Sample

Considerations and Special Procedures

Principle:
To properly and safely collect a sputum sample. The procedure is used to obtain secretions from the
upper respiratory tract by coughing up sputum into a sterile container.

Materials:
Gloves
Hand disinfectant
Container of warm water
Waste container or waste sink
Sterile sample container
Label and requisition form
Procedure:
1. Assemble equipment consisting of a sterile sample container, warm water in a glass, and a
waste container.
2. Have the patient rinse the mouth with warm water. This will reduce the bacteria and food parti-
cles that mix with the sample. Have the patient spit the water into the waste container or sink.
3. Instruct the patient to breathe deeply several times and cough up sputum and then
expectorate the sputum into the container.
4. The patient needs to place the lid tightly on the container and give it to the phlebotomist.
5. Label all samples.



Intestinal parasites and their eggs (ova and parasite [O fz P}) can be detected through
feces examination. Special containers are provided to the patient (Figure 9.29). These
containers are used to preserve the feces until testing can be completed. The containers
may also be used for collection of feces for microbiology culture of feces. The microbiology
department will check for enteric bacteria such as Salmonella, 5higcIla, or other pathogenic
bacteria.













FIGURE 9.28 Occult blood tests, Hemoccult (left), InSure
(right).
 CHAPTER 9

tested in the laboratory. Some of the card test systems require a meat-free diet for at least
3 days before the test (e.g., Hemoccult ® [SmithKline Diagnostics, Inc.]). Some newer test-
ing systems do not have diet restrictions and other requirements to handle the feces (e.g.,
InSure Fecal Immunochemical Test® [Enterix Inc.l) (Figure 9.27). Three separate cards are
usually collected over 3 different days.

Principle:
To properly and safely collect a throat culture sample. The procedure is used to obtain secretions
from the nasopharnyx and tonsillar area to incubate for means of identifying a pathogenic organism.
Materials:
Gloves
Hand disinfectant
Tongue depressor
Commercial culture tube with applicator swab
Label and requisition form
Procedure:
1. Assemble equipment consisting of a commercial collection set and a tongue blade.
2. Use a tongue blade to hold the tongue down. Using the swab, take the sample directly from
the back of the throat. Be careful not to touch the tongue, cheeks, or teeth at any time during
or after collection (Figure 9.26).
3. The throat should be swabbed with enough force to remove organisms adhering to the throat
membrane. Especially swab any red, raw, or white patches for optimum streptococcal isola-
tion. lf a rapid strep test is ordered use two swabs to swab the throat.
4. The collection swab for culture is inserted back into the swab holder, and the swab is placed
in contact with the transport media (Figure 9.27). The swab for the rapid strep test is placed
in the applicator wrapper.
5. Label all samples.














FIGURE 9.26 Using a tongue blade to hold FIGURE 9.27 Insert the collection
the tongue down, take the sample directly swab back into the swab holder.
from the back of the throat.
 Sample Preparation and Handling

Fill in the BIanL: Changes due to Posture

Directions: Indicate whether each acolyte will increase or decrease os a patient does from
lying down to standing up.
Change due to Posture

Anaiyte Change from Lying Down to Standing Up
Blood pressure
Blood volume
Calcium
Cholesterol
Lipids
Drugs
Steroids
Thyroid hormones

Fasting and Timed Before collecting any fasting samples, the phlebotomist should always determine if the
Samples patient is fasting by asking the patient if he or she has had anything to eat or drink. Fast-
ing usually means no food for 8 to 12 hours. Fasting samples are generally collected in the
morning after an overnigh t fast. The patient should not have had chewing gum, orange
juice, or anything other than water. Collecting a sample and labeling it as fasting when the
patient was nonfasting will mislead the physician into treating the patient when the results
were normal. Tests affected include primarily glucose and triglycerides. Patients often say
that they have had nothing to eat or drink when they have had a cup of coffee. The patient
is often under the misconception that black co flee without sugar is not a problem. But
coffee as well as smoking affect metabolism and can affect test results.
Fasting samples do not have a specific time for collection. The sample must be collected
before the patient has anything to eat. This time is typically early morning but could be af-
ternoon as long as the patient has not had any intake. Other tests may require that the
sample be collected at a specific time because of medication or diurna I rhythm. The precise
timing of the collection for these samples is critical. The exact time of collection must be
noied on ihe sample and entered into the computer. Collecting a sample io determine drug
level at the incorrect time could result in a miscalculation of the next dosage for that patient.
Some blood analytes exhibit c ircadian or diurnal changes throughout the day. It is
important to control the timing of the collection of certain samples. Cortisol can vary as
much as 50 percent between samples collected in the morning or evening. Serum iron
levels are lower in the morning than in the evening. Hormones such as renin, aldosterone,
growth hormone, and thyroid-stimulating hormone show daily changes. Some changes can
be cyclical, occurring weekly or montly. A circan nual change is demonstrated by calcium,
which has been known to increase in the summer due to exposure to more sunlight and
the resultant increase in vitamin D. Other analytes also change in different seasons due to
changes in diet and physical activi ty at different times of the year.

Evacuated Tubes Preexamination errors can occur from an incorrect volume of blood in the tube. It is best to
provide the laboratory with the properly filled tube to avoid an error in results or a recall
of the patient. Most tubes should be filled to at least 7â percent of the stated volume to be



C opy r ig h1 2 0 4 8 Cc ogagc L car n irn g A11 R i gh ts R csc rv c d M ay n oi bc co pie d , s ca n n ed, o r fi u pt ica ie b m w h olc o r i n pa r1. WC N 0 2 -200 -20 2
 CHAPTER 10



Cholesterol Increase
Lipids Increase
Drugs Increase
Steroids Increase
Thyroid hormones Increase



Changes in pos tu re can in fi uenc e laborat ory resul ts due io a change in b1 ood
volu me. A patient who goes from lying dow n to standing will have an increase in
Afier lying down,
blood pressure. Conseque ntly, a dec rease in blood volume will occur by fluid moving
have the patient sit
from t he veins into the tissue. Those an alytes that are too I arge to pass through the
up for one minute
before you release ›'ascu1ar wall will be conce ntrated in the blood. Analyses such as calcium, cholesterol,
him or her. A change 1 ipids, drugs, steroids, and th yroid horm ones will inc rease. Th is is usual ly not a con-
in blood pressure will cern because normal values for most ana lytes are established on ambulatory patients,
ofien make a patient n ot pat i ents wh o have been in a reel ining posi I i on . Othe r an alyt es th at chan ge
faint if the patient with exercise and prolonged t ourniquet application will also change as a result of
immediately gets up hemoconce ntration.
and starts to walk.

Fill in the Blank: Exercise and Stress

directions: Indicate how each oJ the listed acolytes change os the result oJa patient’s exercise
and stress (increase or decrcasc in value).

Chnngm due to Exercise and Siress
Analyze Change
Creatine kinase (CK)
Aspartate aminotransferase tAST)
Lactate dehydrogenase (LDH)
Bilirubin
Creatinine
Uric acid
Lactate
Pyruvate
White blood cells (WBCs)
Neutrophils
Glucose
Hemoglobin






Cc ogagc Lear n i n g A11 R i gh ts Re sc rv c d M ay n ot bc co pie d , s ca n n ed o r clu pt ica ie b m w h olc o r i n pa r1. WC N 0 2 200 - 20 2
 Sample Preparation and Handling

Tourniquets The tourniquet is a factor under ihe phlebotomist s control that can c fewie a change in rest
results. The tour niquet should be on the arm no longer than 1 minute. The tourniquet
increases the intervascular blood pressure, resulting in a push of small molecules and fluid
from the capillaries into the surrounding tissue. This reduction of fluid volume results in
hemoconcentration. This inability to circulate lowers the pH and causes potassium to be
forced out of the blood cells. The change in pH also causes an elevation in calcium and
magnesium.

Exercise and Vigorous exercise can affect the results of testing. A patients cell permeability will change
Posture if he or she has just completed vigorous exercise. This causes an increase in concentration
of creatine kinase (CK), aspartame aminotransferase (AST), lactate dehyd rogenase (LDH),
bilirubin, creatinine, and uric acid. The heart will have worked harder and increase the
heart enzymes. Lactate and pyruvate increase in even moderate exercise due to the increased
metabolic activity of skeletal muscle. Long-term exercise by highly trained runners can
cause runner’s anemia. Stress can have a similar effect—for example, the stress of being
in the hospital or the stress of dealing with a disease. Total white blood cells (WBCs) can
increase by as much as 2,000 as a result of exercise or other stresses. The WBCs in a crying
baby will increase the same as in exercise. Neutrophils and glucose levels also show a
marked increase. The patient who makes an extremely tight fist or pumps the hand can
increase lactate by as much as 100 percent or more. With the exception of hemoglobin,
most analyses increase with exercise and stress.




Creatine kinase Increase
Aspartate aminotransferase Increase
Lactate dehydrogenase Increase
Bilirubin Increase
Creatinine Increase
Uric acid Increase
Lactate Increase
Pyruvate Increase
White blood celb Increase
Neutrophils Increase
GI Increased with stress
Decreased with exercise
Hemoglobin Decrease




Changes frown Lying Down
to Standing Up
Blood pressure Increase
Blood volume Decrease
Calcium
 CHAPTER 10

Demonstrate understanding of requisitioning, sample transport, and sample processing.

¥• Explain methods for processing and trans- k Identify and report potential preexamination
porting blood samples for testing at reference errors that may occur during sample collec-
laboratories. tion, labeling, transporting, and processing.
¥• Describe the potential clerical and tech- ¥• Describe and follow the criteria for samples
nical errors that may occur during sample and test results that will be used as legal
processing. evidence, such as paternity testing, chain of
custody, and blood alcohol levels.

KEY TERMS
Circadian Cyclical changes throughout the day.
Circannual Seasonal changes over the course of a year.
Cyclical Occurring in cycles.
Diurnal Daily variation in blood levels at a particular time of day.
Etiologic Agent Viable microorganism or its toxin that causes or may cause human disease.
Pree xamination All processes that it takes to collect the sample and get to the point in which the
testing of the sample can occur.

ithout proper somple prepnrotion end handling, the most nccurotely collected blood
somple could give invalid resells. This chapter probes the reasons why o somple
could give inoccurote results end what con be done to provide on occurote result even if
there is o deloy in testing.



PREEXAMINA- Numerous › ariables can affect test results Once some of these variable s are in pla), the
TION VARIABLES most expensive analytical inst rumen1 available can not gi›'e an accurate and precise result.
Some of these factors are the responsibility of the phlebotoniist, v•hereas others reflect the
Patient ph) siological factors of the patient. I’rc cxain in ai ion errors that occur prior to testing com
Identification prise 46 t o 56 percent of a11 errors en coun tered for 1 aborat or) samp les. Preexaminati on
errors arc sometimes called prcanalytical c rrors, rcfc rring to errors ihat occur before the
ana1)'i ical port io n of the rest in g occurs. The m ost sc ri ous and prat ent iall)' most da nge rons
Helpful Hint
precxamination error is improper patient identification. Misidentification of a sample lea es
Always make sure that ‹open lhe possibilit y that results u•ill gt to thc inct›rre ct par ient. As a consequence t›f this,
you have checked the ph)'sician may prescribe a harmful or even fatal treatment. Follou ing the procedures
the identification of outlined in Chapter 5 ensures proper patient identification.
the patient before
collection. Always
label the samples
at the patient’s
bedside or before
the patient leaves the
phlebotomy chair.

0 C o i1 t o I u iri i iii A11 R i " 1 1 • H c • o r . o‹1 M 1 ‹ I Ii u o i › c ‹1 s z, ‹ ‹ ot| o r ‹1 i i:1+ c , I o t1 i i1 ,v1 c 1s o i i i1 ›,1 i i W C N 0 S ?0 0 2 0 2

 OBJECTIVES After studying this chapter, you should be a6le to:
1. Know what preexamination errors can occur with a sample and how
these errors can affect a patient’s outcome.
2. Explain how exercise and stress can affect laboratory results.
3. List the tests that require chilling or warming and explain why these
steps are necessary.
4. Describe situations that would result in re-collection or rejection of a
sample.
5. Describe methods of transporting samples.

 302 CHAPTER 10

• Labels must have the patients complete name and hospital number or unique identifier.
• The sample must be collected within the time limits requested.
• Samples in syringes must have needles removed and the syringe capped before
transport.
• Urine samples must have the label on the container and not on the lid.
• The appropriate anticoagulant must be used for samples requiring an anticoagulant.
• Anticoagulated blood collection tubes must be at least 75 percent full. All coagulation
tubes must be at least 90 percent full.
• Tubes may not be used beyond the expiration date.
• Certain samples may not be exposed to light.
• Delays in centrifuging or processing a sample will invalidate the results.
• Anticoagulated blood samples must be free of clots.
• Cenain tests require samples to be free of hemolysis and lipemia.
• Blood samples drawn above an intravenous (IV) injection site are unacceptable.
• The sample must be re-collected if the results are not consistent with previous results
on the patient.
This list is not all-inc lusive. The type of sample acceptable and t he volume requi red are
determined by the procedure ordered. There are exceptions to volume requirements where
the laboratory can work with small sample sizes. Re-collection is most often done to recheck
results on a patient. When the results of one sample change significantly from a previous sam-
ple, either retesting the sample or re-collecting the sample rechecks the test. This reconfirms
that the correct sample was drawn from the correct patient and that the patients test results did
change significantly.

SAMPLE Once samples have been collected, they must be transported to the laboratory within the
PREPARATION facility or to a laboratory possibly hundreds of miles away. The phlebotomist, a transporter
AND TRANSPOR- person, or a pneumatic tube system usually does transportation within the facility. There
is little time lost and minimal chance for breakage of the sample within the facility. The
TATION
primary container is the container in which the sample was collected. When a sample is
transported, this primary container must be placed in a secondary container so any leakage
Transportation or breakage of the primary container is contained. The increased use of plastic tubes has
reduced the incidence of breakage but there is still the possibility of the cap coming off the
tube. A plastic self-sealing bag is sufficient as the secondary container for most samples. A
single sample or multiple samples from one patient can be placed in the bag and then the
bag sealed shut. Samples from different patients should not be placed in the same bag. All
labels must be attached to the sample tubes before they are placed in the bag. For large
numbers of samples, the samples can be placed in racks to avoid spillage or breakage, and
the entire rack placed into a bag or leakproof box (Figure 10.4). Standard camping coolers
come in various sizes and are excellent for this purpose. Whatever secondary container is
used, the biohazard emblem must be attached (Figure 10.5).
Pneumatic tube systems that transport samples are more traumatic than hand carrying
the samples but have the advantage of faster delivery. To prevent trauma to the sample, the
bagged sample is placed into a padded container to maintain the integrity of the sample
(Figure 10.6).
Most laboratories have local couriers who pick up samples. These couriers have been
trained in how io handle blood-borne pathogens and have special containers to iransport
the samples to the laboratory The self-sealing bags lot these specimens have two compan-
ments. One compartment is for the sample and the other compartment is for the requisition.



 Sample Preparation and Handling

If a heel warmer or
warming block is not
available, a sample
can be bagged and .
then held in your hand
as you transport it to
the laboratory.

FIGURE 10.3 Protecting sam ples from

light with aluminum foil or an amber tube.

Labeling Exercise
Directions: Indicate iJ the tcst sample should be chilled (C), w0rm Gf), or protected Jrom
light f'L).
1. Lactic acid
2. Cryoglobulin
3. Acid phosphatase
4. Ammonia

Cold agglutinins
6. Bilirubin
7. Vitamin C
8. pH/blood gases
9. Catecholamines
10. Vitamin K



CRITERIA FOR The goal of the phlebotomist is to pro›'ide acceptable samples for laboratory testing as
RE-COLLEGTION required by the physician. Certain general criteria must be followed for a sample to be
OR REJECTION acceptable. If the criteria are not followed, the sample must be rejected and re-collected.
The general criteria are as follows:
OF A SAMPLE
• Each sample must have its own label attached to the sample s primary container.
• Each sample must have on the label the name of the test to be performed (e.g.,
complete blood cell count [CBC} , cholesterol).

C opy r ig h1 2 0 4 8 Cc ogagc L car n irn g A11 R i gh ts Resc rv c d M ay n oi bc co pie d , s ca n n ed, o r fi u pt ica ie b m w h olc o r i n pa r1. WC N 0 2 - 200 - 20 2
 CHAPTER 10

- FIGURE 10.1 Ice bath chilling of a sample.

FIGURE 10.2 Maintaining a sample

at 37° C.

Exposure to Light Light can be detrimental to some samples. Bilirubin is especially vulnerable. Collecting bili-
rubin samples in capillary collection tubes exposes the samples to light more directly; there-
fore, they should be collected in amber tubes. Various other tests must be protected from
Lght (e.g. , vitamins C, E, and K). The laboratorys directory of service will give instructions.
The most efficient method to protect the sample from light is to wrap it in aluminum foil
(Figure 10.3).
 Sample Preparation and Handling 299

Mosi of this hemolysis and clotting is ihe result of the trauma in transferring the blood
from the syringe to the tube and the delay before the blood is mixed with anticoagulant.

Cleaning the The venipuncture site is generally cleansed with alcohol. Occasionally a site must be
Venipuncture Site prepped with povidone-iodine (Betadine) or tincture of iodine, as in the case of a blood cul-
ture. The iodine can increase potassium, phosphorus, and uric acid. The best practice is to
remove the iodine with an alcohol pad if any testing other than a blood culture is collected.
Cleaning a venipuncture site for blood alcohol testing must be done with a nonalcohol
cleaner.

Order of Draw The order of draw is the most common factor that varies test results over which the phle-
botomist has control (see Chapter 6). Blood must be collected with the patients arm in the
arm-down position to prevent the anticoagulated blood from flowing back into the needle
and contaminating the next tube. Following the correct order of draw prevents the anti-
coagulant from one tube from contaminating the next tube. EDTA or heparin can increase
prothrombin (PT) and activated partial thromboplastin time (aPTT) test results if they are
drawn before the citrate tube. EDTA contamination can give a high potassium result if the
tube drawn after the EDTA is tested for potassium. The EDTA used in the tubes is either
dipotassium EDTA or tripotassium EDTA. This is the reason the heparin tube is drawn
before the EDTA tube.

Chilling of Samples Certain samples require chilling immediately after collection. The sample should be placed
in a mixture of ice and water as soon as it is withdrawn from the evacuated tube holder
(Figure 10.1). Some tests require prechilling t he empty evacuated tube before drawing the
blood. Any delay in icing the sample alters test results. The longer the delay, the greater
the change in test results. Examples of common tests requiring chilling of the specimens
include the following:
• Ammonia
• Acid phosphatase
t Catecholamines
• Lactic acid
t p1-1/blood gases

CAUTiOF4: All samples cannot be chilled. Chilling an uncentrifuged serum mbe releases
potassium from the celb and elevates the serum potassium values. Other analytes are also
affected. Only chill a sample when the draw instructions specify.

Cold agglutinins
Cryoglobulin


Warming of In contrast to samples needing to be chilled immediately after collection, some tests need
Samples to be kept warm. The tests are maintained at body temperature (37° C). The best method
of maintaining this temperature is to wrap the sample in a heel warmer (Figure 10. 2) or to
use a plastic block (warming block) that is maintained at body temperature before taking
it to the patient. These blocks have holes drilled in them to accept different sizes of tubes.



