November, 2009

Copyright 2009 Center for Phlebotomy Education, Inc.
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Literature Review of Newly Published Studies

The Center for Phlebotomy Education has its nose in the news every day. Countless hours are spent researching publications for articles and new studies on all aspects of blood sample collection in order to keep ourselves, our products, and our readers up-to-date in the world of phlebotomy. Rest assured, if it's new and pertinent, you'll find out about it here first.

Here are the summaries of some published studies we've recently encountered that we thought our readers might find useful and informative:

Errors in a blood donation center
Researchers in India studied phlebotomy errors occurring at a blood donor center over eight months. After reviewing nearly 12,000 donations, the phlebotomy error rate was 3.1% of all donations. Fifty-five percent were technical while 45 percent were clerical. Nearly 58 percent of the technical errors were classified as minor; 42% were major. Of the clerical errors, 90 percent were minor.  All the major errors in both categories were committed by trained staff as well as most of the minor technical errors. Most of the minor clerical errors were committed by newly recruited staff members.

Residents admit to inadequate phlebotomy training
Medical school residents surveyed about the adequacy of their training reported feeling incompetent at the end of their training when it came to accessing veins and performing venipunctures. Other procedures the residents felt they failed to achieve competence in included neonatal intubation and administering injections.

Sample-labeling errors studied at 147 clinical laboratories
Researchers at UCLA set out to determine the frequency of labeling errors at 147 clinical laboratories. Errors were categorized as mislabeled, unlabeled, partially labeled, incompletely labeled, and labeled illegibly. After reviewing 3.3 million specimen labels, the error rate among all laboratories was 0.92 per 1000. Laboratories that had current and ongoing quality monitors for sample identification achieved the lowest rate of unlabeled samples as well as labs that had 24/7 inpatient phlebotomy services.

Researchers study blood bank sample mislabeling
The rate of tube mislabeling of blood bank samples was 1.12 percent according to a recent Q-Probes study reported in CAP Today. Just over 17 percent of institutions surveyed used the patient's ward or other location as a means of identification, which goes against multiple CLSI standards. A full 93 percent of institutions allow non-laboratory staff to draw blood bank specimens. The percentage of missing, incomplete, or inaccurate identification bracelets was 0.5 percent. The article states that non-laboratory personnel are up to four times as likely to be rejected for any reason than those drawn by laboratory personnel.

ED Hemolysis costs facilities $556 per day
Researchers in Singapore reduced hemolysis rates from 19.8 percent to 4.9 percent by implementing process changes when collecting samples from emergency room patients. Among the changes were performing venipunctures instead of drawing blood samples during an IV start, and by using syringes instead of tube holders. The cost savings of reducing hemolysis rates to this degree were reported to be $556.30 per day in the emergency department alone and $203,037 per year.


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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 10th year of publication, are reading about this month:

  • Feature Article: Eight Questions Everyone Who Draws Blood MUST Answer Correctly, Part 4
  • Phlebotomy in the News: a round-up of articles on phlebotomy and phlebotomists who made Internet headlines in October including these stories:
    • Schwarzenegger Exempts HIV Counselors from Certification Mandate
    • Austin Attempts to Block Police from Drawing Blood
    • Professions with Multiple-Patient Exposures Risky to Patients
    • Doctors Rated Worst at Hand Washing
    • Phlebotomist Accused of Sexually Assaulting Patient
  • According to the Standards: Proper inpatient identification
  • Tip of the Month: Of All the Nerve
  • CEU questions (institutional version only).

Buy this issue for only $9.99.

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


Featured FAQ: Hemolysis and 25-gauge needles

Q: I have always been taught that a 25-gauge needle will hemolyze a specimen and affect patient results adversely. But my staff argues that if this is true, why do manufacturers make them? I don’t have an answer for that. I hate being the mean old phlebotomy supervisor and tell my staff they can't use them just because I said so. How do I answer their challenge?

