Review
Received 4.13.05 | Revisions Received 4.19.05 | Accepted 4.20.05
Phlebotomy Puncture Juncture
Preventing Phlebotomy Errors—Potential For Harming
Your Patients
Helen Ogden-Grable, MT(ASCP)PBT,1 Gary W. Gill, CT(ASCP), CFIAC2
( 1DSI Laboratory, Naples, FL, 2DCL Medical Laboratories, Indianapolis, IN)
DOI: 10.1309/EXTW9LBM0CD7P9EV

Phlebotomy errors may cause serious harm
It is essential, therefore, to establish,
to patients—up to and including death, implement, and practice quality control in
either directly or indirectly. phlebotomy.
The number of patients that may be harmed while undergo-
ing phlebotomy1 procedures is enormous based on a consideration
of sheer numbers alone. In this country, we estimate more than 1
billion venipunctures are performed annually. The Fall 2004 BOR
Newsletter lists the fact that 26,773 phlebotomy technicians have
been certified since the PBT registry examination was introduced
in 1989. Prior to the introduction of safety devices,2 phlebotomists
suffered an estimated 600,000 needlestick injuries or more annu-
ally. One can imagine, therefore, the potential for harm to patients
who, after all, are on the receiving end of every venipuncture.
Phlebotomists enjoy the privilege of patient trust, as they
are being permitted to perform an invasive procedure that no
healthy individual would ordinarily volunteer to undergo. The
dictum “first, do no harm”3 applies to phlebotomists as well as
to physicians. Indeed, the etymology of “safety” is salvus, mean-
ing “freedom from harm.”
Phlebotomy errors may cause serious harm to patients—up
to and including death, either directly or indirectly. This state-
ment might sound radical until we investigate the many possible
errors that might occur while performing a blood collection pro-
cedure. It is essential, therefore, to establish, implement, and
practice quality control in phlebotomy. Phlebotomists who nor-
mally work independently and without direct supervision in the
hospital setting or in the outpatient facility must take the respon-
sibility for performing quality control on their own work. Quality
control consists of those materials and methods practiced in real
time in every venipuncture to promote intended outcomes.
First let’s take a look at the errors that could occur in a typi-
cal phlebotomy setting4:
• identifying the patient
• communicating with the patient
• selecting the venipuncture site
• sites for capillary skin puncture
• choosing the “right stuff”
• special considerations related to patients
Identifying The Patient
Not accurately identifying a patient is indefensible. Phle-
botomists need to know from the first day of training how im-
portant it is to accurately identify their patients.
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Quality control consists of those materials
and methods practiced in real time in every
venipuncture to promote intended
outcomes.
Phlebotomists also need to know the possible outcome of
failing to follow the protocol for identifying patients in their
facility. Failure to follow established identification protocol
might lead to over-treatment or under-treatment of the patient.
If the patient has not been properly identified for blood
bank/transfusion medicine testing, the end result could be fatal.
The ordering physician relies on the clinical laboratory to
provide accurate test results used to diagnose disease and/or to
monitor the course of a disease or treatment.
Each facility should have an established written protocol for
the identification of hospital patients and outpatients as it ap-
plies to the facility. There must be 2 identifiers for both types of
patients.5
Typically, the primary identifier for the hospital patient is
the hospital identification band found on the wrists of older
children and adult patients, and on the ankles of the neonatal
patients. The secondary identifier must be established and used
by all employees needing to identify the patient. In the outpa-
tient setting the primary identifier is usually the script from the
ordering physician while the secondary identifier may be the
birth date or the social security number. For drug testing or
other legally sensitive testing a photo ID may be required by
your facility.
Phlebotomy staff needs to be trained in your identification
protocol. If they understand the importance of complete patient
identification and know what can happen to a patient if they ig-
nore the rules, they are more likely to follow the rules. You need
to put teeth in your identification protocol by using corrective
action when a staff member chooses to not follow the protocol.
Communicating With The Patient
Communication is the means by which information is
exchanged or transmitted between phlebotomist and the pa-
tient. Communication involves 3 components: verbal, non-
verbal, and listening.6
There will always be the chance for error when a phle-
botomist fails to communicate properly with his or her
patient.
When a phlebotomist goes to a patient’s room the first
thing that he must do is to identify himself, stating his name
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and that he is from the laboratory and is there to draw blood
per doctor’s orders. He is informing the patient and obtaining
permission from the patient to move forward. Patients are
covered by the AHA Patient Bill of Rights.7 The patient has
the right of refusal for any procedure. If a phlebotomist does
not look at or listen to their patient, and ignores either a ver-
bal or nonverbal refusal, he is guilty of assault. If the patient
has the perception that the phlebotomist is ignoring her re-
fusal and intends to move forward to perform the procedure;
this is assault. Should the phlebotomist lay a hand on the pa-
tient; this is battery even though no harm has been done to
the patient.
If the patient is asleep at any time of day or night, the phle-
will be no possible defense in the courtroom should the patient
or the doctor take legal action.
If a phlebotomist uses the underside of the wrist, which is a
no-draw area, there is the possibility of hitting the radial or ulnar
nerve or artery. Hitting the nerve in the underside of the wrist
can cause temporary or permanent nerve damage and the pa-
tient may lose the ability to open and close their hand.
Sites For Capillary Skin Puncture
When a phlebotomist makes the error of ignoring the appro-
priate site for capillary skin puncture, he/she may harm the pa-