C a py r i g h1 20c1 8 C ncg a g Lea rn i n g A II R • g h ts R csc xc d M a y nca I b c a p ie b , s cca n n d, a r d u p I ic ¥1e d i n wc h a I a r i n pa rt. WC N 02 -20 0 -202
 298 CHAPTER 10

accurate. Any less blood causes a diluiional effeci, leading the red blood cells to decrease in
size. Too much blood in an anticoagulant tube causes the blood to clot because there is not
enough anticoagulant for the volume of blood. Citrate tubes are the most critical for correct
fill size. The variation in fill can be only plus or minus 1 0 percent from the stated volume.
Any greater variation affects test results.
When the blood tubes fill only partially, another tube must be drawn to obtain the
proper amount. Partial tubes cannot be poured together. By pouring together partially filled
tubes, the amount of anticoagulant in the tube is doubled, resulting in altered test results.
For example, if two partially filled light-blue—stoppered tubes are poured into one tube,
there will be I mL of anticoagulant in the 5-mL tube instead of the recommended 0.5 mL
of anticoagulant. Testing of this sample for coagulation will result in longer times due to the
excess anticoagulant in the tube.
Serum and plasma samples generally cannot be mixed. If there is not enough blood
in a serum tube and the phlebotomist uses blood from an ethylenediaminetetraacetic acid
(EDTA) tube to complete the fill of the serum tube, some test results would be altered.
The EDTA in the plasma tube binds the calcium. The serum tube that is partially filled with
EDTA blood will have a reduced calcium level due to the bound calcium from the plasma
volume. The amount of reduction in calcium is dependent on how much EDTA blood was
put into the tube.
If the patient is not available lot a re-collection, the phlebotomist should send the par-
tially filled tubes to the laboratory and the laboratory can determine if samples can be com-
bined and the testing done. The laboratory also has procedures for small sample volumes.
The partiall y filled tube may be acceptable for certain tests.
Defective tubes give an improper fill even with the best venipuncture. Tubes should
vary no more than plus or minus 10 percent in filling. To verify quality control in the tubes,
use a syringe filled with water. The syringe should be filled with more water than the capac-

ity of the tube that is being tested. The top of the tube is punctured with the syringe needle,

and the amount of water the tube pulls from the syringe is noied. lf several iubes vary more

than 10 percent from the stated volume of the tube, the entire lot number of tubes is con-

sidered defectii'e. Contact the manufacturer to resolve the problem.

All anticoagulant tubes must be mixed by inversion to disperse the anticoagulant with

the blood. Inversion of 5 to 8 times must be completed immediately after the tube is pulled

from the holder. Failure to ini•ert the anticoagulant tubes or inverting them after a delay will

allow microscopic clots to form. The most sensitive tubes are lavender stoppered (EDTA),
resulting in a lower platelet count, and sodium citrate tubes, in which improper inversion
results in erroneous coagulation test results.
Preexamination errors can also result from the use of the wrong anticoagulant. The
proper heparin tube to use can be confusing for even the most experienced phlebotomist.
Ammonium, lithium, and sodium heparin are all available for use. Certain tests are affected
by using the wrong heparin tube. Testing for sodium from a sodium heparin tube can indi-
cate that the patient has an elevated sodium value. In the same manner, lithium is increased
in a lithium heparin tube. Chromosome studies need sodium heparin because lithium is
toxic to cells. If a heparin tube is to be drawn, check that the correct type of heparin is used.

Syringe Collection Problems with syringe collection are common when syringes are used to collect blood.
Clinical Laboratory Standards Institute (CLSI) guidelines discourage the use of syringes.
Difficult draws are best performed with a butterfly system. The evacuated tube system is the
preferred method of collection. If syringe collection is used, there is an increase in hemoly
sis and clotting of the samples collected. In an industry study, visual hem olysis was found in
19 percent of samples drawn by syringe, and 3 percent when drawn by an e›'acuated tube
system . Eleven percent of syringe-collected EDTA samples clotted, compared with none
when an evacuated tube system was used.

Ccngagc Learning All Rights Rcscrycd M ay not be copicd, scan ncd, ar du plicatcd in wh olc ar in part. WCN 02-200-202
 Sample Preparation and Handling

medicolegal samples, a chain -of-custody form must be completed and must accompany
the sample (Figure 10. 10). This certifies that the sample was obtained from the individ-
ual named as the source of the sample. All individuals who had possession of the sample
before analysis are listed, and the technologist performing the analysis is named. During
this process, the sample must be secure to prevent tampering and must not be exposed to
extremes that would alter the results.

Health Care Provkler
Address DO NOT WRITE
a oa i.o. vzweo @ i.o.
Ph‹x›e

FIGURE 10.10 Chain-of-custody form.

Copy rig ht 2018 C engage Learn ing A II R•ghts R cscwcd M ay not oc copie d, scan ncd, ar du pl icated in wh olc or in part. WCN 02-200-202
 306 CHAPTER 10

names for these substances are: UN2814 (infectious substances, affecting humans)
and UN2900 (infectious substances, affecting animals)
b. Biological Substance, Category B: An infectious substance which does not meet the
criteria for inclusion in Category A. Infectious substances in category B must be
assigned to UN 3373. [Note Category B infectious substance is the classification
of clinical specimens requested in support of a VSP acute gastroenteritis outbreak
investigation.]

The integrity of the sample must be maintained during shipment. Extreme varia-
tion in temperature must be avoided. A sample that gets too hot or freezes will rupture
the red blood cells. This is especially signi ficant if the sample is a whole blood sample.
A CBC sample (EDTA sample) will be totally unacceptable after extreme temperature
variations. Serum or plasma samples are more tolerant of changes because the red cells
have been removed from the sample. Test results will still be altered with temperature
extremes. The maximum time the sample takes to arrive at the destination must be
determined . Then the appropriate amount of dry ice or insulation must be ad ded to
protect the sample. All serum and plasma sho uld be removed from the ce11s before
transporting.
Temperature extremes are considered when sending samples long distances but are
often ignored for short distances. This is often the ease when a phlebotomist is collect-
ing samples at different nursing homes. A sample is collected and left in the car while
the phlebotomist goes into the next nursing home on the list of stops. In the short time
it takes to go into the nursing home and draw a sample, the temperature in the car can
change dramatically. The sample can be overheated or frozen when the phlebotomist re-
turns. Any sample that is left in a car should be placed in a cooler to prevent extremes in
temperature.

Medicolegal Transportation of samples for blood alcohol resting, paternity testing, or legal io xicol -
Transport ogy testing must be given special consideration. Blood samples for alcohol are collected
both for medical purposes to help treat the patient and for legal cases. Medical reasons
for alcohol testing are to check i f the patient is unconscious because of intoxication or
if there is a medical condition. Most states that collect samples for legal alcohol testing
tdrunk-driving cases) will have a special draw kit in the emergency depart menis of hos-
pitals. This kit has special collection tubes and chain-of-custod y forms, and samples are
sent to the state police laboratory, noY the hospital laborato ry. This keeps the hospital
laboratory from getting involved in legal cases related to a blood draw. Usually the emer-
gency department physician or nurse will be licensed by the state to collect the sample
and not involve the laboratory. In most states the laborator y records and/or samples can
be subpoenaed even t hough they have not been involved with the chain of custody. For
paternity tesi ing there m ust be docume mation that the sample was collected from the
correct individuals. Pictures are taken of the child, alleged mother, and alleged father in
such circumstances. The medicolegal requirements attem pt to ensure that the sample
was properly processed.
Most chain-of-custody sample s are collecte d for drug testing. Urine is the most
common sample to be collected, but saliva and hair are gaining acce ptance. First the
patien t must have given consent for the test to be collected. The person collectin g the
sample must have documented training on collection of chain-of-custody samples.
The sample must also be properly identi fied and the time of collection noted. On all


c C ogage Lcar n irn g A 11 R ig hts Rc se rvcd M ay noI be' c o pieO, scca n n d, or du pI icaleb in wh oIo or irn part. DC N 02-200-202
 Sample Preparation and Handling

FIGURE 10.7 Samples are placed in the FIGURE 10.8 Requisition is placed in the
self-sealing compartment of the bag. separate compartment of the bag.

FIGURE 10.9 Samples in absorbent packaging.

specimens require packaging that meets Department of Transportation (DOT) (domestic

shipments in the United States) Transportation of Hazardous Materials Regulations (HMR)
and International Air Transport Association (IATA) (international air shipments worldwide)
Dangerous Goods Regulations (DGR).
The International Air Transport Association (IATA) Dangerous Goods Regulations
(DGR) classify infectious substances into two categories, biological substance, category A
and biological substances, category B:
Biological Substance, Category A: an infectious substance which in a form that,
when exposure to it occurs, is capable of causing permanent disability, life-threat-
ening or fatal disease in otherwise healthy humans or animals. The proper shipping
CHAPTER 10

FIGURE 10.6 Pneumatic tube station.

The outside of the shipping container must have the biohazard emblem and wording that
the container holds an eiiologic agent (infectious substance). Some transportation services
do not handle etiologic agents. Check with the transportation service before shipping any
samples. There are severe fines for shipping etiologic agents without proper identification
and packaging.
The Fede ra1 A› iatio n Administration (FAA) and other gove rnment agencies regulate
the shipment of etiological agents. Anyone packaging and shipping these agents must have
special documented training in the regulations.
Centers for Disease Control and Prevention (CDC) references indicate that specimen
shipments in the United States and internationally are regulated under either hazardous ma-
terials regulations (United States) or dange rous goods regulations (international). Clinical
 Sample Preparation and Handling

- FIGURE 10.4 Methods of transporting samples, plastic self-sealing bags or coolers.

Check the destination

and time of year
before packaging the
sample. A sample
shipped from one FIGURE 10.5 Biohazard emblem.
northern city to
another in the winter
will not require as
much dry ice as a
Separate compartments pre›'eni the requisition from being contaminated if ihe sample tube
sample that is being should leak (Figures 10. 7 and 10.8)
Transporting of samples long distances by package service companies requires more
with year-round precautions because there can be no leakage of the sample outside the packaging. These
warm weather. Some companies do not exclusively transport samples but all types of products. Any leakage
samples will require could spread blood borne paihoge ns to packages delivered to someone s home. The pri
packaging to prevent mary container is mapped in absorbent package material (Figure 10.9) and placed in a
them from freezing in secondary container. The absorbent material must be sufficient to absorb the entire contents
transport. of the primary container. This secondaq container is then placed in a shipping container.
 CHAPTER 11

NAACLS Competencies Relevant to Chapter 1 1

Communicate (verbally and nonverbally) effectively and appropriately in the workplace.
¥• List the causes of stress in the work environ-
ment and discuss the coping skills used to
deal with stress in the work environment.

KEY TERMS
Diplomatic Skill in handling affairs without raising hostility.
In-Office Phlebotomist A phlebotomist who works in a physician’s office to collect samples
from patients but is an employee of the laboratory.
Quality Service Superior professional attention and assistance to customers’ needs.
Receiver Person who is being given information by a sender.
Sender Person communicating to someone else verbally or nonverbally.

iN punt n k H)a uti It heirfl omera

its oh cryed iti ib in ih I enn p ntient
h ee xpet & li nvold oh nvek nowledgeo lb ood
tientei k ot h or tions ndr eo mmendi tt o
a It heb h HQ ebotei ib m h b en p em nw ho
sonw § b erb w orko 1h dn org nt{a le-
e Th t e h 9 b ct ib d b iP tp e d perior
d h veo r ewn il ngn ndlli lillig e.

Customer service is composed of many facets that can make a customer either appre -
ciative ol q ualit) sc r ’ice or angr) because the customs rd e ntire needs w'ere not met. The
ph leboi omi st v h o meets t he customers needs is the ph lebot omi st who provi des i he best
customer sc rvoice. Howes cr, consistentl)’ meeting these expectations is difficult
The ph1cb‹iiomisi 'r›rks with both external and internal customers. A cust omcr is an '-
one who is affected b) the phlebotomist s work An external customer for the phlebotomist
is the patient. But thc pat ie nt is not the onl)• c ustome r. There are man) internal customers.
These can be the nurse caring for the pat ient, the physician, the fami1)• of the ›° 'I nt, and
othe rs. Each customer has an interest in what the phlebotomist docs. The patient wants a
caring, pain free procedure. The ph)'sician wants t imel)', quad it) result s. The family of the
patient wants a caring, qua lity person taking care of t he family member. T he fami 1) also
wanis someone who kcc ps them in formed and docs not meat them as if the are in the ›•-a '.
How the phlebotomist treats each of these customers determines the quality of customer
service gi› en. The customer wants the phlebotomist to demonstrate the attitude that he or
she is the phlebotomist s most important concern Customers think t hat they are alwa)'s
right. They u ant the phlebotomist to listen and exceed their expectations. A simple ques-
tion to ask 'oursclf is how you w'ould like to be treated if you were in the same situation.
i ri 1 2B 18 oi t c I ,i r i i i i i . A11 R i " 1 ! • H c • o r o‹1 V ‹ I_ I a c i ›• ‹1 s s , ‹ o‹1 o r ‹1 i ,; 1 i c . i o‹ i i i • v1 o 1; u i i i , › i i t’V C N_ 0 ?0 0 2 0 2

 OBJECTIVES After studying thfs chapter, you should be able to:
1. Know the three expectations to meet quality service.
2. Give types of nonverbal communication.
3. Be able to follow the nine do’s and don’ts of customer service.
4. Explain the five different ways a person will approach conflict.
5. Explain ways to cope with stress.
6. Understand why a patient chooses a particular location to have
laboratory work completed.

 Sample Preparation and Handling



Multiple Choice
Choose the one bes I uns wer.
1. The results of a test can change due to
a. exercise. c. posture.
b. stress. d. all of the above
2. Citrate tubes must be thin percent of full to give accurate results.
a. 10 c â0
b. 25 d. 75
3. Circadian changes are best described as
a. changes throughout the course of a year. c. cyclical changes th roughout the day.
b. hour-by -hour changes. d. changes every 10 years.
Protecting a sample from light is best done by
a. placing the sample in an amber-colored tube. c. wrapping aluminum foil around the sample.
b. placing the sample in any tube because all tubes d. a and r are correct.
protect the sample from light.
Samples may be re jected for testing if
a. the sample was drawn above a running IV c. an ant icoagulatcd sample had a clot.
h. the sample was not labeled with the patient’s d. all nf the ahox’e
complete name.

1. A patient comes to an outpatient laboratory for a physician-ordered fasting test. The patient indicates that he forgot
that the test was to be fasting and ate a candy bar 2 hours ago. The patient insists that you should draw the test
because he cannot come back at another time. What should you do?
2. You are hainng dilIicult)• drawing blood from a patient and try two successive light-blue—stoppered citrate tubes for
the collection of a PT test. Both tubes fill only half full. To avoid redrawing the patient, you pour one tube into the
other to make a full tube and send it to the laboratory Will this affect the test results?
3. A patient arrives to submit a sample for a chain-of-custody urine test. Upon entering the restroom, she says that
her 10-year-o1d daus^••r must go in the restroom with her because the 10-year-old is afraid to be left alone. How
should you handle this situation?
You have just left one nursing home after having collected a lavender-stoppered tube for a CBC. This tube is in your
car in a resealable plastic bag. You leave the sample in the car as you go into the next nursing home on your sched-
ule. The temperature outside is well below freezing, and when you return to the car you notice that the CBC sample
looks slightly frozen. How will this change the results of the CBC?









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 308 CHAPTER 10

E KERCISE 4 Labeling Exercise

Directions: lndicate if the criteria listed will produce an acceptable ) or unacceptable
N) sample.
1. Blood sample collected above a running intravenous line
2. Lavender top tube sent for a prothrombin test
3. Half-filled light-blue—top tube
Red-top tube sent for a serum drug level
Light-blue—top tube collected after a green-top and a lavender-top tube
are collected
6. Blood sample collected in the antecubital area of the arm
7. Blood samples that are labeled after the phlebotomist returns to the laboratory
8. Chemistry test sample that is centrifuged one hour after collection
9. A glucose test collected in a gray top tube
10. Identifying a patient by a patient label on the foot of the patients bed
11. A bilirubin sample collected on a baby while the incubator lights are on
T2. Keeping several cups on your phlebotomy tray and labeling the cups with
the patient name
13. Indentifying a patient by asking the patient his first name only
14. Using a lavender tube to finish filling a tube to be used for blood
chemistries

15. Asking a patient to spell his first and last name and tell their birthdate for
patient identification
16. Samples sent to the laboratory by the pneumatic tube system in a sip lock
biohazard bag
IW A courier transporting samples to another lab by placing them in his coat
pocket
18. A sample for medicolegal requirements where the chain-of-custody form
was not signed by the phlebotomist
I9. A CBC sample that was left in the courier car on the seat for three hours
20. Samples transported in a cooler with an ice pack
21. Cleaning the patients arm with alcohol prior to collecting an ethanol level
22. A chemistry sample that was left on the cabinet top in the physicians
office and not set to the lab until the next morning

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 Customer Service




1'li1 ‹ l›oIi›in isI R‹sspon e
Patient: “You have to use Phlebotomist: “Let me take a look at your arm. Would you mind rolling up your sleeve
tlus arm.” for me and showing me where you had blood drawn before? I see the vein you are
referring to, but 1 think this one All be much better today. Could we use this one?”
or
“I know you told me the other arm, but this one is really popping up today. Could we
use this one that is popping up?”
NOTE: Let the patient feel the difference. Take the time to explain what you feel to him
or her. Patients like to be involved because one of their fears is that the procedure is
not explained to them enough.
Patient: “You have to use a Phlebotomist: “Where have you heard about butterfly needles?” Let the patient
butterfly when you draw explain to you the information that has been given to him or her.
my blood.” Phlebotomist: “We use butterfly needles sparingly, and in your case 1 really believe we
do not need to use a butterfly. Let me show you where I will get your blood. Is it okay
to use a regular needle?”
NOTE: Patients will let you proceed as long as you explain to them how you can be
successful. Take the time to converse with patients and make them feel you care
about them.
Patient: “I am a hard stick.” Phlebotomist: “I have been doing this for quite a while. Let me take a look first and
see what 1 can find. Where do they usually get your blood?”
more: By saying this, you have gotten the patient involved and shown that you were
listening. The patient obviously has had problems before and needs reassurance that
you are capable of collecting the blood.
Patient: “How much longer Phlebotomist: “Let me check the list of patients in front of you. I see we only have
will it be before I am called two people in front of you. You should be called in about 10 minutes.”
to get my blood drawn?” sow: Always be specific about how many people are in front, so patients can count
the people who are called back and know when they are next. Always make the time
you give them a couple of minutes longer than you expect, so if there is a problem
with a previous patient, the time you gave them will still be met. If you get them back
sooner, you will have exceeded their expectations.
Issue: Patient is fasting and Phlebotomist: “Good morning, come on in and have a seat. We don’t open for
comes in very early for the 10 minutes. I still have to get the computer up and running and get the rooms ready.
test. The patient arrives Let me take your paperwork, so as soon as 1 get everything ready, I can get you staned.”
before opening time and now: There are tasks that must be completed before patients can be accepted. Most
before you are ready. patients will realize that if you explain it to them. You need to allow yourself time to get
these done so that you can start processing patients when the facility is scheduled to open.
If everything is ready early do not sit and wait on the scheduled opening time if patient
are waiting. You will exceed expectations of the patient by starting even 2 minutes early.
Issue: You have turned Phlebotomist: “I am sorry, we have closed and all our labs are packaged and ready
off the lights and locked to be picked up by our courier. Can I look at your order? This is for routine work
the door to the outpatient and can be done tomorrow. We open at 8:00 A. u. We have a location that is open
phlebotomy area. Someone until 7:00 r.u. that is a couple of miles from here. Would you like me to give you
knocks on the door to get directions to that location?”
your attention. The patient NOTE: If patients can see you in the facility, they think you are open. Do not ignore
can see you in there working. them if they are insistent enough to knock on the door.