A: Your staff's argument that the availability of 25-gauge needles justifies their use is irrational. Just because 18-gauge needles are available, does that mean that they can use them, too? Of course not. You are exactly right about 25-gauge needles causing hemolysis. Tell your staff 25-gauge butterflies are available, but they have limitations, they often compromise specimens, and should only be used when it clear that no other needle will work. For example, venipuncture on infants or geriatrics where veins are so small or fragile, that a 23-gauge needle will blow the vein. By no means should they be considered for routine draws. Take a stand and stick to it. It’s up to you to define the boundaries; expect for them to be challenged.

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/category/Phlebotomy-Central.cpe.


Survey Says: Outpatient identification practices

Our latest survey asked Phlebotomy Today STAT! readers: Does your facility provide outpatients with an identification band prior to a blood draw? Forty-one percent of respondents indicated their facility tags their outpatients with identification bracelets. Fifty-nine percent worked in facilities that did not provide outpatients with an ID band. Responses include the following:

  • All patients wear identification bands-Lab, EKG, Radiology.... works great!!
  • ...but we have had issues with admitting not putting them on & just handing them to the patient;
  • However, sometimes the patient has the wrong band on;
  • All patients are required to be banded prior to blood collection. Series [sic] patients need to also check in and have a band put on prior to phlebotomy;
  • No! especially outpatient or walk-in patients as long as the doctors requisition is there and also [a] Healthcard is the best way to identify a patient prior to blood collection.
  • Unless they are being drawn for Blood Bank, that changes everything and they have to have a wristband on.

Identifying outpatients with identification bracelets is up to the facility. Even when identification bracelets are used for outpatients, steps must be implemented that guarantee the band is correct and was applied to the right patient. Asking patients to confirm their identity is one method for discovering banding errors that might have occurred during registration.

This month’s survey asks two questions: Do you routinely ask inpatients to state their name as verification of their identification bracelet? Have you ever found an identification bracelet attached to the wrong patient?

Featured Product: To the Point® Articles

To The Point® is a library of pay-per-download articles offered by the Center for Phlebotomy Education covering many aspects of blood specimen collection including technique, safety, difficult draws, preanalytical errors, and more. Highly researched and extensively referenced, each "To The Point" article provides the most current information available to all who perform, supervise and teach blood collection procedures. All articles are current with CLSI standards and OSHA guidelines.

The To The Point library consists of 17 individual documents in pdf format, each between 4-17 pages in length and are available by download only. A partial list of titles in the library includes: "Drawing Under Special Conditions," "What Every Phlebotomist MUST Know!," "Preanalytical Errors (Parts I, II & III)," "When Professionals Aren't: Behaviors that Create Bad Impressions," and "How Phlebotomists Can Alter Potassium Results."

For more information and to view the entire library of To The Point® articles, visit: www.phlebotomy.com/category/TTP-Articles.cpe

To the Point articles in phlebotomy
To the Point

Center Launches Redesigned Web Site

The Center for Phlebotomy Education launched its newly redesigned web site (www.phlebotomy.com) on October 30 with global enhancements designed to improve its visitors' searching, browsing, and purchasing experience. The redesign is the first major upgrade to the site in four years, and is the work of Joseph Sims, the Center's graphic/web designer acquired in 2007. Features of the new site include:

  • Better, more centralized organization of products;
  • Faster loading web pages;
  • More readable typography;
  • Simpler browsing through products and informational pages;
  • Fresher, more contemporary look and feel;
  • Content of www.phlebotomy.com now searchable from every page;
  • Smoother, more intuitive checkout process;
  • More dynamic previews of videos and books;
  • Easier navigation and searching through Phlebotomy Today–STAT! archives;
  • Search window filtering to include content from newsletters only;
  • Elastic architecture to accommodate visitors' varying monitor sizes;
  • Enhanced features using CSS3 styling techniques;
  • Standards-based HTML and CSS coding.

     "The primary goal of this redesign was to create a new architecture for our site that helps visitors find what they're looking for quickly, and with the least amount of frustration." says Sims. "We also wanted the re-architecture to permit the kind of content delivery our customers and visitors want and need."

Each month nearly 20,000 visitors roam www.phlebotomy.com's web pages seeking products, services, and information to help them teach, manage, and perform blood collection procedures. The re-architecture has been over a year in the making, and paves the way for more educational and interactive content scheduled for phlebotomy.com in 2010. Future features being developed for phlebotomy.com include more robust CEU options, blogs from the Center's director, the establishment of an online phlebotomy community, and streaming videos.