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botomist must awaken him/her. If the phlebotomist attempts to
draw blood from a sleeping patient, identification errors or phys-
ical injury to the patient could occur. This would also bypass the
patient’s right to informed consent and could result in a legal
action of assault and battery.
Assault may be defined as the unjustifiable attempt to touch
another person or the threat to do so, causing the other person
to believe that this will take place.
Battery is the intentional touching of another person with-
out their consent. Battery includes assault so the 2 words are
combined into assault and battery.8
Selecting The Venipuncture Site
When a phlebotomist chooses to ignore the rules of site
selection for venipuncture, he/she runs the risk of causing harm
to their patients. See Table 1 for a guide to selecting the
venipuncture site.
If a phlebotomist has chosen to use the basilic vein when
there is a usable median antecubital vein or cephalic vein, and
the patient suffers an arterial nick or nerve damage—with the
possibility of loss of arm movement or bleeding into the arm—
legal action may be taken by the patient or the doctor.
If no written order from the doctor exists and the phle-
botomist performs a foot draw and complications arise there
tient. See Table 2 for a guide to sites for capillary skin puncture.
The thumb develops callous from using it daily with the
index finger as opposing digits. It may be impossible to retrieve
an adequate blood sample from the thumb. Certain occupations
lead to major callous growth; for example, sailors and cowboys
who work with rope or seamstresses who work with rough fab-
rics such as burlap.
Puncturing the index finger may result in pain due to the
many nerve endings in this finger, and this soreness may inten-
sify and be prolonged due to the use of this opposing finger with
the thumb.
When performing finger sticks puncturing the little finger
may result in hitting the bone.
Phlebotomists who choose to ignore the appropriate sites
on a neonatal heel and use the toes or the center back of the heel
Table 2_Sites for Capillary Skin Puncture
Fingersticks Use the middle finger or the ring finger.
Neonatal heelsticks Use the lateral (side) plantar surface of the baby heel.
Earlobe punctures Possible request for earlobe punctures in the patients
on chemotherapy or the diabetic patient.

Table 1_Selecting the Venipuncture Site

Vein? Choice? Anchored? Potential for Error?

Median antecubital vein.
This vein is located in
the antecubital fossa.
(the area of the arm in
front of the elbow).
Cephalic vein which is
located on the upper or
shoulder side of the arm.
Basilic vein which is located
on the under side of the
arm.
Dorsal hand veins
Foot veins
First choice for venipuncture
Second choice for venipuncture
in the antecubital area.
Third choice for venipuncture
in the antecubital area.
Good alternatives when the
antecubital veins are not usable. some patients.
Need for use must be proven.
Most physicians are reluctant
to order foot draws due to the
possible complications listed
in column 3.
Well anchored vein, usually large and prominent. Very few problems. Offering the best chance
for a close to painless puncture, as there
are few nerve endings close to this vein.
This vein is usually well anchored. The cephalic vein may lie close to the sur-
face. A low angle of needle insertion must
be used to avoid possible spurting or blood
forming a drop at the puncture site. (15°)
In many patients this vein may not be well Syringe draw should be considered as it gives the
anchored and will roll, making it difficult to phlebotomist more control over a rolling vein.
access with the needle. Pooling of blood and hematoma formation possible.
Well anchored in most patients. May roll in Select equipment suitable for the hand veins.
Venipuncture from the foot veins may create You must check the rules in your facility.
a dangerous situation for the patient who is Usually the phlebotomist must be shown the
prone to clot formation. written order from the physician before
Also, you must remember that a significant attempting a foot draw.
number of our patients are diabetic.
Wounds may not heal and infection could lead
to necrosis, gangrene, and serial amputations.