 316 CHAPTER 1 1

the negative comment, express empathy by saying, “I understand how frustrating this must
be.” Empathy is showing care and concern without agreeing or disagreeing with what the
customer said.

5. Do not say: “Thats not my fault.”

Say: ‘ Lets see what we can do about this.”

If an angry customer accuses you of creating a problem, the natural reaction is to become
defensive. If you allow this reaction to take over, your mind becomes closed to hearing
what the c ustome r has to say Before you say, “Thats not my fa ult,” stop, take a breath,
and then, with all the empathy you can muster, say, “Let's see what we can do about this.”
By resisting the urge to defend yourself, you can resolve the problem faster and with less
stress.

6. Do not say: “You need to talk to my manager.”

Say: “I can help you.”

Customers sometimes ask you for things that are outside of the facility’s policy or proce-
dure. Passing them off to your manager is tempting. Instead, focus on what you can do to
help them. lf your manager is needed, go to him or her yourself and return to the customer
with a solution in hand. This makes you the service hero.

7. Do not say: “You want it by when?”

Say: “I'll try my best.”

When customers demand something that is unreasonable or difficult to provide, your first
reaction may be annoyance. Because you have little control over such requests, the best
approach is to resist a negative judgment and try your best to accommodate the requests. Do
not promise something with the hope that you can deliver. Giving unrealistic expectations
may get customers off your back now, but it may blow up later Make promises you know you
can accomplish. Assure customers, with confidence, that their deadline is important and that
you will try your best to meet it.

S. Do not say: “Calm down.”

Say: “I apologze for what happened.”

When customers are upset, angry frustrated, or concerned, telling them to calm down is like
saying that their feelings do not matter. If you want a customer to calm down, take the oppo-
site approach and apologize. Apologizing does not mean you agree with the customer’s point
of view. lt means that you are sorry for what has happened and the negative impact it has on
the customer.

9. Do not say: “I’m busy right now.”

Say: “I’ll be with you in just a moment.”
Stopping to assist another customer who is asking for your help is not always easy,
especially when you are already helping a customer. Some people handle this by tossing out
a curt, “I’m busy right now at the customer. Stellar service providers use a better approach
by saying, "I’ll be with you in just a moment.” This little sentence, along with a pleasant
tone of voice, lets your customers know that you are aware of them and that you will help
them soon.

Proper Patients will often ha›'e a request that you may or may not be able to fulfill. Following are
Communication some patient requests and proper answers to those requests.
with a Patient



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 Customer Service

Person A Person B

Frame of Reference Frame of Reference

Education Education

FIGURE 11.1 To create a common understanding
between two people.

Do’s and A phlebotomist can feel that he or she is doing everything correctly in communicating to
Don‘ts of the customer, but the customer continually complains about poor customer service. The
Communication phlebotomist may feel that he or she and the customer are reaching a cornmon ground, and
that the phlebotomist is using proper verbal and nonverbal communication, but the cus-
Skills
tomer is never happy. A slight change in what is communicated to the customer can often
leave a totally different impression. In the book Customer Service Jor Dummies: A ReJerence
for the Rest o} Us (Leland H Bailey. 2006), several dos and don’ts of customer service are dis-
cussed that can make the difference and win loyal customers:

1. Do not say: “1 don’t know.”

Say: “I’ll find out.”

When you say, “I don’t know,” your customer often hears, “I don’t have the information you
want, and I’m not going to go out of my way to get it.” By offering to find the answer, even if
doing so means taking a little extra time researching or checking with another department,
you score several points with customers for going the extra mile.

2. Do not say: “No.”

Say: ‘ What 1 can do is ...”

Sometimes you have to say no to a customers request. Rather than using what Leland and
Bailey (2006) call a “hard no,” where no alternatives are provided, focus on what you can
do. Starting your sentence with "What I can do is . ” shows customers that you are taking
a problem-solving approach to their situation.

3. Do not say: “Thats not my job.”

Say: “This is who can help you ...”

When customers ask you to do something that you do not have the authority or knowledge to
carry out, become a catalyst by leading them to the person or department who can help solve
the problem.

4. Do not say: “You’re right, this stinks.”

Say: “I understand your frustration.”

If a customer expresses annoyance at something another person or department has done,

do not make matters worse by commiserating with the customer. Instead of agreeing with
 CHAPTER 11

Nonverbal communication is a collection of postures, gestures, eye contact, and facial
expressions that accompany verbal communication. This body language is known as k inesics.
Talking to someone who smiles and looks you in the eye is more pleasant than talking to
someone who is frowning and looking at something else. Eye contact and a smile also can
help when it is busy and you are working with another customer. For example, if you are
talking to one customer, and another customer walks into ihe room, eye contact and a
smile to the second customer will let that person know that you recognize that he or she is
there. Customers will be much more patient in waiting their turn if they are recognized. In
addition, a receiver can detect these nonverbal postures and gestures even when he or she
cannot see you. A person who is smiling and happy while talking on the telephone can be
“heard” in the speaker’s tone of v-oice.
Communication also includes listening. Listening is often difficult to maintain. The
phlebotomist may be trying to listen carefully to the patient but is distracted because several
other customers are waiting. People speak at a rate of 100 to 200 words per minute. People
can listen at a rate of 500 to 000 words per minute. Because people can understand and lis-
ten at a faster rate than they can speak, there is extra time when the receiver can be distracted
with his or her own thoughts. Actix'e listening requires the listener to follow five steps:
1. Focus on the customer.
2. Limit your talking. This allows the customer to express their feelings.
3. Do not interrupt.
4. Manage your own thoughts.
5. Listen for feeling, not just words.
The goal of communication is to create a common understanding between two or more
people. This common ground of understanding is affected by each persons frame of refer-
ence. The frame of reference consists of a persons:
1. Background
2. Education
3. Experience
If people differ in any one of these frames of reference, they may have difficulty com-
municating with each other. For effective communication, all persons involved must find
common ground (Figure 11. 1). If their backgrounds are not the same. certain slang terms
should not be used, because one or more people will not understand what is being commu-
nicated. These slang terms possibly could mean something totally different in their culture.
Different education levels will mean that the conversation needs to be on the level or the
least-educated individual. Experience is similar to education in that the conversation must
find common experience before effective communication can be maintained. Only a small
area is common for all individuals in the conversation.

Short Answer
Directions: Complete the setttences with the best onswer(s).
1. Know what the customer
2. Determine whether or not the customer is getting the
3. Continuously take action to the customer.
4. Communication starts with a
5. Communication is accepted by the
6. Creating a goal of common understanding requires a common ground between
, and

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 Customer Service

lf phlebotomists would put themselves more often in their customers’ place, the customer
service would always be quality service.
This quality service is the start of a chain of events that leads back to the phlebotomist.
This chain is as follows:
1. A phlebotomist is hired to perform the task of collecting blood and nonblood samples.
2. The phlebotomist gives quality service.
3. Customer satisfaction improves.
4. More customers are retained and they tell others about the quality service.
5. As the profitability of the company goes up, salaries may rise.
h. More phlebotomists are given jobs due to the increase in customers.
7. The cycle stans again at step 2.
The three customer expectations for quality service shown in the box that follows each
relate to one another. The phlebotomist interacts with customers every day and is required
to meet the expectations of the patient. Remembering even the smallest courtesy can keep a
customer loyal for life.

1. Know what the customer wants.

2. Determine whether or not the customer is getting the service.
3. Continuously take action to satisfy the customer.

COMMUNIGA- Communication is one of the primary methods of showing the customer that there is an
ZION SKILLS attitude of caring. Improper communication can demonstrate that an attitude of caring is
not being communicated, resulting in customer complaints. Proper communication skills
can assure the customer that he or she is the most important person to the phlebotomist.
Each customer wants to feel that he or she is the only person the phlebotomist has to care
about. For the moments that the phlebotomist is with the customer, the customer can be
made to feel that he or she is the most important person in the world. To accomplish this,
the phlebotomist must have excellent communication skills.
Communication is the sending and receiving of messages. Communication starts with a
sender, who creates a message, which is then accepted by the rcce ivcr. The sender begins
this communication cycle by creating a message. The message must be created so that the
receiver is able to interpret it. The message is the information that is being communicated.
This information can be communicated by (1) speaking, (2) listening, (3) gestures or body
language, or (4) writing (words). The receiver must decode the message and then provide
feedback to the sender. It is only through this feedback that the sender will know thai the
message was understood.
This message is made up of both verbal and non›'erbal communication. When words are
spoken, we have verbal communication. The words must have meaning to carry a message to
the receiver. The communication must be in the language that the receiver understands. One
person should not speak English when the other person only understands Spanish. This also
penains to the technical nature of the language. Telling a child that he or she needs to “urinate
in the cup" will likely not tell the child what is needed. The phlebotomist should communi
cate on a level that the child will understand. A more understandable instruction to the child
could be for the child to ”pee in the cup.” This may not be the terminology that would be used
for adult instruction, but it may be the only instruction that is understandable for a child.



 CHAPTER 11

Stress is our emotional turmoil that results from distressing thoughts or difficult life
events. Usually it is not the event itself that is stressful, but the thought process we go
through when we encounter the e 'ent. Some stress is good; it drives us, keeps us focused
on the job, and keeps us in flow with our duties.
Stress is mostly seen as negative. It wears us out, it makes us think negatively, and
it seems like a burden we cont inue to carry Stress can be acure (immediate) or chronic
(long cerm).

Acute Stress Acute stress is usually caused by a one-time incident, such as narrowly avoiding an automo-
bile accident or having a vocal misunderstanding with someone. This can last from minutes
to hours or even weeks. Acute stress affects you for the short time it occurs. How you react
to the incident determines how detrimental it can be to you.
If after narrowly avoiding an automobile accident, you refuse to drive and do not go to
work for months, there will be serious outcomes: You will not make a paycheck, you will
not be able to pay your bills, and, therefore, your quality of life will deteriorate.

Chronic Stress Chronic stress is caused by continuous siressful incidents. Examples are a difficult job
environment, caring for someone Auth a long-term illness, personal illness, and depression.
People usually do not realize how chronic stress is affecting them until they become ill.

Thinking about Distoned thinking about an event causes stress. Irrationality in thinking leads to obsession
Stress and anxiety. As a phle botomist, you may have several patients in a row who are difficult,
and each patient may be very rude to you. With distorted thinking, you would say to your-
se1 f, “I just don’t know how to draw blood anymore. Every patient will be rude to me and
make me feel bad. I probably will never be able to laugh with the patients again or be able
to get blood without any trouble. They used to call me the best phlebotomist; now after
20 years 1 might as well quit. ” This distorted thinking can create stress and make the phle-
botomist doubt his or her abilities. Everyone has had several patients in a row who were not
the friendliest. You must realize that these were a series of patients who were unfriendly and
that it is no reflection on your skilL as a phlebotomist.
To reduce chronic These were a series of events t hat were negative for t he ph lebotomist . These events
stress it is best to undermined the phlebotomist s confidence and created the stress. The phlebotomist will
have a hobby or feel a lack of control over how he or she performs the job. Maintaining a sense of control is
outlet that is unre-
key to having a red uced-stress environment. Restructuring thinking to accept the fact that
lated to your work.
there are days when nothing goes right reduces stress.

Reducing Stress Laughter is an excellent way to reduce stress. Children laugh up to 300 times per day.
Adults laugh under 20 times per day. lt has been shown that some patients heal faster if
they are given daily doses of laughter. Stress is also reduced with a humorous joke, a funny
movie, or simply some laughs with a friend. Charles Swindolls quotation in Chapter 1 illus-
trates thai attii ude can make a difference.
Everyone likes to feel in control. When events that they cannot control occur, most
people become stressed. To reduce this stress, realize what you cannot comlot and work to
change those events you can control.
Other ways to reduce stress include managing your time and commitments. Learn to say
no to commitments that will increase your stress. Also find someone you can talk to. It is often
reassuring to find out that other people hax•e the same problems and emotions. You can talk it
out and develop aciion plans to get you through various crises.
Your body can physically handle stress if it is healthy. Getting adequate sleep, eating
right, maintaining a cotieci weight, and avoiding unhealthy habits can prepare your body
to fight off those stressful events. Stress can be relieved through an active lifestyle with exer-
cise and physical activity.
 Customer Service

The phlebotomist must liste n to what the cusiome r is saying—for the key problem the
customer has, which may not be the problem the customer is explaining. A mother may be
complaining that the child was hurt during the phlebotomy. She may be angry because all
she wanted was some medicine from the physician for her child, and instead t he physician
ordered laboratory tests. She was after a “quick fix” to the problem, and now it is going to
rake more time and money than expected.
To find out the true problem, the phlebotomist All have to ask questions. Gi› e feed-
back to the customer. Summarize to the customer what you are hearing the customer say
is the problem. Do not place blame. Define the problem in a nonthreatening way. Through
this feedback the customer will agree or disagree. This is the only way to find out what the
customer wants.

Just before the 7:00 s.u. opening time for the patient service center the two phlebot-
omists in that location were getting the computers turned on and making sure that
everything was ready for another day. Outside the door two patients were waiting for
the door to be unlocked. Promptly at 7:00 A.u. everything was ready and the door was
unlocked. One phlebotomist was nearly knocked down by the two patients fighting
to get through the door first and at the same time yelling at each other that they had
been first in line.
Seeing this battle under way, each phlebotomist asked the individuals if she could
help them. It suddenly became a one-on-one phlebotomist—patient relationship and
distracted the individuals from each other. Luckily there were two phlebotomists and
two computers to enter patient information. Each patient was happy because he was
’first” to get service. The patients were now involved in the process and were receiving
attention. Wisely, the phlebotomists timed entry of each patients information into the
computer so that both patients were finished at the same time. Each patient was then
taken to separate rooms at the same time. The end result was that both patients felt
they were first.
It often takes some quick thinking and quick reacuons to prevent a volatile situa-
tion from escalating. In this case there were two of everything, so the patients could be
serviced without making one of them actually ’first."
lf there were not two of everything, this could be made into a game to break the
tension. The phlebotomist could have said, “It looks like we have a tie on who got in the
door first. I’ll flip a coin to see who gets to be first.” This will usually redirect the patients
to the ridiculousness of the situation and they will most likely agree to that solution.


After determining what the customer really wants, try to meet his or her needs. If this
is impossible, suggest alternatix'es. Clearly state your position, and explain why you cannot
meet his or her demand. Share information that you have to inform the customer, but do
not share too much. Confidentiality of all other customers must be maintained . Finally,
agree on a solution, and follow up to make sure that the solution was achieved.


COPING WITH Maintaining outstanding customer service is difficult if there is stress in your own personal
STRESS life. How you cope with stress helps determine your own attitude. This attitude is ponrayed
to the customer as part of your level of competence.

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 320 CHAPTER 11

The phlebotomist will work with many types of customers. The largeness and complex-

ity of the health care environment are confusing to some. Some customers are very pleasant
Toys should be
and rational, whereas others are angry and do not listen to anything that is being explained
cleaned with a bleach
solution daily to to them. Most of this anger is not directed at anyone individually; they are angry that they
prevent the spread are ill and have lost control over being able to do what they want to do. Illness is dictating
of infection. their life. They are worried and angry that illness is taking time and probably will be costly
Some are realizing for the first time that they are mortal beings and that their current illness
could cause the end of their lives. They are realizing that if their lives are not ended totally,
the quality of life that they have been accustomed to may be coming to an abrupt end.
Understanding these fears and concerns of the customers will allow the phlebotomist to
give the quality service they demand.


THE SMALLEST Chapter 8 discusses skills the phlebotomist needs to care for the pediatric patient. The
PATIENTS pediatric patient should not be forgotten in providing excellent customer service. Color-
ing books and toys provide a distraction while pediatric patients wait for their turn to be
ALSO NEED
with the phlebotomist. Once the pediatric patient is in the draw chair, you will be able to
GUSTOMER demonstrate the pediatric skills and customer service techniques discussed in Chapter 8.
SERVICE

CONFLCT Over the course of iime, the phlebotomist will need to deal with one or more angry custom-
MANAGEMENT ers. Conflict happens each day in our lives. This is a result of the fact that all people have
differences. Conflict can be destructiv'e to the person, the relationship with coworkers, and
customer service if not controlled. Conflict management is a process in which the situation
is analyzed and appropriate action is taken. The action the phlebotomist takes depends on
past experience and training.
The phlebotomist approaches conflict in one of five ways:
1. Accommodntor. Smoothing over the conflict is a method of accommodating, to be the
peacemaker in the conflict. There is little concern for the conflict or understanding the
conflict. The goal of the accommodator is to maintain the peace at whatever cost.
2. Avoider. The avoider will ignore ihe conflict. Posiponing the conflict or changing the
subject of the conflict are methods the avoider will use to avoid becoming involved in
the conflict. Sometimes the avoider will simply walk away and withdraw from a threat-
ening situation.
3. Collaborator. The collaborator works to understand the conflict and find a solution.
The collaborator works to resolve the problem and involve all parties in the conflict in
the resolution.
4. Compromises. The compromiser works to find a mutually acceptable compromise that
partially satisfies all parties. This is usually done through manipulation and domina-
tion of the parties in conflict.
5. Controller The controller tries to overpower everyone and dictate what needs to be
done for a resolution. The controller feels that this is a win-or-lose proposition and will
do everything possible to win.
One conflict style is not ideal for all situations. Dealing with a conflict requires the
phlebotomist to use a blend of all the styles for the best resolution. To resolve the conflict,
the phlebotomist must use his or her best communication skills to handle the conflict
in a diplomatic way. The phlebotomist must fi rst deal with the customer’s fee lings.
Realize that no matter how minor the issue may seem to you, it is important to the cus-
tomer. The customers feelings are involved, and the customer is emotionally concerned.
 Customer Service 319

Following are reasons a patient chooses a location to have his or her blood drawn:
1. The insurance carrier dictates this is where the patient should go.
2. The physician directs the patient to a certain location, or the physician draws the
patient in his or her office.
3. The draw site is in a convenient location.
4. The image thai the draw site ptojects is good.
Laboratory management must contract with the insurance carriers so that the labora-
tory is the patient’s primary laboratory for insurance. This is advantage ous to the patient
because a lower copay for the laboratory tests is likely if the patient goes to the designated
laboratory. This contract does not relieve the phlebotomist of providing good customer ser-
vice. Most contracts have a clause that patient satisfaction must be maintained at a certain
level for a contract to continue. If patients are dissatisfied with the phlebotomy experience,
the insurance carriers may void the contract and seek a different laboratory.
There may also be contracts for t he physician to draw samples in t he office that will
both benefit the physician and be a convenience for patients. This is why many laboratories
have an in-office phlebotomist working in physicians’ offices. The phlebotomist is paid
by the laboratory but works in the physicians office. This is done to offer convenience to
patients and to obtain those patients’ business. The duties of the in-office phlebotomist are
discussed in more detail in Chapter 12. This phlebotomist will have many interna1 and
external customers. The patients are the internal customers, and the physician and staff are
the direct external customers. The in -office phlebotomist must satisfy all these individuals.
If the phlebotomist does not maintain excellent customer service with the patients, the phy-
sician may seek a new laboratory to provide phlebotomy services. If the phlebotomist does
not maintain a good relationship with the physician and staff, a request may be made to
replace either the phlebotomist o f the laboratory. Professionalism and phlebotomy skills are
the attributes that the phlebotomist contributes to patient satisfaction.
Convenience of the draw site is best with an in-office phlebotomist. However, a lab-
oratory may not be able to provide a phlebotomist for each physician in a particular city
Therefore, a compromise must be made by having patient service centers near large groups
of physicians. Pro›'iding ihis convenience to patients gives them a level of satisfaction.
The image that the patient service center projects must highlight the professionalism
of both the phlebotomist and the laboratory A phlebotomist who is sloppily dressed or a
location that is old and dirty will have a negative impact on patients. Even if such a location
is convenient, patients will drive farther to find a location that is more physically appealing
and customer friendly.
In some cases. a customer comes into the facility already dissatisfied. This chat lenges
the phlebotomist to “read” the customer and improve his or her satisfaction. Factors that
made the customer dissatisfied could be any of the following: a previous negativ'e experi-
ence, personality characteristics, high expectations, or the time the customer allowed for
the laboratory visit. Not matching a customer’s expectation created the dissatisfaction. for
example, a negative expectation for a customer is created if the minimum time it takes for
a patient to give the appropriate information and get blood drawn is 15 minutes but the
patient expected the process to be completed in 5 minutes. For this customer to become
satisfied, he or she will need to understand that 15 minutes is the minimum time it takes
to complete the process and more than 5 minutes is needed to get his or her blood drawn.
Helping the customer to understand the process will take time. The more information the
customer is given, the better the customer will understand how long the process takes.
A customer waiting will become quickly impatient. Once the customer is called back and
someone is working with them, they do not become concerned about the time it takes for a
process to be completed.


