBCs are slightly lower between 5:00 PM and 7:00 AM and after meals (up to 10% lower); they are up to 5.7% lower if drawn from a recumbent patient."(1)

Passages regarding the effects of recumbency and posture on HCT results also appear in Effects of Preanalytical Variables on Clinical Laboratory Tests:(2)

  • Six percent drop at 20 minutes in [sic] normal. (Tan MH, Wilmshurst, EG, Gleason RE et al. Effect of posture on serum lipids. N Engl J Med, 289 416; 1973)
  • Change of seven percent with lying, four percent with sitting. (Tan MH, Wilmshurst, EG, Gleason RE et al. Effect of posture on serum lipids. Clin Res 20, 884; 1972)
  • In 20 healthy individuals after 10 minutes of recumbency, mean changed significantly to 0.3785 from 0.4023 while standing. (Fogh-Andersen N, Altura BM, Altura BT et al. Composition of interstitial fluid. Clin Chem, 41, 1522-1525; 1995)
  • A change from the supine to the erect position leads to a reduction of the blood volume with an increase of the hematocrit of about 13 percent. (Guder, WG, Narayanan S, et al. Samples: From the Patient to the Laboratory, 1-101; 1996)
  • In 20 healthy men, mean increase from baseline of 0.418 to 0.455 after 18 minutes standing; decline to baseline within 30 minutes of lying down. (Muldoon MF, Bachen EA, et al. Acute cholesterol responses to mental stress and change in posture. Arch Intern Med, 152, 775-780; 1992)

Diurnal, postural and postprandial variations of hematocrit were documented in the literature as early as 1965. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936443/pdf/canmedaj01137-0011.pdf

Some of these studies are dated, but by sharing this information with your medical director, your facility can make an informed decision. We know of no facility that has posture requirements for HCT testing. Nor do the CLSI standards or guidelines make such a recommendation.


  1. Wu, A. Tietz Clinical Guide to Laboratory Tests; Fourth Ed. W.B. Saunders Co. St. Louis, MO. 2006.
  2. Young D. Effects of Preanalytical Variables on Clinical Laboratory Tests; Third Ed.  AACC Press. Washington, DC. 2007.


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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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 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.