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Table 3_Choosing the Right Stuff

Choice Reason

Tourniquet: latex or non-latex.
Adapter and safety needle (evacuated tube system).
Syringe and safety needle.
Butterfly needle or winged infusion set.
Lancets for capillary skin puncture (finger).
A tourniquet must be used for all venipunctures even when the vein is prominent. Failure to use a tourniquet
may result in missing the vein with the needle and the patient will have to be redrawn. Non-latex tourniquets
must be available for patients who have an allergy to latex.
Should be used for routine venipuncture. Allows for multiple tubes to be collected with one puncture. Preferred
method.
Should be used for rolling veins or when the phlebotomist needs to control stresses placed on a fragile vein.
The phlebotomist should be accountable for the use of the butterfly needle. Such needles are more expensive,
are in the vein longer, and may hemolyze the blood sample. If used, the phlebotomist must coordinate the
size of the needle with the size of the tubes to avoid hemolysis of the blood sample. Note: butterfly needles
are responsible for the majority of needlesticks/exposures suffered by phlebotomists.
Must have and use the appropriate size lancet available for the adult, adolescent or pediatric patient.

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Lancets for neonatal heel punctures. Must not exceed 2.0 mm in length to avoid possible injury to the bone in the baby foot. Must restrict heelsticks
to the appropriate areas of the baby foot.

run the risk of hitting bone. Punctures in these areas may result
in osteomyelitis and/or osteochondritis. Should these compro-
mised areas of the baby foot come into contact with feces from a
soiled diaper infection might occur, which in turn may lead to
septicemia.
Choosing The “Right Stuff”
The phlebotomist must choose his/her equipment to fit the
vein used for venipuncture. Failure to do this may result in harm
to the patient (Table 3).
Noting Technical And Procedural Details
Every phlebotomist must be knowledgeable in the various
techniques learned in phlebotomy (Table 4). They must also
maintain awareness of the possibility of different complications
should they fail to follow technique. The phlebotomist needs to
recognize the possibility of certain procedural issues.
As you have read, there are many opportunities for error in
the phlebotomy arena. Equally there are opportunities for learn-
ing and awareness that can prevent these errors being made.
Awareness equals prevention. LM
1. "Bloodletting," c.1400, flebotomye, from O.Fr. flebotomie (13c.), from medical
L. phlebotomia, from Gk. phlebotomia "blood-letting," from phlebotomos
"opening veins," from phleps (gen. phlebos) "vein" + -tomia "cutting of," from
tome "a cutting."
2. 29 CFR Part 1920.1030 Bloodborne Pathogens. Available at:
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDA
RDS&p_id=10051. Accessed 04/02/2005.
3. Contrary to a widely held misconception “First, do no harm.” is not in the
Hippocratic Oath, though Hippocrates did write something similar elsewhere.
However, his eponymous oath does include these words: “Whatever, in
connection with my professional service, or not in connection with it, I see or
hear, in the life of men, which ought not to be spoken of abroad, I will not
divulge, as reckoning that all such should be kept secret.” The sentiment of the
latter statement is embodied in the privacy provisions of HIPAA, which
perhaps should be known as the Hipaacratic Oath. Available at:
http://www.geocities.com/everwild7/noharm.html. Accessed 02/12/2005.
4. Bologna LJ, Mutter M. Life after phlebotomy deployment: reducing major
patient and specimen identification errors. J Healthc Inf Manag. 2002;16:65-
70. Available at: http://www.himss.org/content/files/jhim/15-4/original02.pdf.
Accessed 04/02/2005.
5. JCAHO. 2005 Laboratory Services National Patient Safety Goals. Available at:
http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_nps
g_lab.htm. Accessed 04/02/2005.
6. McCall RE, Tankersley CM. Phlebotomy Essentials, 3rd ed. Philadelphia:
Lippincott Williams & Wilkins, 2002.
7. American Hospital Association. A Patient’s Bill of Rights. Available at:
http://www.injuredworker.org/Library/Patient_Bill_of_Rights.htm. Accessed
on 04/02/2005.
8. Garza D, Becan-McBride K. Phlebotomy Handbook Blood Collection Essentials,
7th ed, Upper Saddle River, NJ: Prentice Hall; 2004.