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 CHAPTER 11

E KERCISE 2 Matching/Identification
Dircctions: Muted the communication statcment thai is tmp Roper with the statement that
would be more nrceptohie.
Improper Commuaicntion Acceptable Communication Statement
1. Calm down. a. I’ll be with you in a moment.
2. No. b. I'll try my best.
3. 1 don't know. c. I'll find out.
4. You need to talk to my manager. d. I'm sorry
5. I’m sorry. e. I understand your frustration.
6. I’m busy right now. f. Let’s see what we can do about it.
7. You want it by when? g. What I can do is
8. You’re right, that stinks. h. This is who can help you.
9. That’s not my fault. i 1 can help you.

PATIENT Keeping patients satisfied is one of the primary roles of the phlebotomist. Patients expect
and demand a quality encounter in the phlebotomy experience. Their encounter with
SATISFACTION
the phlebotomist will be the basis of t heir opinion of t he entire laboratory. Patients never
see the testing being completed. The ir only contact with the laboratory is thro ugh the
phlebotomist. Phlebotomists have an advantage by dealing directly with patients and not
over the Internet or or the telephone. People like dealing with people. This gives the phle-
botomist t he opportunity to shine. This quality encounter consists of more than commu-
nicating effectively with the patient. The patient will also see quality in the skill level of
the phlebotomist and the physical surrou ndings. The area should be neat and clean; the
ph lebotomist should also ha›•e a professional appearance. Patients assume they are coming
to a professional office and expect the facility and the staff to project that image. Just like
you clean your home when you are expecting guesis, the phlebotomy area should be clean
for your patients. The patient will tell others that the phlebotomist was excellent at drawing
blood and very friendly and that the wait was not very long. The patient does not care about
the details or the problems of the day; the patient only cares about being treated kindly and
fairly and having a quality sample obtained. Each patient should be treated like a guest in
your home. Treat each patient as if he or she is the most important patient you will have
that day, and give that patient individualized attention.
Patient satisfaction is affected by factors not always controlled by ihe phlebotomist. The
physical facilities can determine what the customer thinks of the experience. These can be
ease of access to the facility, availability of parking, the time it takes to get to the facility, and
the time waiting to be served. These are the elements that make the patient satisfied or dis-
satisfied if they do or do not meet the patients expectations.
Health care is unique in that most people do not shop for ii by price. If you are pur-
chasing a tele›nsion, you may know the brand and the size you want. The first thing you do
is go on the Internet or shop different stores until you find the best price and then purchase
it. You may go to a store that is not the cleanest or the clerks the friendliest becnuse you are
looking for a good price. Patients usually do not shop for a blood test based on price. Most
patients have some type of third party insurance payer so they do not look at the price of
the test because someone else is going to pay for it. Patients make the choice of where they
go to get blood collected based on se›'eral factors.

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 Compliance: Legal and Ethical Issues

The laboratory should develop a compliance plan to determine how the laboratory will
adhere to the guidelines of the Office of the Inspector General (OIG). The plan should
establish a culture within the laboratory that promotes prevention, detection, and resolu-
tion of instances of conduct that do not conform to the laws. A person within the labora-
tory should be assigned to the task of chief compliance officer. This person develops the
laboratory compliance plan and sees to its adherence. To advise the compliance officer, a
compliance committee should be formed to assist in the implementation of the compliance
program. This committee consists of individuals with various responsibilities within the
organization.

WHY Compliance is essential to prevent overcharging. This can be overcharging of t he patient,

COMPLIANCE IS Medicare, Medicaid, or the insurance carrier. In 1992 a civil false claim case, United Staics
ex reI DowJen versus National Htulth Labo reto ries, Inc., was settled. This case involve d a
ESSENTIAL
mu ltimillion-dollar settlement between the government and National Health Laboratory.
This was the first of several cases invo1›'ing laboratories. In this case, the laboratory was
offering a special chemistry panel to physicians for a set price. This special chemistry panel
included Medicare and Medicaid-approved panel elements but also additional tests that
could be billed to Medicare and Medicaid. The traditional chemistry panel that did not have
the additional tests added had been eliminated from the laboratory requisition. Physicians
ordered the special chemistry panel, thinking that they had ordered the traditional panel.
Instead of one bi]l being sent to Medicare and Medicaid, as was being done with the physi-
cian, Medicare and Medicaid received a bill for the chemistry panel and any additional tests
the laboratory added onto the special chemistry panel. In one part of the National Healih
Laboratory case, the reimbursement from Medicare grew from $300,000 to $31,000,000 in
one year. Each patient who had a chemistry panel did not have a medical necessity for the
additional tests. Therefore, Medicare was being charged for tests that were not needed to
diagnose or treat the patient.
The government indicated that National Health Laboratory had manipulated ihe physi-
cians into ordering medically unnecessary tests that had been added to the chemistry panel.
These medically unnecessary tests had been fraudulently charged to Medicare, whereas the
physicians were not charged an increase. The physicians were unaware of the increase in
charge to Medicare.
The National Healt h Laboratory case was the first of several cases that resulted in multi
million-dollar lines. As a result of this government enforcement, the panels approved by the
American Medical Association were developed (see Chapter 1, Figure 1.3).


LAWS THAT The laws that regulate fraud and abuse generally have monetary penalties for noncom-
REGULATE pliance. Sometimes the penalties are assessed in multiples of (e.g. , two or three times)
the amount originally billed. For some laws the penalty is up to $ 15,000 per service
COMPLIANCE (laboratory test) billed. Criminal penalties and imprisonment for individuals can occur.
Companies may be excluded from participating in Medicare or Medicaid. Once a com-
pany is excluded from Medicare or Medicaid, the private insurance companies usually
also exclude this company from the companies their patients can go to. This exclusion
results in the majority of the income that the company was receiving being stopped.
Most companies will fail with this cut in income. A general description of the pertinent
laws follows

Antikickback Law The federal anti kickback law prohibits the knowing and willful payment or offer of any
remuneration directly or indirectly in return for inducing, referring, or soliciting seo•ices,
including laboratory testing paid for by a federal health program. Remuneration can be

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 CHAPTER 12

NAACLS Competencies Relevant to Chapter 12

Communicate (verbally and nonverbally) effectively and appropriately in the workplace.
¥• Define the different terms used in the med- policies and protocols designed to avoid
icolegal aspect of phlebotomy and discuss medicolegal problems.

KEY TERMS

Best Practices The most efficient and effective way of accomplishing a task, process, or activity
based on repeatable procedures that have proven themselves over time for large
numbers of people.
CLIA Clinical Laboratory Improvement Act.
Compliance The formalized monitoring of an organization’s adherence to laws and regulations.
CPT Current Procedural Terminology manual listing a coding of procedures and
services performed by physicians. Published by the American Medical Association.
Ethics Professional code of conduct related to treatment of patients. Ingrained in this is a
moral philosophy of how the phlebotomist treats the patient.
HHS U.S. Department of Health and Human Services.
HIPAA U.S. Health Insurance Portability and Accountability Act.
ICD-10 International Statistica/ Classification ol Diseases and Related Hea/th Problems list
of diagnosis codes for illnesses. Published by the American Medical Association.
Malpractice Failure of a professional person to offer a standard of care, resulting in injury or
harm to the patient.
Medical Necessity Service that is reasonable and necessary for the treatment of the patient’s illness.
U.S. Office of the Inspector General.
Protected health information.

a o rd n ndi n rd w 9 oh ondld lferents tuotions

ebotei a ee a ry1 n t hep hlb omib t o
enp o ree a ntinlt on void hep itlii 1s

enea lw hntd ti b omib

a e np erm mingt }a ob.




WHAZ IS C.o in p1 ia n cc is the formalized monitoring of an organization s adherence to law's and reg
COMPLIANCE? ulations. Compliance for t he health care industry is required to prevent fraud, abuse, and
wasie in ihc clinical laboratory indusi ry while ai the same time providing qualii ' sc r› ice
to the customer. Various laws, regu1ati‹ans, and plans have been developed to monitor the
laboraior y. These law's Cover ning relationships between provider and referral sources are
ge nerally kn‹a 'n as fraud and abuse laws. These ensure t hat t he customer is not being over-
charged for testing or charged for testing that was not ordered and that unnccessary• testing
is not being conducted

' I‘ u 1 ir i A R " ! H o r . o‹1 V ‹ I I i ' c' ' a ›• ‹1 ,‹ o‹1 i › r ;1 i . ; 1 i c . i o i' i i .v1 ‹ i ie i › ‹ i i i, i i i ••7 I? N 0 I ? 0 0 2 0 2
 OBJECTIVES After studying thfs chapter, you should be able to:
1. Explain the laws that regulate compliance.
2. Discuss why it is essential that laboratories maintain compliance and
follow these laws.
3. Define ethics and describe a situation in which a phlebotomist would
need to make an ethical decision.
4. Discuss the best way for a phlebotomist to avoid injury-related lawsuits.

 CHAPTER 1 J

1. Through self-analysis, determine what type of person you are when you deal with conflict. Talk to your friends, and
determine how they feel you handle conflict. Are the answers different? If so, what were the differences?
2. Ask five people to write down their answers to the following six questions:
a. What is the price of an expensive car?
b. How long ago did a particular incident happen if it happened recently?
c. The person will be gone “a while.” How long will that person be gone?
d. The person had “many” dogs. How many dogs did she have?
e. The friend will return in the “near future.” When will he return?
f. The woman is “older.” What is her age?
List the low and the high values for each question. Why are there differences?
 Customer Service

Pre paring yo u rself both ph 'sicall y and me ntall y to handle e en is as the y occu r will
reduce the effects of stress. Stress will alw•ays be there. lf you approach it with distorted
thinking, the stress will be detrimental. It is not the events of the day that de velop stress in
the phlebotomist ; it is how the ph lebotomist deals wu th those even is.

Ma h ng Ke Te Re e
directions: Identify the appropriate deJinition Jor each be y term.
1. Diplomacy A. Su perior professional attention and assistance
to customers’ needs.
2. In-Office- B. Person communicating to someone else verbally or
Phlebotomist nonverbally.
3. Quality C. Skill in handling affairs without raising hostility.
Service
4. Receiver D. Person who is being given information by a sender
5. Sender E. A phlebotomist who works in a physicians office
to collect samples from patients but is an employee
of the laboratory.





Multiple Choice
Choose the one best ansitei:
1. To achic›’e quality customer sc rvice, the phlebotomist musi meet what customer needs*
a. know the customer b)' name, determine I he tests c. know what the customers insurance will pa)' for,
needed b) the customer, know wh o the patient s keep the patient from z•ait1ng too long, say as little
ph)'sician is as possible to the patient
b. know what the customer wants, determine the
level of service rece ived, and take action t o satisfy
the customs r
2. When two people are communicating, they understand each other and have a common ground. This common
groun‹1 is based on which three frames of reference?
a. language, nationalit)', experience c. background, education, experience
b. education, nationality, seniority
3. The phlebotomist who tends to smooth over a conflict is known as a(n)
a. accommodaior. c. controller.
b. col I aborator.

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 CHAPTER 12

Reliance on Standing Orders. The use of a recurring or standing order on a patient
is discouraged but not denied. These orders, which continue on the same patient at a
recurring (e.g., monthly) schedule, must be reviewed and updated periodically. This is
usually semiannually or annually. For example, the order could be for a prothrombin
time (PT) to be done on a patient the first week of every month. The reason for the
required periodic review is to make sure thai the patient does not continue to come in
for blood work when the medical necessity for that blood work may have changed.
5. Compliance with Applicable HHS Freud Alerts. The OIG will periodically issue fraud
alerts, which list activities that raise legal and enforcement issues. These should be
reviewed by the chief compliance officer to ensure that the laboratory is in compliance.
These fraud alerts could be noti fications that certain physicians are no longer able to
order laboratory tests.
6 Mor§eting. The laboratory should have honest, straightforward, fully informative, and
nondeceptive marketing. The marketing cannot offer one test or service and then give
the patient something else.
7. Prices Charged to Physicians. The laboratory prices must not provide any inducements
to gain a physicians business. A reduced price to a particular physician must be justi-
fied, for example, based on a large volume or the physician providing the phlebotomy
equipment that the laboratory does not need to pro›nde.
Retention oJ Records. All records that could be required by state or federal law are
available if the laboratory comes under government scrutiny. The time for retention is
dependent on the type of record.
9. Compliance as on Element oJ o PerJormnnce Plan. Adherence to compliance must be
a part of the evaluation of all employees. The employees must be periodically trained
in new compliance policies and procedures. This compliance training is usually done
during the new-hire orientation and then annually.

PHLEBOTOMY- Compliance covers a wide area in the laboratory. Many compliance policies do not relate to
RELATED the phlebotomist. For the purposes of this text, only policies that directly relate to the phle-
botomist are discussed. Laboratory compliance plans require written compliance policies.
COMPLIANCE
A three-ring notebook is the best way to keep the policies. As policies change, they can be
POLICIES easily removed and a new policy inserted. The policies and information that a phlebotomist
should be aware of are discussed next.

Requisition Design The requisition used by the laboratory should have a standardized listing of tests for the
most commonly ordered tests. The requisition should be designed to encourage the physi-
cian to order only those tests that are medically necessary and appropriate for each patient.
The requisition should include Medicare-approved profiles and discourage the use of cus-
tomized profiles that may not be approved by Medicare. If a physician requests customized
profiles, the physician must realize that some of the tests on a specific customized profile
may be denied payment by Medicare. All requisitions should include a patient diagnosis
to determine the medical necessity of the tests ordered. A physician who orders medically
unnecessary tesis may be subject to civil penalties. The compliance officer should review all
requisitions before they are printed and distributed.

Client Supplies The laboratory may provide laboratory-related supplies and equipment if these supplies and
and Equipment equipment are used solely for the purpose of collecting and preparing samples for the labora-
tory to do the testing. Fax machines and computers can be supplied, provided that they are
not used for anything other than laboratory work. For example, if a fax machine was placed in
a physicians oIIice and the physician used the fax to send a prescription to the local pharmacy,


 Compliance: Legal and Ethical Issues

COMPLIANCE The OIG of the Department of Health and Human Services (HHS) promotes voluntarily
PLAN ELEMENTS developed and implemented compliance programs for laboratories. The O IG offers
guidelines to follow in designing a compliance program (Office of the Inspector General,
1998). Seven elements should be included in t he laboratory compliance plan.
Elements of 1. The development and distribution of written standards of conduct as well as written
a Laboratory policies and procedures that promote the laboratory’s commitment to compliance.
Compliance Plan These standards of conduct should address specific areas of potential fraud. such as
marketing schemes, coding issues, and improper claims submissions.
2. The designation of a chief compliance officer and corporate compliance committee
responsible for operating and monitoring the compliance program.
3. The development of regular effective training programs for all affected employees.
4. The maintenance of the compliance process to receive complaints in an anonymous
manner without fear of retaliation.
5. The development of a system to respond to allegations of improper/illegal actiݖties
and appropriate disciplinary action against employees who have violated compliance
policies.
6. The use of audits or other evaluation techniques to monitor compliance and assist in
the reduction of identified problem areas.
7. The investigation and remediation of identified systematic problems and the develop-
ment of policies addressing these problems.
These seven elements should be included in the compliance plan in the form of written pol-
icies and procedures. The policies and procedures should include sections on the following:
1. Standards oJ Conduct. A standard for all employees that details the policies of the lab-
oratory in relation to fraud, waste, and abuse, and adherence to all government regu-
lations. Included in this are instructions on what to do when a government inspector
comes to a location and how to respond to unqualified requests for patient information.
2. Medium Necessity. The ability to order only those tests that are appropriate for treat-
ment of t he patient. In rare cases a patient will add check marks to t he order form and
order laboratory tests on himself or herself. The test may not be medically necessary
but the patient is curious about his or her blood levels for cenain tests and will add
these tests to the form. Usually this will show on the form as a different type of check
mark or handwriting. If there is ever a question on what is ordered, the physician’s
office will need to be called to clarify that order. This will keep the laboratory and the
physician in compliance. The physician has to be able to justify that only medically
necessary tests were ordered. The laboratory needs to be able to ensure that only tests
ordered by the patients physician were completed.
3. Billtng. The assurance that all claims submitted to Medicare or other federal health
programs are correctly identified as services or tests that were performed before the
patient is billed. In lernational Statistical Classification o[ Diseases end Related Health
Proble me, usually called by the shortened name Inte rnotionnf CfessJication of Diseases (ICD-
10) codes, is the 10th edition of these codes. They are used to identify the type of
disease or illness the patient has. The ICD-10 is monitored under the direction of the
Health Care Financing Administration (HCFA). If the physician does not furnish the
codes, the codes must be obtained from the physician before billing can occur. Codes
cannot be added by the phlebotomist based on the tests ordered or what the patient
says. The Current Procedu rat Te rminology (CPT) codes are codes for all tests that are
completed and billed. Each iype of laboratory test has a specific CPT code based
on the test and methodology of that test.