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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 To the Point® library of 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:
A little help from an addict

Your next patient is a drug addict with no veins. After two failed attempts, you are ready to give up. He asks for the needle so he can place it into a vein himself. What would you do?


Every reader who responded to this month's case study indicated they know better than to let a patient draw his/her own blood. Many underscored the liability it brings to the facility should an injury occur; others recognized the risk to themselves when giving a sharp to any patient, much less a habitual drug user. Handling the request tactfully requires a polite rejection of their request, and most of those who responded indicated they would be diplomatic.

Sixty-one percent said they would ask the patient for their suggestions on where to obtain blood while 46 percent said they'd seek the assistance of another caregiver with phlebotomy expertise. Some of those would do both.

One respondent indicated he would ask the physician for direction while another indicated she'd find a warm blanket for the patient as a means to increase circulation and, hopefully, distend veins for easier location.

Some comments:

Jan C. said "As a new phlebotomist over 30 years ago, I meet a man with abscesses and dark lines running up both arms from abusing drugs.  After just one failed attempt and causing him pain, he offered to draw his own blood.  I assumed this was against hospital policy and there was no way I was going to put a sharp object in this man's hands.  So I asked him to teach me where and how to get his blood as painless as possible.  He showed me, I was successful and we both parted feeling good.

According to Mary M., "I smiled to myself after reading this one.  My ex-husband had this exact scenario as a medical student almost 30 years ago, except that the addict was a prisoner and was wearing a leg cuff. He did give the syringe to the prisoner and was able to obtain a sufficient amount of blood for sampling from a foot vein.  Needless  to say, my ex- was very fortunate that any number of adverse things that might have happened, didn't. In any case, if I remember correctly, at no time are lower extremities to be used by non-MDs for draws and I would politely decline the addict's kind offer but ask for his/her suggestion of a site."

Dean S. was very articulate and professional in his response as well. "Listening attentively to patients goes a long way in providing great customer service, and may also give valuable insight into finding a viable site to draw blood. However, competently drawing blood from a patient goes much further than any skill or knowledge gained from being a intravenous drug user. Not only do I have a responsibility towards safety, but the physician is counting on me to provide a quality specimen—one that yields an accurate result. This includes ensuring proper fill levels, and the correct order of draw at a minimum. I would say to the patient, 'I appreciate your desire to help, but your safety is paramount and, because of that, I will be calling for assistance from a coworker. I will be sending so-and-so who is very competent—someone I would trust drawing blood from myself.'"

Each of these entries are excellent responses, and deserve to be recognized. However, we particularly liked Dustin H.'s response, which includes an experience in which safety needles saved him from an exposure:

"Similar situations came up for me when I was an ED tech at a suburban trauma center. Knowing the drug abuse history ahead of time, this is a case where I would ask the patient where he has had the greatest success and give careful evaluation of his recommended site for quality of veins, scar tissue, and recent damage or use to the area.

Under NO circumstances should the needle be placed in the hands of ANY patient, as it can become a weapon if the patient stops being cooperative. I have been in physical struggles with psychiatric patients, including one who grabbed the needle out of my hands—and her arm!—during collection and tried to threaten me with it, thankfully engaging its safety device in the process.  I've never had issues with safety devices, but, after that situation, I'll never complain about the minor inconvenience they occasionally impose.

Because of Dustin's well-articulated response, he'll receive a free download from the Center for Phlebotomy Education’sTo the Point® library of articles.



This Month’s Case Study:
Restrain or refrain?

Your next inpatient is one you drew blood from successfully yesterday, and with whom you engaged in a pleasant conversation. Today he refuses to be drawn. Despite your best diplomatic efforts to convince him of the importance of the laboratory results that come from the blood you'll draw, he is adamant. His physician happens to be at the nurse's station, so you excuse yourself from the patient and notify the physician of his patient's refusal. The physician orders you to find someone to restrain the patient long enough for you to perform the venipuncture. 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.