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Table 4_Technical and Procedural Detail
Complication
Allergies to antiseptics adhesives or latex.
There may be the occasional patient who
will react from exposure to iodine, the glue
found on adhesive bandages or to latex
containing products.
Bleeding from the puncture site. Many patients
are on blood thinners, which may cause
prolonged bleeding following venipuncture
procedure.
Syncopy or fainting. Some patients feel weak
and become dizzy or faint at the sight of blood.
Some patients have a morbid fear of needles.
This fear is very real to the patient. Patients in
the hospital are in a safe place in their hospital
bed. Outpatients are ambulatory and will be
sitting in a blood draw chair.
Hematomas
Nerve damage
Vein damage
Pain
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Awareness
The phlebotomist must listen to the patient who may be
alerting them to an allergic condition. They must watch
for color-coded armbands or posted signs indicating
specific patient allergies.
The phlebotomist must make checking the site for bleeding
the last step in the venipuncture procedure. Do not leave
a patient who is still bleeding from the puncture site
without notifying their nurse. Do not allow an outpatient
to leave while the arm is still bleeding.
Watch and listen to your patients. They may bring an order
from the doctor stating that the patient should be drawn in
a bed or in a safe chair due to a history of syncope.
Patients have no control over this condition and under no
circumstance should the phlebotomist take the warning
lightly or make fun of the patient.
Should the patient faint or collapse the phlebotomist must call
for help and quickly lower the patient to the floor and treat
them for shock.
The phlebotomist must respond by calling for help and quickly
moving the patient to a safe place for the blood draw.
The phlebotomist must be aware that using correct technique
when performing venipuncture will help avoid the formation
of hematomas in their patients.
The phlebotomist must know the anatomy of the antecubital
area and dorsal hand area. They must know how to properly
insert a needle into the vein.
The phlebotomist must be aware of correct technique to
avoid errors that may cause vein damage.
The phlebotomist should always be honest with the patient and If the phlebotomist is not honest with the patient and does
explain that there will be a small amount of pain. They should
alert the patient to every step of the procedure:
Placement of the tourniquet on the arm.
When we are about to clean the skin with alcohol.
When the needle is about to be inserted into the arm.
Removal of the tourniquet.
Removal of the needle.
Review
Potential for Error
Failure to identify allergies may cause reactions that vary
from minor to fatal in nature.
With the hospital patient failure to check the arm for
prolonged bleeding may result in the nurse finding
blood on the patient and on the bedsheets. In our
facility this will result in a Variance Report being
written and corrective action for the phlebotomist
responsible.
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Failure to properly check the arm of an outpatient for
prolonged bleeding may result in the patient finding
blood running from their arm after leaving the draw
site. There is also the possibility that the patient will
collapse in shock upon seeing the blood and suffer
injury from a fall.
Failure to properly respond to a patient who is trying to
tell you that they feel weak or dizzy or who has a
history of syncopy may result in the patient fainting
in the phlebotomy chair. If they slip under the
armrest they may strangle themselves by getting
their chin caught on the armrest. In addition they
could chip a tooth or hurt themselves as they land
on the floor.
If the needle is inserted partially into the vein or if the
needle penetrates the lower wall of a vein a
hematoma may form.
Using veins that are fragile may result in hematoma
formation.
If the phlebotomist performs a blind stick (unable to see
or palpate the vein) or probes (both should be out-
lawed in your facilities) a hematoma may form.
If the needle is pulled out of the vein while the tourni-
quet is still in place a hematoma may form.
If the phlebotomist fails to hold firm pressure (or have
the patient hold pressure) over the venipuncture site;
a hematoma may form.
If the phlebotomist does not choose the correct vein or if
they are rushing using jerky movements or if they
probe they may hit a nerve and cause temporary or
sometimes permanent damage to the nerve which
may result in loss of movement to the arm or hand.
This type of injury is preventable and may result in
legal action against the phlebotomist.
If the phlebotomist does not follow protocol or probes
blindly, vein damage may occur and scar tissue may
form, making venipuncture more difficult.
not warn the patient that there may be minimal pain,
she may lower the confidence level of the patient. The
patient may accuse the phlebotomist of lying or with-
holding information.
Failure to allow the alcohol to completely dry on the skin
will cause a stinging pain when the needle is inserted.
If the phlebotomist does not remind the patient to hold still
when inserting the needle, the patient may jump and
force the needle deep into the arm, causing serious
pain and possible nerve damage.
Any probing is excessive, and deep vigorous probing will
be extremely painful, and lead to numbness and nerve
involvement. Each facility should have a policy on how
to handle a patient who has pain following the
venipuncture.
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