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 CHAPTER 12

Antikickback law: Prohibits payment in money or services to a physician in order to

solicit business from that physician
Stark law: Prohibits a physician from referring business to a laboratory in which the
physician has a financial interest
False Claims Act: Prohibits knowingly submitting a false claim to the government for
service not performed or charging for more services than were performed
Civil Monetary Penalties law: Prohibits claims for services not provided as claimed
CLIA: Includes specifications for quality control, quality assurance, patient test man-
agement, and personnel and proficiency testing
PHI: Patients’ personal information that is connected to their medical information
HIPAA: Provides the guidelines to keep PHI private and secure


Phlebotomists cannot look up a friend s test results or their own test results unless they

hai'e a need for those results. The results can be released only to the person who ordered
A friend of yours says
the test, to an authorized representative, or as required by law.
that she knows you
work in the laboratory
and asks if you can

look up her daugh-
ter‘s test result. You Matching/Identification
will have to tell her directions: Match the lnw regulating compliance with ihe explnnntion oJ the law.
no. Doing so could
result in your being Law Explanation
discharged from
your job. 1. Antikickback law a. Includes specifications for quality control,
2. Stark law quality assurance, patient test manage-
ment, and personnel and proficiency
False Claims Act testing

Civil monetary
penalties b. Provides guidelines to keep PHI private
and secure
CLIA
6. c. Prohibits payment in money or services
PHI to a physician in order to solicit business
7. HIPAA from that physician
d. Patients’ personal information that is
connected to their medical information
e. Prohibits a physician from re ferring
business to a laborator y in which the
physician has a financial interest
f. Contains the guidelines to keep PHI
private and secure
g. Prohibits claims for services not provided
as claimed



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 Compliance: Legal and Ethical Issues 329

CLIA The Clinical Laboratory lmproi'emeni Act (CLIA), as discussed in Chapter 1, includes
specifications for quality control, quality assurance, patient test management, and person-
nel and proficiency testing. This includes some of the regulations thai direct the labora-
tories in how the phlebotomist is proven to be competent in his or her job performance.

Competency and its documentation are discussed in more detail in Chapter 13.

PHI When a patient s personal information is connected to his or her medical information,
it is referred to as protected health information (PHI). This in formation must be kept
private and confidential. Any paperwork with patient information must not be disposed
of in the trash until the paperwork is shredded. This includes insurance information,
physician orders, and labels for tubes. Most locations have a shredder or a container for
PHI documents.

HIPAA The Health lnsurance Ponabiliiy and Accountability Act of 1996 (HIPAA), Public Law 104-
191, was enacted on August 21, 1996. This law started as an act to protect health insurance
coverage for workers and their famdies when they change or lose jobs. Title I of this act was
created to lower a person’s chance of losing health insurance coverage when there is a job
change and disallows limiting or refusing coverage because of preexisting conditions. It also
hel ps people buy healih insurance when they lose their employer’s plan and have no other
coverage available.
Title II of the act required the De partment of Health and Human Services to establish
national standards for providers, health plans, and employers. The purpose was to stan-
dardize electronic data for widespread use in health care.
Where most people have been affected by HIPAA is in the portion that took e ffect on
April 14, 2003 (April 14, 2004, for small health plans). On this date most health insurers,
pharmacies, doctors, and other health care providers were required to follow federal privacy
standards to protect the security and confidentiality of health information. HIPAA encour-
aged electronic transfer of information but also required all health-related businesses to
protect the security and confidentiality of health information.
What this means for phlebotomists is that they are limited in the information they have
on each patie nt. The phlebotomist has access to only information that is necessary for the
treatment and care of t hat patient. The phlebotomist also needs to limit how this informa-
tion is shared. Part of this requires that there be more confidentiality of patient information
when registering patients and drawing their blood.
In some cases there needs to be more pri›•acy when asking patients for information
such as address, date of birth, and diagnosis when completing the paperwork before
blood is collected . Historically, the physical setup of facilities did not allow for privacy
when asking these questions. Other patients in the waiting area could hear the answers
pat ients gave. The abilit y of ot her patients t o overhear con versations n ow m ust be
limited.
Patient healt h information cannot be shared or looke d at by employees unless
there is a specific need. No longer can employees look up a patient’s computer health
records just because they are curious. Each employee is given only limite d access to
com pu ter systems for what is necessary to do the j ob. H IPAA provides guidelines
to kee p PHI private and sec ure. Only those individuals with a need to look at the
information should have access to the information. This prevents individuals who are
not invo lved in the patient’s care from seeing t he patient’s medical information. It is
critical to keep a patient’s medical records confidential. It is i ust as critical to protect
the personal information the patient provides phlebotomists. Identi ty theft, which
involves the theft of pe rsonal information, is a fast-growing crime. All patient info r-
mation should be shielded from view by other patients or other employees who do not
need the information.

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 CHAPTER 12

anything of service or i'a1ue. These items of value could include computer equipment,

laboratory equipment, or free courtesy testing. The item of value does not have to be given
A physician comes into
your phlebotomy area to the physician. lt could be given to an employee or relative of the physician, and it would
and says he needs a com- still be considered a kick back. To test whether the law is violated, the following question
plete blood cell count should be asked: Can the service provided to the physician reasonably be deemed to be
(CBC) drawn on himseñ. directly related to the services provided, or does it provide a broader benefit? Examples of
When you ask for his
insurance information, he fraud follow:
says it is a professional l . A laboratory-provided phlebotomist in a physicians office doing duties not related to
courtesy. You will need to phlebotomy and normally done by the office staff
instruct him that you can-
not draw the blood for a 2. Provision disposal of biological wastes that are a result of the physicians oIIice and not
professional courtesy ac- the laboratory testing
cording to company pol-
icy. He will need to direct 3. Provision of computers and faxes that are not exclusively used by the laboratory
any questions to the lab- 4. Professional courtesy testing
oratory pathologist.
Penalties for violation of the antikickback law are imprisonment up to 5 years and/or fines
up to $25,000. Exclusion from Medicare/Medicaid is possible.

Stark Law The Stark law, designe d by U.S. Re prese ntative Frotney (Pete) Stark, forbids a physician
from referring a sample to a laboratory in which t he physician or an immediate family
member has a financial interest. The following are prohibited by the Stark law:
1 . The physician refers a Medicare patient to a laboratory and has a financial relationship
with the laboratory.
2. The laboratory submits a claim to Medicare or Medicaid for the service provided to a
patient whose physician has a financial interest in the laboratory

Penalties for violation of the Stark law are fines up to $15,000 per service and/or twice the
amount originally billed. Exclusion from Medicare/Medicaid is possible.

False Claims Act The False Claims Act prohibits knowingly presenting a false claim to the government.
Knowingly is the reckless disregard for the truth. Specific intent to defraud is not required.
Examples of false claims include the following:
l . Billing for services that are not medically necessary for diagnosis or treatment of a
Medicare pat ient
2. Billing for services not performed

3. “Upcoding” (misrepresenting the services performed) to increase reimbursement

4. Filing duplicate claims for the same seoñce

5. Inserting diagnosis codes that were not provided by the physician
Penalties for the violation of the False Claims Act include triple damages (three times the
amount of the damage sustained by the government) and a mandatory penalty of $5,000 to

$10,000 per claim. Exclusion from Medicare/Medicaid is possible.

Civil Monetary The Civil Monetary Penalties law applies to claims for services that are not provided as
Penalties Law claimed. These false claims are similar to the false claims under the False Claims Act. The
penalties can result in fines up to twice the amount billed to the gox'ernment and up to
$10,000 per seoñce. Exclusion from Medicare/Medicaid is possible.

State Laws Many states have their own set of laws that prohibit the payment of refe rral fees as well
as the referral of the laboratory tests to a laboratory in which the physician has a finan-
cial interest. These state laws are not limited to the Medicare and Medicaid programs.
They apply to all payers, including insurance companies. Penal ties vary depending on
the state.
 Compliance: Legal and Ethical Issues

When the patient is fully recovered, move the patient io a place where he or she can lie
down with the head lower than the feet. Place cold or wet towels on the patients forehead
or neck. The patient may be given cold water if he or she is conscious and not nauseated.
Keep the patient lying doom for at least 1 5 minutes or until the patient is fully recovered.
For a patient with a known or suspected low blood glucose level, small amounts (20 to
25 mL) of orange juice or glucose tolerance beverage may be administered until ihe patient
feels better. This technique will improve a low glucose rapid ly but will not change a high
blood glucose significantly. Contact the patient s physician to explain what happened. The
physician may want to see the patient.
For severe reactions—extensive perspiration, convulsions, persistent clamminess, or
gray color—or if the patient does not reinve in 2 to 3 minutes, call the emergency contact.

Hematoma A hematoma is the leakage of blood out of a vein during or after venipuncture that causes
a bruise. This results when the nee dle nicks the wall of the vein, the needle punctures
through the vein during venipuncture, or blood leaks around the needle shaft. A lump can
develop immediately or after the patient has left. The size of the lump is an indication of the
amount of bleeding that has occurred. As the blood migrates in the tissue toward the skin,
the characteristic discoloration or ecchymosis (the black and blue) will appear.
A bruise does not necessarily resuli in a lawsuit. Many patients will experience bruising.
Severe bruising that causes pain is usually the result of nicking an artery when attempting a
draw from the basilic vein. This severe situation results in a hematoma that puts pressure on
the nerve and can lead to permanent injury To prevent legal action from a bruise, it is best
to try to draw from the cephalic or median cubital vein if at all possible. Carefully observe
the puncture site immediately after any draw. Pressure should always be applied to the sire
immediately after collection. Any patient on anticoagulant therapy should hax•e an elastic
bandage applied to prevent bruising. Be watchful of the patient with a purse. Instruct the
patient to carry the purse with the arm opposite the venipuncture. This helps avoid stretch-
ing the muscles and tissue and opening the puncture site to bleeding. If the phlebotomist
notices that a patient is going to bruise, it is best to admit it to the patient before he or she
leaves. Evidence of a potential bruise does not result in the visible darkening of the skin im-
mediately. This usually occurs after the patient is at home. If a patient calls with a complaint
about a bruise, document this call on an incident report and then give the patient some basic
instructions.
Ask the patient to apply ice or an ice pack for approximately 20 minutes several times
in the first 24 hours. If the arm is still tender after the first day, the patient may apply warm
moist cloths for 20 minutes four or five times a day and take non—aspirin-containing pain
medication. If the problem continues, the patient should consult a physician.
Several techniques to prevent hematomas are as follows:
• Remove the toumiquet before removing the needle.
t Apply a small amount of pressure to the area after removing the needle. Also apply a
tight bandage over the gauze or cotton ball.
t Do not use superficial veins.
• Puncture on ly the uppermost wall of the vein. Do not puncture through both sides of
the vein.
t Make sure the needle fully punctures the uppermost wall of the vein. Partial penetra-
tion may allow the blood to leak into the tissue surrounding the vein.
t If there is a possibility that the patient will move during the venipuncture, the phlebot
omist should take special care to hold the patients arm still during t he venipuncture.
The best method is to have someone else help hold the patient’s arm. This is especially
important with the pediatric or combative patient.

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 336 CHAPTER 12

How the phlebotomist handles each of these situations is dependent on the training the
phlebotomist received. What the patients lawyer will try to prove is that a standard of care
for that patient was not given to that patient, resulting in injury to the patient. The patients
lawyer is trying to prove malpractice on the part of the phlebotomist. Proof of injury to the
patient as a result of the phlebotomist not using standard procedures and best practices
usually results in monetary damages being paid to the patient.
The laws ›'iolated can be either tort laws or criminal laws. Most malpractice cases in
civil court involve tort law. The distinction between a tort law and a criminal law is one of
intent. If one intends to harm a patient, then it involves a criminal law and not a tort law
Most cases of patient injury are unintentional. If you are ever involved in a legal issue, the
health care facility’s attorney will explain the laws and how you are involved. lt is not
the intent of this book to explain all the implications in a lawsuit. The best defense is to
follow standard procedures and best practices and not deviate from these.

Consent The patient or legal caregver must give consent to have a blood sample taken. Some health
to Perform care facilities have a written consent signed when the patient is registered. The courts have
Venipuncture recognized implied consent from patients. Implied consent is when the patient goes to the
facility and presents his or her arm to have blood drawn. This is called legal implied con-
sent because if the patient did not want to consent, the patient would not have volunteered
his or her arm or gone to the health care facility to have blood collected.
Working with the resistant patient is discussed in Chapter 7. The resistant patient
is not giving consent and shout d not be forced to have blood d rawn. Drawing from the
refusing patient can result in assault and battery charges. If there is ever a question as to
whether the patient is consenting to the draw, consult with the patient s nurse before the
attempt.

Fainting or Lawsuits brought by patients who have fainted are usually a result of patients injuring them-
Convulsing Patient selves when they fall. The phlebotomist must be cognizant of the patient to determine if he
or she is feeling weak or light-headed. Never walk away from a patient without first asking
if he or she feels all right. It is best to keep the patient sitting while the phlebotomist labels
the tubes. This gives the patient time to rest after the draw and keeps the patient available
to answer any questions on how to spell his or her name or obtain other pertinent infor-
mation. Escort the patient back to the waiting room or walk with him or her for a short
distance to ensure that the patient is not going to have a reaction.
Negligence occurs when actions are not taken to watch the patient or to prevent injury
during fainting. Always keep the arms to the draw chair locked in place until you are finished
labeling the tubes and you are certain that the par ient is able to leave without complica-
tions. Only then should the arms of the draw chair be moved out of the way for the patient
to stand u p. Patients will often try to move the arms up themselves and lea›'e the instant
the needle is out of their arm. Have the patient stay seated until you are sure the bleed -
ing has stopped and you have the tubes labeled. This is usually enough time to assess the
patients reactions and permit the patient to leave. Escort the patient a short distance out of
the phlebotomy room to make sure the patient is stable.
If the patient faints during or after the venipuncture, do not leave the patient. Call for
assistance if additional laboratory personnel are a› ailable. lf the patient is displaying signs
of possible fainting, lower the patients head toward his or her knees or lap while holding
the patient in the chair. If the patient is conscious, tell the patient to breathe slowly to
avoid hyperventilation. If the patient has gone into convulsions, do not try to restrain him
or her, but move objects or furniture out of the way to prevent injury. Notify a physician.
If t he ph lebotomist is aIone and has access to a telephone in t he phlebotomy area, he or
she should call the emergency contact (another office in the building, hospital emergency
department, or 911).


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 Compliance: Legal and Ethical Issues

For releasing of results ordered by a specialist to a family physician, the specialist needs
to be called to ask if the laboratory can release results to that specialist. After permission is
If you are not sure if a
obtained, the family physician is listed as a physician to whom the results should be copied.
task is in compliance,
ask your supervisor The job of phlebotomy requires thought before action. Compliance has restricted the
before performing the phlebotomist in many tasks that the phlebotomist may be willing to do in order to be help-
task. ful. The phlebotomist in the physicians office cannot file records for the physician to help
out. Supplies and equipment cannot be given to a physician to make the job easier. All
the restrictions seem at times to be against good customer se rvice. Compliance is boob
customer service because it helps the customer avoid being overcharged for tests through
double billing or unnecessary testing.

Short Answer
What are the seven elements that should be included in a laboratory compliance plan?
1.

2.

3.

6.

7.

MEDICOLEGAL Very few patients experience any type of reaction to having their blood taken. However, it is
PROBLEMS an invasi e procedure that can result in complications as a result of patient reaction or the
phlebotomist not following proper procedure. Realize that you are entering the patient with
surgical steel, which, if used improperly, can have detrimental results.

• Consent to perform venipuncture

• Fainting or convulsing patient
• Hematoma
• Accidental anerial puncture
• Nerve damage
• Mislabeled/unlabeled sample
• Exposure of the patient to blood-borne pathogens of another patient

Any of the complications listed in the box above can result in a lawsuit, depending on
the severity.

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 CHAPTER 12

Questionable Test At times a physician writes an order that the phlebotomist cannot interpret, or the requested
Requests test was not marked on the requisition. The patient cannot be asked what test the physician
ordered or to help read the physicians handwriting. In each of these cases, the phlebotomist
needs to contact the physician to clari fy what is wanted.
If the diagnosis (CPT code) is not given, the patient cannot be asked, “What is wrong
with you?” to deie rmine a diagnosis. A diagnosis cannot be determined from the test that
is ordered. If a glucose test was ordered, the phlebotomist cannot write down diabetes as a
diagnosis. The diagnosis must come from the physician.
A physician often gives a handwritten order that cannot be found in the laboratory list

of tests. Such a requested test is nonspecific in that it does not have an exact match to any
other test. The phlebotomist cannot assume that the physician wants a specific test without
checking with that physician.






• Time and date of confirmation of the question
• Any diagnosis information obtained
• Name of the individual with whom the phlebotomist spoke

• The irfitials of the phlebotomist

• Any instructions given by the physician



Each time a physician must be called to verify an order or diagnosis must be
documented.

Release of Test The phlebotomist is often asked to give patient results to someone other than the ordering
Information physician. The results can be released only to the person who ordered ihe tests. This policy
is followed to maintain confidentiality of patient results. The Clinical Laboratory Improve-
ment Act of 1988 (CLIA 88) and HIPAA state that results can be released only to autho-
nzed persons or the individual responsible for usin g patient resul ts. The patien t cannot
receive his or her own results unless the physician has given permission. This may upset the
patient, but the phlebotomist must explain to the patient that the physician has to request
that the results be released.
The patient will often go to a specialist and then ask the phlebotomist to have a copy
of the results sent to the family physician. Unless the specialist speci fically wrote that the
results can be released to the family physician, no copy of the results can be sent.
Results can be released to another physician only if a different physician starts treating
the patient for an emergency. For example, Joe Smit h came in for a complete blood cell
count (CBC) ioday as an out patient and then later in the day went to the emergency depart-
ment for abdominal pain. The emergency physician could request the results of the CBC.
The emergency physician was not the ordering physician, but the result could be released to
the emergency physician, because he or she is the physician treating the patient and these
results could be critical to treatment.
There are systems in place to give patients their own results when they are requested.
Most laboratories have release forms that the patient can sign to have the results released
to them. This usually requires a positive picture identification of the patient, and only the
patient can receive the results.
 Compliance: Legal and Ethical Issues

this would be in violation of compliance. The idea is that if the fax machine is being used for
purposes other than laboratory work, the laboratory is enticing the physician into using the
laboratory. Computers are the same. A computer could be placed in a physicians office, but
that computer could have no other information on it other than laboratory data. The device
will need to be removed ftom the physicians oiTice if it is continually misused.
What are subtler are the smaller supply items. If a physicians oilice draws 10 patients a
day but asks to be given a box of 50 pairs of gloves per day, then the physician is using the
additional 40 pair per day for omice use. This is considered an inducement to the physician
to send work to the laboratory. This violates the antikickback laws and could subject all
parties to legal penalties.

Courier Services To get the samples from the physician’s office to the laboratory, a courier service is used and
paid for by the laboratory. The physician may ask the courier to transport something that
is not a laboratory sample. This again violates the antikickback laws. The courier could
transport additional items, but the physician must be charged a fair market › alue for the
transportation of the items. This arrangement will need to be approved by the laboratory
compliance officer.

Hazardous and The laboratory may dispose of only those hazardous wastes and sharps containers that were
Infectious Wastes generated during the collection of samples and nothing generated by the physicians office
use. The shar ps containers can contain only needles used for blood collection and no nee-
dles the physician has used to give injections. Any hazardous waste that the laboratory dis-
poses of must be old blood tubes and no other items such as bloody dressing changes. The
law is working to avoid anything of value—including a service such as hazardous waste dis
posal—being given to the physician to entice the physician to continue Auth the laboratory.

Phlebotomy The laboratory may place a phlebotomist (in-olIice phlebotomist) in a physicians office to
Services provide sample collection that is convenient to the patient. The laboratory cannot place a
phlebotomist in a physicians office as a cost-cutting measure for the physician. Before the
phlebotomist can be placed, the physician and the laboratory must agree that the phleboto-
mist is being placed there for the sole purpose of collecting samples for the laboratory.
The phlebotomist is permitted to do the following:
1. Obtain samples from patients when the sample is sent to the laboratory that is provid-
ing the phlebotomist. The phlebotomist cannot collect samples for other laboratories.
2. Prepare these samples for shipment to the laboratory.
3. Enter billing or other information on the laboratory patients into a computer system
pro›'ided by the laboratory.
4. Perform any other functions related to the laboratory sam pie collection or testing.
The phlebotomist is prod ibited from doing the following:
1. Taking vital signs or performing other nursing functions not related to the collection of
samples
2. Collecting any samples that will be tested by the physicians office staff
3. Filling reports, answering telephones, or performing other functions that are normally
done by the physicians staff
4. Entering billing information or performing tests for the physicians office
5. Reviewing patients’ charts for diagnosis information
6. Performing any duty ihat is not related to the laboratory and sample collection
The phlebotomist in a physician’s office is in a unique position and for the first time is per-
mitted to say, “Its not my job.” Doing any job that is not related to the collection or shi p-
ment of the samples can put the laboratory in violation of antikickback laws.

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 CHAPTER 12

1. A physician s office draws samples from an average of 10 patients a day. The physician’s office requests a box of
50 pairs of gloves per day from the laboratory. How would you handle this request?
2. A phlebotomist is placed in a physician’s office, and the phlebotomist has a large amount of extra time between
draws. The phlebotomist likes to stay busy so he helps the physician’s office staff with checking in patients and
filing medical records. Is this phlebotomist putting the laboratory in a possible violation of the antikickback law?
 Compliance: Legal and Ethical Issues

Matching: Key Terms Review

Identify the appropriate definition for each key term
1. Best Practices A. Clinical Laboratory Improvement Act
2. CLIA B. Current Procedural Terminology manual listing a coding of procedures
and services performed by physicians. Published by the American Medical
Association.
3. Compliance C. Service that is reasonable and necessary for treatment of the patient's illness.
4. CPT D. Protected health information.
5. Ethics E. The most efficient and effective way of accomplishing a task, process, or
activity based on repeatable procedures that have proven themselves over
time for large numbers of people.
6. HHS fnternationAl Classification of Diseases list of diagnosis codes for illnesses.
Published by the American Medical Association.
7. HIPAA G. Oâice of the Inspector General.
8. ICD-9CM H. Health Insurance Portability and Accountability Act.
9. Malpractice I. The formalized monitoring of an organizations adherence to laws and
regulations.
10. Medical Professional code of conduct in treatment of patients
Necessity
11. OIG K. Department of Health and Human Services.
12. PHI A. Failure of a professional person to o ffer a standard of care, resulting in
injury or harm to the patient.

Multiple Choice
Choose the one best answer:
1. The OIL is the
a. Office of the Inspector General. c. t9ffice tit lnte r natitinal €›tivernment.
b. Office of Independent Guidance.
2. Of the three situations listed which one is compliant with the antikickback law?
a. furnishing a computer for the physician io keep his c. furnishing the physician with the blood collection
office records on tubes that are returned to the furnishing laboratory
b. lcasing space in the physicians office, with thc ' ' **St "S
physician using half the space for the office
manager's office
3. A patient is ha›'ing bloocl collected and asks the phlebotomist to ha› e a copy of the results sent to a physician 'ho
u.'as not listed on the requisition. What should the phlebotomist do?
a Grice the patient the rcsu Its c. Call the ordering physician to determine i I this is
b. Show the patient the results in the computer but pc rmisslblc.
not print out a cop for t he patient.
 340 CHAPTER 12

patient to pro›'ide high-quality patient care. Aciing ethically is a standard of conduct thai a
phlebotomist must follow when working with patients and the public. Following this code
of ethics is being professional.
Daily patient contact makes the ph lebotomist unique among t he laboratory associates.
Phlebotomists receive training in a skill and then are sent to be the laboratory representatives
throughout the hospital. Phlebotomists see many patients at their worst. These patients do
not want the phlebotomist to even come near them, and often phlebotomists have to talk
and beg patients into letting them draw the blood. Often patients do not realize that with-
out the work of phlebotomists they would not be able to improve and return home. The
nicest patients will often be irritable and may even strike out at the phlebotomist physically
when they find themselves in the strange world of the hospital. The phlebotomist may find
it difficult to be ethical and professional with these patients.
The phlebotomist often has to deal with dying, death, and grief for the first rime. Dying
is a process. Death is an event. Grief is a response. These can all become very personal when
you have worked closely with a patient. Even if the phlebotomist does not experience deep
feelings and emotions, the patient and family are very emotional during the process. The
emotions generally take five stages:
1. Deniql—When the family and patient deny reality (“I will be OK, just let me go
home.”)
2. Anger—When persons express their anger and rage (“1 don’t want you to draw my
blood! I’m going to die anyway.”)
3. Bargaining—When persons are willing to do anything to change what has happened
or is happening to them f“Let me live. I’ll change my ways.”)

4. Depression—When the process is recognized, and there is deep sorrow over the

thought of dying ( ‘1 will do whatever you want to me to do, I don’t care.”)

5. Acceptance—The realistic acknowledgment of the fact that one is going to die (“God’s
will be done, I am ready.”)

The phlebotomist sees patients at all these stages. The ability to recognize them helps
Ethics is doing the the phlebotomist to offer sympathy and consolation to the patient and family. The family
right thing when no will often not be in the same stage as the patient. After the patient dies, the family members will
one else is looking. usually go through the stages again.

Short Answer

directions: A patient s emotions generally Ake five s Ages during the dying process. List them.


2.

3.

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Upon completion of
collecting a sample and
labeling the tubes, the
tubes should be placed
in a self-closing bag or
a tube rack to prevent
accidental breakage or
blood-borne pathogen
exposure.
Prevention of Lawsuit prevention is as simple as following the established procedures and being obser-
Lawsuits vant of the patient.
ETHICAL CON- The phlebotomist is intricately involved with ethics and sees ethical decisions being made
SIDERATIONS daily Ethics is hard to define. It consists of more than a set of written rules, procedures,
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Compliance: Legal and Ethical Issues 339
of negligence was that you should have never set the tray on the patient s bed. You created
a blood -borne pathogen exposure. Another example is in an outpatient setting where you
have just drawn a patient and had the tubes on the table next to the phlebotomy chair.
The next patient sits down and knocks t hese tubes to t he floor, breaking them. Again you
have a possible blood-borne pathogen exposure.
Exposing a patient is not always the result of tube breakage. You could be going from
room to room drawing patients. After one patient you do not have anywhere to discard the
gauze that was on the patients arm, so you lay it in your phlebotomy tray to dispose of later.
You draw the next patient and then accidentally use that gauze from the previous patient
on the next patient s arm. You have just exposed the open venipuncture site to a possible
blood-borne pathogen. All of these are negligence because the phlebotomist did not follow
best practices and a standard of care.
• Drawing at a 15-degree angle and avoiding deep, probing venipunctures will avoid
most nerve damage.
• Avoiding draws from the basilic vein will reduce the possibility of nerve damage and
accidental arterial puncture.
• Labeling all tubes at the bedside will avoid mislabeled and unlabeled samples.
• Observing the patient after the draw for bleeding and light-headedness will avoid
lawsuits from bruising and falls.
• Making sure that all filled tubes are placed in racks or bags will prevent breakage and
accidental blood-borne pathogen exposure.
Once the patient takes legal action, documentation of the phlebotomist’s training will
help to proc e that the appropriate standard of care was given to the patient. This documen-
tation of competency is discussed in Chapter 13.
EXERCISE 3 Short Answer
What complications of phlebotomy can result in legal action?
1.
2.
3.
or guidelines. Ingrained in ethics is a moral philosophy that varies by individual, religion,
social status, or heritage. Ethics requires that the phlebotomist act responsibly toward the
 CHAPTER 12

• After the venipuncture is performed in the antecubital (bend of the arm) area, do not
bend the elbow with the gauze pad or cotton ball held in the bend of the arm. The clot
will often break loose as soon as the arm is extended. It is preferable to hold the arm
straight. over the head if possible, with the gauze or cotton pressed gently but firmly
over the area of puncture.
Treatment of a hematoma consists of the following:
• Immediately discontinue the x'enipuncture if you notice swelling (a lump) under
the skin. Apply pressure to the site, and hold this pressure until the bleeding has
stopped.
• Applying ice packs wrapped in a washcloth of iowel will help control bleeding,
swelling, discoloration, and pain.
• The venipunci ure site should be bandaged tightly to apply continual pressure.
• The patient should be informed that a black-and-blue mark may appear and that it
will take at least a week for the mark to totally disappear.

Accidental Arterial Accidental arterial puncture can cause hemorrhage that can result in major bruising and
Puncture compression of the nerve. This nerve injury can bring a lawsuit. If an artery is punctured,
measures must be taken to prevent hemorrhage and nerve injury. Apply pressure to the site
for at least 5 minutes after the accidental puncture.
Avoidance of the artery is the best prevention of legal aci ion. All at tempis should
be made to avoid drawing from the brachial side of the arm. Most accidental a rte rial
punctures occur when the phlebotomist attempts to draw from the basilic vein and
goes too deep, resulting in puncturing the brachial artery. Rather than a clean puncture,
this is usually a nick that results in bleeding around the artery and nerve. The median
cubital vein and the cephalic vein should be the veins of choice for the phlebotomist.

Ner.•e damage can occur as a result of the accidental arterial puncture but can also occur
Nerve Damage by going too deep for the venipuncture. Just as with the accidental arterial puncture, the
basilic vein should be avoided to reduce the possibility of damaging the underlying nerve.
If a nerve is touched, the patient will have a sharp shooting pain in the arm down to
If a patient complains
about a shooting the fingertips. This will usually go away in a few hours to a few days if the nerve was not
pain when the needle damaged. Continual pain could mean that the nerve was damaged due to the venipunc-
enters the arm, ture. A physician will need to test the patient to determine if damage did occur. If damage
immediately remove occurred, there will probably be a resulting lawsuit.
the needle. You are Prevention of nerve damage is best accomplished by following the procedure of
possibly near a nerve inserting the needle at the recommended 15-degree angle. This angle of insertion prevents
and this location the phlebotomist from going deep enough to cause nerve damage.
should be avoided.
Mislabeled tubes can result in improper care for the patient. The wrong results will go to the
Mislabeled patient and the patient will possibly be over- or undermedicated. This can have a detrimen-
/UnIabeIed Sample tal effect on the patient and e›'en resuli in death.
The laboratory should immediately reject unlabeled tubes. Tubes should all be labeled
at the patients side before the patient is released. Attempting to label an unlabeled tube later
leads to a great risk of mislabeling.

Negligence can be the result of simple accidents. The patient can be exposed to the blood of
Exposure of the another patient if a tube is dropped and broken. For example, in a hospital patient’s room
Patient to Blood- you set your phlebotomy tray down on the patients bed. The patient moves his or her legs
and knocks the tray to the floor, breaking some of the tubes you had collected on other
Borne Pathogens
patients. This exposes both you and the patient to possible blood-borne pathogens. The act
of Another Patient
 Competency

collapsing vein. The syringe plunger is pulled gently; a light steady pull may prevent the
vein from collapsing. If the vein collapses with the light steady pull, a small pull with a
hesitation between pulls may be more successful. The timing between the pulls allows the
vein to refill. During each pull on the syringe, a smal1 amount of blood enters the syringe.
With either method, do not work so slowly that the blood starts to clot in the syringe.
A butterfly and evacuated system works to draw from collapsing veins, but only small
(pediatric) tubes can be used. The larger the evacuated tube, the more vacuum in the tube.
If a 10-mL tube collapses the vein, draw three 3-mL tubes to obtain a similar volume.

AGE-SPECIFIC Phlebotomy techniques vary as the age of the patient changes. The competent phlebotomist
GARE recognizes these differences in patients and adjusts techniques appropriately. The compe-
tency checklist must cover the different age groups of patients. The phlebotomist works
with four age groups. Even though specific ages are listed, there is some overlap in tech
niques depending on the age and size ot the patient.

Infant Microcollection through capillary puncture is the method of choice for the infant. From birth
to about 6 months, the heel is the proper area of capillary puncture. After 6 months the heel
starts to become too thick, and a fingerstick or large-toe stick may be appropriate. The choice
after 6 months depends on the size of the child. Puncture of the fingers of infants less than
1 year of age should be done only after other options have been considered. Both heelstick
and fingerstick require a microcollection of the sample. The puncture must be done with a
controlled-depth lancet. The optimal depth of puncture for the heel of a full-term infant is
2 mm. The optimal depth of puncture of an infants finger is 1.2 to 2 mm.
The depth of puncture will be dependent on the size of the infant.
The infants comfort must also be considered in any collection. Excessive crpng of the
infant can lead to inaccurate results. It is best to be ready to collect the sample before you
take the infant into the phlebotomy area. The infant should be placed on his or her back for
the collection of the blood sample. Never leave an infant unattended; even the most sedate
infant can quickly roll off a drawing table.

Pediatric Venipuncture in children younger than 2 years old should be limited to superficial veins.
Collection of blood from superficial veins generally is most successful with a butterfly col-
lection set and a 23-gauge needle. Once the needle is in the vein, the flexibility of the tubing
allows the child to move slightly while the blood is being collected. The butterhy will also
have a “flash” of blood in the tubing when the needle enters the vein. Venous collection can
be accomplished with an evacuated system if the child is held v'ery still.

Infant Neonate (birth to 28 days)

Infant (29 days to 1 year)
Pediatric Toddler (1—3 years)
Preschool (W years)
School age (6—12 years)
Youth—Adult Adolescent (12—18 years)
Adult t19—65 years)
Older Adult Geriatric (65 years and older)

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 346 CHAPTER 13

PATIENT Concern for the patient’s safety and comfort is essential in providing excellent customer
SAFEZY AND service. Patients are not going to talk to family and friends about the laboratory tests that
were ordered and the results sent to the physician. Patients assume that after the sample is
DEVELOPING
collected, the testing is completed with high quality and accuracy. They are going to talk to
COMPETENCY others about how they were treated; whether the venipuncture hurt; and what side effects,
FOR ALL TYPES such as bruising, they experienced. The laboratory also wants to assure patients that they
OF PATIENTS are safe and will not develop any diseases from their visit to the laboratory. The same safety
concerns apply for the associate. All associates need to know that their own safety in their
work environment is a concern. Safety for the patient and phlebotomist must be stressed
in the competency training program. There are several factors to consider in ensuring the
safety and competency training of a phlebotomist.

Fainting or Chapter 12 discusses the fainting or con›'u1sing patient. The competency of the phleboto-
Convulsing Patient mist will be dependent on how he or she reacts to a patient who faints or convulses. Ex•en
if the phlebotomist does not experience such a patient during training, the phlebotomist
should be able to explain the necessary care that would be needed for that patient.

Hematoma The instructor must also observe what the phlebotomist-in-training does to prevent
hematomas. Does the phlebot omist take precautionary measures? What does the
phlebotomist do if he or she thinks the patient will get a hematoma? Elastic bandages
should be used at appropriate times, such as on patients taking blood thinne rs. Does the
phlebotomist-in-training explain to the patient the appropriate actions to take to treat a
hematoma or not increase its severity? The steps outlined in Chapter 12 must be followed
in treating a hematoma.

The Obese Patient The obese patient presents a special challenge but the phlebotomist must have experience and
competency Cth this type of patient. This is where the instructor can be a valuable guide in
perfecting the phlebotomists skills. The obese patients veins are often difficult to feel through
the layers of tissue. The tourniquet has to be rather tight to exert pressure deep enough to
slow the flow of venous blood. Before a venipuncture is attempted, follow the course of the
vein. Obese patients have localized tissue globules under their skin that resemble veins when
first feeling them, but ihese “veins” do not continue and will not result in blood return. The
median cubital vein is usually the most prominent vein to feel. Blood circulation of these
patients may be somewhat poor. Firm palpation is necessary to identify depth and size and to
estimate the elasticity and response condition of the vein. If the median cubital vein cannot be
located, the veins in the hand and wrist may be more readily accessible.

The Patient with just like the obese patient, obtaining a blood sample from a patient can be challenging be-
Damaged or cause of the condition of the patient’s ›'eins. For example, the veins were damaged and healed
Collapsing Veins improperly. This is usually the result of the patient having been burned, scars on the veins
from d rug abuse, chemotherapy, accidents, or surgical procedures in the areas of
the veins. The damage makes the veins inaccessible because the scar tissue is too thick or the
vein no I onger carries blood. Any site showing damage or injury may infiict pain unneces-
sarily if used for venipuncture.
Purple or dark-blue discoloration of the skin indicates mild or pre›'ious bruises caused
by overuse of the site for phlebotomy. Selection of another site is imperative. lf no other site
is available, insert the needle at a point lower in proximity to the damaged site and thread
the needle up to the proper position in the vein.
A collapsing vein is weak, and the vacuum of the syringe or evacuated tubes sucks the
walls of the vein together so no blood can flow. The vein re fills the instant the vacuum is

discontinued. Using a syringe and/or butterfly is the best method to obtain blood from a



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 Competency

of an instructor assigned to the phlebotomist-in-training. Each phase is completed by the
instructor and the phlebotomist-in-training and then turned in to the appropriate supervisor.
This competency program ensures quality in the obtaining of samples. Most of this is
done through training of the phlebotomist.
The following text details information that is to be covered in a competency program.

FREQUENCY OF Any personnel performing procedures must undergo initial training when starting the job,
COMPETENCY an evaluation 6 months after the hire date, and an annual competency evaluation. This is
DOGUMENTRROR followed even for a phlebotomist who has many years of experience and is certified. After
the first year of employment, there must be an annual review of the phlebotomists skills.
The annual review does not have to be as detailed as the initial training evaluation. Each
evaluation must clearly indicate what skills were trained, who was being trained, the trainer,
and the dates of training. A final supervisor signature must be on the evaluation.
This documentation of competency is used to verify that the associate is capable of
performing the duties of the job.
If a phlebotomist is certified by the American Society for Clinical Pathology (ASCP) after
January 2004, he or she is required to maintain certification by completing and documenting
continuing education. This Cenification Maintenance Program (CMP) is required for individu-
als newly certified in 2004 and thereafter. The phlebotomist has a 3-year period to complete a
specific amount of continuing education to maintain certification. lf the phlebotomist does not
complete the required continuing education, he or she will no longer be cenified. The goal of the
program is to demonstrate to the pubLc that laboratory professionals stay current in their practice.


LIMITS ON The limits of what procedures a phlebotomist may perform must be stated in the compe-
INVASIVE tency program. Procedures that would be normally performed are as follows:
SAMPLE • Routine phlebotomy
COLLECTION • Blood cultures
PROCEDURES • Capillary punctures
BY • Heelsticks
PHLEBOTOMISTSt Template bleeding times
• Urine collection
• Throat (oropharyngeal) swabbing for patients age 3 years and older
The following procedures may have limitations on who is allowed to perform them:
• Nasopharyngeal swabbing
• Eye or ear swabbing
• Wound swabbing
t Manipulation or withdrawal of samples from indwelling catheters (intravenous,
arterial, urinary)
t Arterial punctures
t Therapeutic phlebotomy
t Injections
• Tuberculin skin tests or other skin tests
• Skin scrapings
More experienced phlebotomists perform some of these procedures. Some procedures
require the skills of a pathologist or physician. Many of these procedures can be performed
by a phlebotomist with proper training and documentation of competency.
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 CHAPTER 13

NAACLS Competencies Relevant to Chapter 1 3

¥• Follow written and verbal instructions in
carrying out testing procedures.

KEY TERMS
Competency Ability to correctly perform a task according to a standard procedure.

nyone can soy they know will the procedures end policies, but until it is documented,
none o1 the accrediting agencies nre going to recognize o phlebotomist’s abilities.
This is the reoson for scheduled competency assessment, to prove the phlebotomist’s abil-
ities. Chapter 13 outlines the competencies thot must be met end the limitations of proce-
dures o phlebotomist con perform.



Training of the phlebotomist docs not stop with a short course and on-the-job instruction.
Each phlebotomist musi be proven skilled and co mpcte ni in pe rforming phlebotomy.
A detailed procedure that takes many factors into consideration in performing phlebotomy
must be used tti dticument the competency of the phleboto mist. The par ie nt s age, ihe
pat ient's physical and men ta1 condition, and the tests being performsd on the patient
delineate the skills the phlebotomist needs to perform the task. At all times the comfort and
respect of the patient must be of ut most consideration.
A competenc)• program is based on a stcpwise training/compctcncy gut dc t hat t he
phlebotomist can p rogrcss through at his or her own pace. The ultimate goal is io have
the phlebotomist competent in all phlebotomy procedures for all age groups of patients.
This will standardize the training so the phlebotomist will feel comfortable ›vorkin g at
di fferent sites throughout different laborer ories.

GENERAL INFORMATION TAUGHT

IN PHLEBOTOMY TRAINING
• Limits on phlebotomy procedures
• Patient safety
• Patient reactions
• Age-specific care
• Competency checklists on specific procedures
• How many successful procedures must be completed during training for each
specific procedure

A program should consist of an explanation of the procedure, the writ ien procedure,
a competency chec klist, and t he number of different age groups of patients on whom the
procedure must be pc rformcd. Performance of these tasks is done under the obser 'ation

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 OBJECTIVES After studying thfs chapter, you should be able to:
1. Understand what knowledge and skills are necessary to be competent
in phlebotomy.
2. Be able to set up a competency training program and know what
to include.

 CHAPTER 13

CERZIFICAZION On successful completion of all parts of the training manual, practical evaluation, and
written examination, each trainee is awarded a certificate of completion. This is not the
cert i treat ion that is completed by a nat ional test ing agency but a cert i ficate of completion
of the competency progtam for the specific laboratory. The phlebotomist has earned this
award and has worked hard to aliain ihis 1ev'e1 of experience.




Multiple Choice

1. An associate is hired as a phlebotomist and completes the initial training and competency certification. When will
the next competency certification be needed?
a. 6 months c. 2 years
b. 1 year
2. Phlebotomist competency must verify the ability to collect blood samples from what age group?
a. adults c. all age groups
b. young adult and geriatrics
3. The competency assessment check-off form must include what information?
a. all the sieps involved in completing the procedure c. only a statement staring thai the requirements were
b. the main steps in a procedure
•t

An associate is hired to do phlebotomy for the laboratory and is ready to work the first hour that he or she steps
into the laboratory. What must be done first?
2. An elderly patient comes to the laboratory to have his blood drawn. He mentions that each lime he comes in he
gets a bruise. He said this never happened when he was younger. What has changed to make him bruise after a
i’enipuncture?

















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350 CHAPTER 13

Phlebotomy Competency Assessment Student/Associate:

Venipuncture Collection with an Evacuated Tube System
Competency: Demonstrate proper patient identification and sample collection technique when performing a
venipuncture with an evacuated tube system.
Behavior: Patient identification
Uses appropriate collection tubes
Follows correct collection procedure
Follows order of draw

Satisfactory improvement Unsatisfactory

Performance Needed Performance
Task 2 points 1 point 0 points
1 Identifies self and the patient correctly.
2 Checks the requisition for all peninent information.
3 Performs hand hygiene.
4 Explains the procedure to the patient.
s Selects the correct tubes and equipment for the procedure.
6 Assembles the equipment.
7 Positions the patient's arm.
a Ties the tourniquet.
9 Locates the vein by palpation.
10 Releases the tourniquet if needed.
11 Cleanses the site n concentric circles and allows 1 to air dry.
12 Puts on gloves.
13 Reapplies the tourniquet if removed in step 10.
14 Positions the noadle holder between the thumb and index fingers.
15 Uncaps the needle; inspects the needle for defects.
16 Anchors the vein.
17 Positions the needle at the appropriate angle.
18 Inserts the needle bevel up into the vein.
19 Collects blood following order of draw.
20 Changes the tubes smoothly; does not move the needle.
21 Releases the tourniquet.
22 Removes the last tube collected from the holder.
23 Covers the puncture site with gauze or a cotton ball.
24 Withdraws the needle smoothly and presses down on the gauze or cotton.
25 Activates the safety device on the needle.
26 Disposes of the needle and holder in a sharps container.
27 Inverts tube(s) with additives several times.
28 Labels the sample(s) with patient infomation. phlebotomist’s initials, and
correct draw time.
29 Checks the puncture site when the procedure is complete.
30 Disposes of used supplies in the proper containers.
31 Removes gloves and performs hand hygiene.
32 Thanks and releases the patient.
Total points each category.
Total in all categories.
Student/associate signature: Date:
Instructor signature: Date:
Supervisor signature: Date!
FIGURE 13.1 Observed competency check-off.
 Competency

8. Bagged urine collection

Remember that an 9. Throat culture collection
older patient may be 10. Glucose tolerance test
hard of hearing and 11 . Gestational screen
will probably have
a slower reaction 12. Sample preparation and transport
time than a younger To complete a compliance program, the phlebotomist must understand t he procedures to
patient. Patience for be followed. The competency program must include an explanation of the procedure, a
your patients who are copy of the procedure, and a detailed observed check-off of the procedure. In a compe-
older individuals is tency training manual, the short explanation of the procedure is in paragraph form, telling
necessary. about the procedure and the equipment used. This is followed by a detailed procedure in
outline form. The procedures are the procedures currently in use, and the explanation is
similar to those in the earlier chapters of this text. This is concluded with a competency
check-off that is used by the superviso r or designate d trainer. The competency check-off
is completed as t he trainee is observed performing the procedure. The phlebotomist must
read each explanation of the procedure and then read through it again before attempting
any procedure. All forms must be signed by the studen i, the instructor, and the supervisor.
An example of the outline of this section of the training manual follows:
1. Procedure Explonotion. This information is the same thai is in textbooks. The
information is a condensed version of chapters of a textbook that explain the principle
behind the procedure.
2. Procedure. This is a procedure that follows the guidelines published by the Clinical
Laboratory Standards Institute (CLSI).
3. Observed Competenc y C hech-Off. The competency check-off is a form that is
used as the supervisor or designated trainer observes the trainee’s performance in
a procedure. A different check-off is used for each different procedure. Only one
check-off is necessary for a procedure. This ensures that the trainee is following all
the correct steps of the procedure. An example of the type of check-off to be used
is illustrated in Figure 13.1 . A complete listing is located on the student companion
website (www.cengagebrain.com).

The practical evaluation helps keep track of the number of procedures the phlebotomist
PRACTICAL has performed during training. The practical evaluation form is initialed each time a suc-
EVALUATION cessful phlebotomy procedure is completed. An example of an evaluation form is shown in
FORM Figure 13.2.

The phlebotomy competency examination is to be taken before a phlebotomist is approved

PHLEBOTOMY to perform independently. The exam consists of as many questions as the supervisor feels
GOMPETENCY are necessary to test the knowledge level of the trainee. Usually 25 to 50 q uestions are
EXAMINATION sufficient. A multiple-choice format is the preferred method of testing. The exam is best
taken after the practical evaluation is completed, or after at least half has been completed.
The phlebotomy competency examination must be completed with at least 70 percent of
the answers correct; the supermsor signs off, and the phlebotomist has then completed all
requirements for certification. If a 70 percent score on the tesi is not met, the laboratory
must set the standard as to how to proceed. Possible solutions are to have a second test
available to be taken the next day or a retraining program for a set period and then a retake
of the test. The remedial action that is taken with the trainee who does not pass needs to
be consistent with all trainees. One trainee cannot receive different treatment than another.

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 CHAPTER 13

Holding the child properly is the key to any successful blood collection. It is best if the
hlebotomist can pair up with a colleague or family member to draw samples from pediat-
Do not forget to
xc patients. Often the parent wants to be involved and should be given the duty of holding
include the parent in
the process of phle- the child in the parent s lap. Someone else can hold the child’s arm while the phlebotomist
botomy on a child. draws the blood. The person drawing the blood needs to stabilize the vein, because chil-
dren have little muscle tissue.

Youth-Adult Venipuncture on 12- to 65-year-old individuals reduces the number of problems the phle-
botomist has with other age groups. Individuals in this age group can be communicated
with and usually understand and cooperate. They may be a little apprehensive about having
their blood drawn. They feel they are in the healthiest time of their lives. The laboratory
testing being done may lead them to realize that they are going to be faced with a challenge
and that they may not be as healthy as other individuals they know. They are now feeling
unsure and concerned. Polite customer service will go a long way to let them know you are
professional and knowledgeable in what you are doing. Each patient must be evaluated for

the best method of venipuncture. The evaluation must include questions like the follow-
ing: Are the veins going to roll? Are the veins small, deep, or near the surface? Generally,
youth—adult veins are supported by more muscle tissue and do not have a tendency to roll.
Venipuncture with an evacuated tube system holder and needle is the method of choice for
the blood collection.

Older Adult When approaching elderly patients, you may have to speak more deliberately. Your voice
should reject warmth and friendliness, and your manner should demonstrate your con-
cern. Touch the patients arm or hand as you confirm the patient identification. Talk to the
patient in a friendly and courteous manner. The patient may be unable to hold the arm or
hand steady. You may need assistance in holding the patient s hand or arm. You may also
find that when patients have reduced or restricted physical function or movement, they will
be unable to straighten their arms easily or close their hands.
Observe any unusual physical conditions in these patients, such as thin arms, transpar-
ent skin that looks fragile and feels tearable if touched, and veins that, although easily seen,
After venipuncture of
feel taut and threadlike and could easily roll sideways under the pressure of the needle.
an elderly patient, an
Often, the iourniquet can be placed over the sleeve of the patient s clothes io ease the ten-
elastic wrap should be
used instead of tape sion and not pinch the patients skin. Before inserting the needle, anchor it firmly with your
to avoid tearing the finger to pres'ent it from rolling.
skin when the tape is Elderly patients are at more risk for hematomas because of their thin veins and reduced
removed. elasticity of the skin. If the phlebotomist takes extra care with the patient during the blood
collection procedure, the risk can be minimized. Elderly patients also require extra care due
to their likely slower mental functions and longer reaction time. An attitude of compassion
rather than condescension will help restore a sense of dignity io the elderly patient.


PHLEBOTOMY Procedures that normally are included in the phlebotomy training manual consist of any
PROCEDURES procedures possibly being done by the phlebotomists. An example of the listing follows:
1. Venipuncture, evacuated tube
2. Venipuncture, syringe
3. Venipuncture, butterfly
4. Blood culture collection by butterfly or other methods
5. Capillary puncture
b. Metabolic screen (newborn screen)
7. Template bleeding time


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 APPENDIX B
FREQUENTLY ORDERED
LABORATORY TESTS
Acid Phosphotare Enzyme of the prostatic gland. Amylase Enz) me of the pancreas. Increased levels found
Increased in prostatic cancer of the male. in pancreatitis.

Act ixated Partial Thromboplastin Time (aPTT j The Antibiotic Sensiti bit y (Antimicrobiol Susceptibilit y)
aPTT finds its widest use in monitoring heparin Method of determining whether the bacteria that grew
therapy. Heparin is an immediate-acting anticoagulant from a sample source are inhibited by different types
that is given by injection or intravenously Anticoag- of antibiotics. T his information is used to determine
ulants scope to treat or prevent aclive blood clots. An which antibiotic(s) would be best io use to treat ihe
aPTT may also be abnormal in severe clotting factor infection
deficiencies.
Anti nuclear Antibody (AMA) Fluorescent test that
Adrenocorticot ropic Hormone (ACTH) A test to help detects the presence of antibodies to several t)•pes
diagnose adrenal and pituitary diseases and tumors. of antigens present in the nucleus of cells. Different
fluorescent patterns and the amount of antibody
Aminotrons erase (AST) Enz e of the 1iver. suggest the presence of certain kinds of autoimmune
Increase d in hepatitis and liver disease.
disease, such as systemic lupus eryihematosus (SLE),
Albumin Major fraction of the five distinct fractions that mixed connective tissue disease, or rhe umaioid
make up the serum total protein level. Abnormal levels hnt s
re fleet a disease process
cal..late Aminof ransJernse (AST) Enzyme of the heart
Aldosterone A test for aldosterone levels produced by the and 1i›'er. Increased in myocardial infarction or liver
adrenal glands. disease.

AI Saline Phosphatase Erizyme of bone and liver. Basic Metabolic Ponel Consists of sodium, potassium,
Increased in obstructi› e jaundice and bone cancer. chloride, carbon dioxide tCO Z), glucose, blood urea
nitrogen (BUN), calcium and creatinine.
Amiitncin: Predose (Trough); Amihscin: Postdose
(Peak) These tests determine the concentration of the ' I ttbin Metabolic breakdown product of hem oglobin.
antibiotic amikacin in ›'arious body fluids (usually Increased levels found in red blood cell destruction or
blood) at a specific time. A blood sample collected ID liver disease/obstruction. This test is for adults and
5 minutes before ihe antibiotic is given is called the for children more than 15 days old. Neonatal bilirubin
predose sample and the sample collected 30 to 60 is Ordered for infants less than 15 days old.
minutes after infusion of the antibiotic is called the
Bleeding Time The bleeding time is measured by making
postdose sample. Either sample with a large concen -
a standardized incision in the skin and timing the du-
tration of the antibiotic may be toxic to the patient.
A low concentration of the antibiotic may be inade- ration of the bleeding. Time is dependent on adequate
platelet and vascular function. Thus it may be prolonged
quate to suppress the growth of the microorganisms.
in diseases that decrease platelet number, platelet func-
Ammonia Metabolic waste product normally eliminated tion, or the ability of the vessels to constrict and retract.
from the body via the liver. Increased levels found in Often done on patients suspected of hating a bleeding
hepatic disease or lii'er failure. problem and also used as a preoperative screening test.

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 Appendix A

• Follow standard operating procedures to perform a competent and effective
venipuncture on a patient.
• Follow standard operating procedures to perform a competent and effective capillary
puncture on a patient.
Demonstrate understanding of requisitioning, sample transport, and sample processing.
• Describe the standard operating procedure for a physician requesting a laboratory
analysis for a patient. Discuss laboratory responsibility in responding to physician
requests.
• Instruct patients in the proper collection and preservation for various samples,
including blood, semen, and stool.
• Explain methods for transporting and processing specimens for routine and special
testing.
• Explain methods for processing and transporting blood samples ioi testing at reference
laboratories.
• Describe the potential clerical and technical errors that may occur during sample
processing.
• Identify and report potential preexamination (preanalytical) errors that may occur
during sample collection, labeling, transporting, and processing.
• Describe and follow the criteria for samples and test results that will be used as legal
evidence, such as paternity testing, chain of custody, and blood alcohol levels.
Demonstrate understanding of quality assurance and quality control in phlebotomy.
• Descñbe the system for monitoring quality assurance in the collection of blood
samples.
• Identify policies and procedures used in the clinical laboratory to ensure quality in the
obtaining of blood samples.
• Perform quality control procedures.
• Record quality control results.
• Identify and report control results that do not meet predetermined criteria.
Communicate (verbally and nonverbally) effectively and appropriately in the workplace.
t Maintain confidentiality of individuals’ privileged information.
t Value diversity in the workplace.
t Interact appropriately and professionally with other individuals.
• Discuss the major points of the American Hospital Associations Patient Care
Partnership.
• Model professional appearance and appropriate behavior.
• Follow written and verbal instructions in carrying out testing procedures.
• Define the different terms used in the medicolegal aspect of phlebotomy and discuss
policies and protocols designed to avoid medicolegal problems.
• List the causes of siress in the work environment and discuss the coping skills used to
deal with stress in the work environment.
• Demonstrate ability to use computer information systems necessary to accomplish job
functions.





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 Appendix A

• ldentify the veins of the arms, hands, legs, and feet on which phlebotomy is
performed.
• Explain the functions of the major constituents of blood, and differentiate among
whole blood, serum, and plasma.
• Define hemostasis, and explain the basic process of coagulation and fibrinolysis.
• Discuss the properties of anerial blood, venous blood, and capillary blood.
Demonstrate understanding of the importance of sample collection and sample integrity in
the delivery of patient care.
• Describe the legal and ethical importance of proper patient/sample identification.
• Describe the types of patient samples that are analyzed in the clinical laboratory.
• Define the ph lebotomist's role in collecting and/or transporting these samples to the
laboratory.
• List the general criteria for suitability of a sample for analysis and reasons for sample
rejection or re-collection.
• Explain the importance of timed, fasting, and stat samples, as related to sample
integrity and patient care.
Demonstrate knowledge of collection equipment, various types of additives used, special
precautions necessary, and substances that can interfere in cl inical analysis of blood
constituents.
• Identify the various types of additives used in blood collection, and explain the reasons
for their use.
• Identify the evacuated tube color codes associated with the additives.
• Describe substances that can interfere in clinical analysis of blood constituents and
ways in which the phlebotomist can help to avoid these occurrences.
• List and select the types of equipment needed to collect blood by x'enipuncture and
capillary and arterial puncture.
• Identify special precautions necessary during blood collections by venipuncture and
capillary and arterial puncture.
Follow standard operating procedures to collect samples.
• Identify potential sites for venipuncture and capillary and arterial punctures.
• Differentiate between sterile and antiseptic techniques.
• Describe and demonstrate the steps in the preparation of a puncture site.
• List the effects of tourniquets, hand squeezing, and heating pads on capillary puncture
and venipuncture.
• Recognize proper needle insertion and withdrawal techniques, including direction,
angle, depth, and aspiration, for arterial puncture and venipuncture.
• Describe and perform the correct procedure for capillary collection on infants and
adults.
• Identify alternate coñecao ri sites for anerial puncture, capillary puncture, and
venipuncture. Describe the limitations and precautions of each.
• Name and explain common causes of phlebotomy complications. Describe signs and
symptoms of physical problems that may occur during blood collection.
• List the steps necessary to perform an arterial puncture, venipuncture, and capillary
puncture in chronological order.



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 APPENDIX A
NAACLS PHLEBOTOMIST
COMPETENCIES
Demonstrate knowledge of the health care delis ery system and medical terminology.
• Identify the health care providers in hospitals and clinics and the phlebotomist s role as
a member of this health care team.
• Describe the ›'arious hospital depanments and their major functions in which ihe
phlebotomist may interact in his or her role.
• Describe the organizational structure of the clinical laboratory de partment.
t Discuss the roles of the clinical laboratory personnel and their qualifications for these
professional positions.
• List the types of laboratory procedures performed in the various sections of the clinical
laboratory department.
• Describe how laboratory test ing is used io assess body functions and disease.
• Use common medical terminology.
Demonstrate knowledge of infection control and safety.
• Identify policies and procedures for maintaining laboratory safety.
• Demonstrate accepted practices for infection control, isolation techniques, aseptic
techniques, and methods for disease prevention.
• Identify and discuss the modes of transmission of infection and methods for
prevention.
• Identi fy and properly label biohazardous sam pies.
• Discuss in detail and perform proper infection control techniques, such as
handwashing, Downing, glowing, masking, and double bagging.
• Define and discuss the term nosocomiai injection.
• Comply with federal, state, and locally mandated regulations regarding safety
practices.
• Use the OSHA Standard Precautions.
• Use prescribed procedures to handle electrical, radiation, biological, and fire
hazards.
• Use appropriate practices, as outlined in the OSHA Hazard Communications
Standard, including the correct use of the material safety data sheet as directed.
• Describe measures used to ensure patient safety in various patient settings, such as
inpatient, outpatient, and pediatrics.
Demonstrate basic understanding of the anatomy and physiology of body' systems and
an atomic terminology in order to relate major areas of the clinical I aboratory to general
pathologic conditions associated with the body systems.
• Describe the basic functions of each of the main body s)'stems, and demonstrate basic
knowledge of the circulatory, urinar); and other body systems necessary to perform
assigned specimen collection tasks.


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 362 Appendix B

Lithium Drug used in ihe meat ment of psychosis. Peri- Phosphate (PO) Phosphorus Element derived from
odic monitoring of its amount in the blood is made to the diet, present in bones and teeth. It is necessary
determine dosage le el. Blood levels too low may be for many metabolic reactions in the body. Abnormal
ineffective, and levels too high may lead to harmful levels may reflect a problem with parathyoid gland
side effects. function.

Magnesiu m Magnesium is increased in renal dysfunction Pinworm Exam: 5coich Tape Prep Clear cellophane tape
or failure. Low magnesium levels are usually a result of is pressed against the pentoneal region. Any pinworm
a chronic dietary or intestinal absorption problem. eggs that are present stick to the tape and are detected
when the prep is examined microscopically.
Mono Screen Detects a serum antibody that is increased
in infectious mononucleosis, cytomegalovirus infec- Potassium An increase in potassium is usually attributed
tions, Burkitts lymphoma, rheumatoid arthritis, and to renal failure. Decreased potassium is the result of
viral hepatitis. any disease process that causes diarrhea or severe
vomiting.
Myoglobin A protein that is elevated after heart damage
or skeletal muscle injury. Pronestyl/Procoinemide Drug used in the treatment of
heart arrhythmias. Periodic monitoring of its amount
Neonnfnl Bilirubin This bilirubin assay monitors neona- in the blood is done to determine the dose to be given.
tal jaundice in neonates (newborns less than 15 days Blood levels too low may be ineffective; levels too high
old). More accurate for neonates than a total bilirubin, may lead to harmful side effects.
which is appropriate for adults and children more
than 15 days old. Prostate-fpecJic Antigen (PSA) PAA is found in normal
prostate cells of all males. An increased PSA occurs in
Newborn 5creen As required by most state laws, new- prostate cancer.
horns are screened for genetic disorders such as
phenylketonuria, galactosemia, hypothyroidism, Protein Electrophoresis Total protein level in serum,
homocystinuria, maple sugar urine disease, and sickle urine, or spinal fluid is quantitated, and then the pro-
cell anemia. teins are separated into five distinct fractions based on
their movement in an electrical field. Increases in any
Gccu!t Blood: Fecal Method of detecting hemoglobin one fraction may reflect a specific set of disorders.
(blood) in a stool sample. The method detects blood
produced from gastrointestinal lesions caused by many Prothrombin Time (PT) One of the blood coagulation fac-
factors, including ulcers and colorectal cancer. tors, prothrombin is produced in the liver. Vitamin K
is necessary for its production. The test finds its widest
Osmolal ity Osmolality (number of dissolved mole- use in monitoring the administration of Coumadin
cules) of serum causes the pituitary gland to secrete, (warfarin) therapy. Coumadin is a delayed-acting
which in turn causes the kidneys to retain more or oral anticoagulant that acts to rapidly decrease all the
less wate r. Measurement of urine osmolality is a test vitamin K—dependent factors. Anticoagulants serve
for the diluting and concentration ability of the kid- to treat or prevent active blood clots. Protime may be
neys. Urine and serum osmolalities are often ordered abnormal when there is decreased vitamin K in a poor
together. diet, in se›•ere liver disease, or in some severe clotting
factor deficiencies.
Ova and Parasites (0 G P) Combination of three meth
ods of wet mount and stains used to detect and iden- Quinidine Level Drug used in the treatment of heart
tify intestinal parasites or the eggs of the parasite. The arrhythmias. Periodic monitoring of its amount in the
usual sample is feces: howe›'er, parasites or eggs can blood determines the dose to be given. Blood levels
also be found in sputum, urine, blood, or tissue. too low may be ineffective; 1e›'els too high may lead io
harmful side effects.
Phenobarbital Level Anticonvulsant drug used especially
in ihe treatment of epilepsy. Periodic monitoring of its Rapid Plasma Rengin (RPR) Test Detects the presence of
amount in the blood is made to determine dose. Blood reagin, a nontreponemal antibody that may occur in
levels too low may be ineffective; levels too high may syphilis, infectious mononucleosis, malaria, systemic
lead to harm fu1 side effects. lu pus erythematosus (SLE), vaccinia, viral pneumonia,


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 Appendix B

Glucose Levels are derived from the intake of sugar and HomocJsteine Determines if a par ient has vitamin B,
maintained by the insulin levels of the body Glucose or folate deficiency. High levels of homocysteine are
is the body s energy source. Low lei'els may reflect related to heart and blood vessel disease.
hypoglycemia; high levels may reflect a diabetic
condition. Human Chorionic Gonadotropin (Beta-HCG) Detects
the presence of the beta subunit of human chorionic
Gram Stain Material from a sample is placed on a glass gonadoiropin (BHCG). BHCG is present in pregnancy,
slide and stained. The bacteria and body cells present choriocarcinoma, hydatidiform mole, and some testic-
can then be microscopically classified. ular tumors.

Hematocrit The hematocrit is the percentage of red Humnn lmmu node}icienc y Virus (HfV-1, HfV-2) Scree ii
blood cells compared with the amount of plasma in Detects the presence of antibody to the retrovirus HIV
whole blood. A decrease in the hematocrit value can Positive results must be confirmed by additional test-
be indicative of destruction of red blood cells, inter- ing. Positive results indicate previous infection with
ference in the production of red blood cells, or over- the virus. lt cannot be assumed from these results
hydration. An increase in hematocrit is the result of an alone that the patient has acquired immunodeficiency
increase in red blood cell production or dehydration. syndrome (AIDS) or will develop AIDS or related con-
ditions. Negative results do not preclude exposure or
Hemoglobin Hemoglobin is the main constituent of red infection.
blood cells. The primary purpose of hemoglobin is to
carry oxygen from the lungs to the cells and to carry Immunoelectrophoresis Laboratory procedure whereby
carbon dioxide from the cells to the lungs. A low specific protein fractions in serum or urine are identi-
hemoglobin value indicates various types of anemia. fied in serum or urine by their differing mobilities in
an electrical field and by their reactions with specific
Hepatic Function Panel Consists of albumin; total pro- reagent antibodies.
tein; total and direct bilirubin; alkaline phosphatase
(ALP); aspartame aminotransferase (AST), also known Indin Init Prep Stain used mainly on spinal fluid to detect
as serum glutamic oxaloacetic transaminase (SGOT); the capsule on the yeast Cryptoi:occus neoJormans.
and alanine aminotransferase (ALT), also known as Called a negative stain because the capsule of the yeast
serum glutamic pyruvic transaminase (SGPT). appears as a halo against the dark background of ink.
Cryptococc us neoJorm‹ins can cause meningitis.
Hepatitis A Virus (HAV) Hepatitis A, also known as
infectious hepatitis, is caused by HAV Hepatitis A can f'tOH Prep Method of detecting yeast or fragments of
be diagnosed by two antibodies against hepatitis A, mold in samples such as sputum, skin scrapings, nail,
immunoglobulin M (ISM) anti-HAV, and total anti-HAV and hair, thus determining the cause of an infection in
that body site.
Hepatitis B SvrJaee Antibody (Anti-HBs) Detects the
presence of the antibody to the hepatitis B virus sur- Lactate Dehydrogennse (LDH, LD) Enzyme of the
face antigen. Appearance of the antibody signifies a liver and heart. It is increased following a myocardial
convalescent state and recovery from the acute phase infarction or during liver disease. Total LDH level con-
of the disease. Also indicates prior exposure to the sists of five distinct fractions referred to as isoenzymes.
›'irus through vaccination, or indicates passive acquisi- These isoenzymes may be separated according to their
tion for administration of hyperimmune serum. differing mobilities in an electrical field.

Hepatitis B Surface Antigen fHBsAg) Detects the pres- Lipase Lipasc is an enzyme produced by the pancreas.
ence of the surface antigen part of the hepatitis B virus Increased lipase levels indicate pancreatic damage by
in serum. pancreatitis and pancreatic cancer.

High-Deiisi ty Lipoprotein (HDL) CitoIesteroJ The pro- Lipid Panel A lipid panel consists of measuring le›'els of
tern transport molecule for cholesterol as it travels cholesterol, triglycerides, high -density lipoproteins
through the blood. High levels of HDL have been cor- (HDL), low-density lipoproteins (LDL), and very
related with reduced risk for coronary artery disease. low density lipoproteins (VLDL). The purpose of the
Decreased levels may indicate a higher risk for the lipid panel is to detect disorders of lipid metabolism
disease. and to assess the risk of heart disease.

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 360 Appendix B

Culture: Fungus (MJcoIogy) Method of growing and are megaloblastic and hemolytic anemia. Iron storage
identifying mold and yeast that may be living in the disorders such as hemochromatosis and hemosiderosis
sample and causing infection in that body site. cause high ferritin levels. Decreased ferritin levels can
be seen in iron-deficiency anemia, severe protein defi-
Culture: Routine Method of growing bacteria that may be ciency, and patients undergoing hemodialysis.
living in the sample. Both normal and disease-causing
bacteria grow and are identified. Fibrinogen Fibrinogen is manufaci ured in the liver and is
used for the production of fibrin. Increased fibrinogen
C ytomegalov rms (CMV) Cytomegalovirus is a human is associated with diseases such as hepatitis, multiple
viral pathogen that belongs to the herpesvirus family. myeloma, cancer, rheumatic fever, tuberculosis, and
This virus causes serious illness in people with acquired septicemia. Genetic disorders or severe liver disease can
immunodeficiency syndrome (AIDS), in newborns, and cause decreased fibrinogen. In most cases, decreased
in individuals being treated Cth immunosuppression fibrinogen is attributed to disseminated intravascular
therapy. Setologic tests are available to detect CMV-spe- coagulation (DIC) syndrome. This syndrome causes a
cific immunoglobulin M (lgM) antibody. depletion or decrease of fibrinogen and other clotting
factors by overstimulating the coagulation process.
DehJdroepiandrosterone 5ulJaie (DHEAS) A male
sex hormone produced by the adrenal cortex of the Fluorescent Treponemal Antibod y Absorption (ATA)
adrenal gland. It is found in both males and females. Detects presence of antibodies specific for Treyon emu
DHEAS tests are used to monitor adrenal function. pall idum. The fluorescent treponemal antibody absorp-
tion (FTA-ABS) test is used to confirm reactive results
D erentinl: WBC Study and tabulation of at least a hun-
to a screening test for syphilis (rapid plasma reagin
dred white blood cells (WBCs) on a stained blood smear.
[RPR]) or to diagnose patients with symptoms of late-
The normal WBCs present are regs, bands, lymphs,
stage syphilis. FTA-ABS has been demonstrated to be
monos, basos, and eos. Abnormal and immature forms
highly sensitive and specific, but false-positives may
are also counted. Abnormal red and white cell morphol-
occur with pregnancy, systemic lupus erythematosus
ogy, as well as a platelet estimate, are also recorded.
(SLE), antinuclear antibodies, and abnormal globulins.
Digoxin (Lonoxin) Drug used in the treatment of heart
Fungol Immune Di IIusion (FID) Screening test for the
arrhythmias. Periodic monitoring of its amount in
detection of antibodies (in serum or spinal fluid) to
the blood is made to determine the dose to be given.
Blood levels too low may be ineffective, and blood lev- the fungi causing histoplasmosis, blastomycosis, coc-
cidiomycosis, and aspergillosis.
els too high may lead to harmful side effects.
Fungus fmepr Material from a sample is placed on a
Dilantin (Phenytoin) Level Anticonvulsant drug used
glass slide and stained. Any mold or yeast in the sam-
especially in the treatment of epilepsy. Periodic moni-
toring of its amount in the blood is made to determine ple may be detected.
the dose to be given. Blood levels too low may be inef-
Gastrin Gastrin is a hormone produced by specialized
fective, and those levels too high may lead to harmful cells in the stomach. High levels of gastrin can be sup-
side effeci s.
portive of a pancreatic tumor, gastric cancer, or perni-
Electrolytes (Lytes) Group of tests including sodium cious anemia.
(Na), potassium (K), chloride (CI), and dissolved
Geniamicin Level: Predose (Trough); Geniamicin level:
carbon dioxide (CO,). The relationship among these
Postdose (Penh) The.se tests determine the concentra-
electrolytes is maintained in careful balance by the
tion of the antibiotic gentamicin in various body fluids
function of the kidneys, lungs, and endocrine glands.
(usually blood) at a specific rime. A blood sample col-
Epstein-Barr Virus (£BV) The Epstein-Bart virus causes lected 5 minutes before the antibiotic is given is called
an increase in heterophil antibody formation. The the predose sample, and the sample collected 30 — 60
presence of heterophil antibodies is highly diagnostic minutes after infusion of the antibiotic is called the
of infectious mononucleosis. postdose sample. If either sample has a large concen-
tration of the antibiotic, it may be toxic to the patient.
Ferritin Ferritin is the storage fotm of iron. Anemic A low concentration of the antibiotic may be inade-
conditions associated with increased ferriiin le›'els quate to suppress the growth of the bacteria.


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 Appendix B 359

control the distribution of water between the cells and Coombs, Indirect (Antibody Screen) Detects the presence
blood plasma and to help maintain the acid—base bal- of unexpected antibodies in the patients serum.
ance in the body.
Cord Blood (ABO, Rh, Direct Coombs) Determines
Cholesterol Fatty compounds (lipids) of the body. by- infant/maternal blood compatibility. If a cord blood
percholesterolemia is a much-publicized risk factor for sample is unavailable or unsatisfactory, a heelstick
coronary artery disease. sample may be used.

CK-MB One form of the creatine kinase enzymes found in Cortisol Principal corticosteroid hormone secreted by
the heart muscle that rises when there is heart damage. the adrenal cortex. Levels of this hormone in blood or
urine are used for the evaluation of adrenal oi pitu-
Clostridium Oij(icile Toxi ti A stool test that identifies a itary dysfunction.
Clostri Jium JiJirile infection.
C-Reactive Protein (CRP) C-reactive protein is an indi-
Cold Agglutinin Tite r Measures the approximate amount cat or for inflammation. It is often present in higher
(titer) of a serum antibody (agglutinin) that only amounts in individuals with heart disease.
reacts with antigen at room temperatures below body
temperature. Cold agglutinin titers may be elevated in Creatine Kinase (Ch Total) Enzyme of the heart that
M ycoplusma pneumonia. Certain ›'iral diseases, such dS is increased following a myocardial infarction. Total
infectious mononucleosis, cytomegalic inclusion diS- creatine kinase is made up of three distinct fractions
ease, influenza A and B, parainiluenza, autoimmune referred to as isoenzymes.
disease, and autoimmune hemolytic anemia, cause an
elevation of cold agglutinins. Creatinine Metabolic waste product of muscle tissue that
is eliminated from the body via the kidneys. Increased
Come !•te Blood Cell Count (CBC) The following in serum in renal disease.
parameters are included: white blood cell (WBC)
count, red blood cell (RBC) count, hemoglobin (Hgb , Culture: Acid Fost Method of growing and identifying a
hematocrit (Hct), mean corpuscular volume (MCVj, certain type of acid-fast bacteria that may be living in
mean corpuscular hemoglobin (MCH), mean cor- the patient and causing an infection. Usually synony-
puscular hemoglobin concentration (MCHC), red mous with culture for tuberculosis.
cell distribution width (RDW), mean platelet vol-
Culture: Blood Culture Patients blood is injected into
ume (MPV), and platelet count. This is an excellent
two small bottles containing sterile media. If bacteria
screening test. lndi›ndual increases and decreases in
are present in the patients blood, they grow in the
the parameters provide the physician with invaluable
media. Identification of the bacteria may help deter-
information relating to the diagnosis and prognosis of
mine cause of fever and chills or other patient symp-
a disease. For example: (1) An increased WBC count
toms. One of the two bottles collected is an anaerobic
is a common nonspecific symptom ranging from the
bottle for bacteria that cannot grow in the presence of
slight elevation that occurs with a sore throat to the
oxygen. An aerobic bottle is also collected for those
extreme elevation found in leukemia. (2) A decreased
organisms that require oxygen to grow. The aerobic
RBC count may be the result of blood loss, abnormal
bottle often contains a resin (antibiotic remo›'al device
destruction of blood, or diminished production of
[ARD]). This aerobic bottle contains media and res-
blood, all of which may result in anemia.
ins that absorb and neutralize antibiotics that may be
Comprehensive Metabolic Ponel Consists of glucose, present in the patient s blood. With these antibiot-
blood urea nitrogen (BUN), creatinine, sodium, res neutralized, bacteria inhibited by the antibiotics
potassium, chloride, calcium. carbon dioxide Eco, , are able to grow. After the bacteria grow, they are
albumin, total protein, alkaline phosphatase, aspartate identified.
aminotransferase (AST), Alanine Aminoiransferase
(ALT) and total bilirubin. Cu!ture: Colony Cou nt Method for counting how many
bacteria are S••wing in l mL of urine. Determines
Coombs, Direct (Anfiglobulin, Direct) Determines whether the bacteria that are growing are present in
the presence of antibodies attached to t he patient s large enough numbers to be considered a cause of the
red cells. urinary tract infection.


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 Appendix B

Blood Cross-motch Tests are ordered for specific compo- Blood Urea Nitrogen (BUN) Protein metabolic waste
nents needed. Determines the compatibility between product formed in the liver and transported by
donor and recipient. the blood to the kidney for excretion in the urine.
Increased in renal disease or renal failure.
Blood Cross-match: Len Doc yte-Poor Paclted Ce fIs
Packed cells with accompanying filter removes Brain Natriuretic Peptide (BNP) Test measures the
99 percent of white cells. Indicated for patients with amount of BNP hormone in the blood. A high amount
febrile reactions or white cell antibodies. Also may be indicates that the heart is working harder than it
used prophylactically to eliminate the production of should, such as in heart failure.
white cell antibodies.
Calcium (Co) Element deriv ed from the diet and pres-
Blood Cross-mulch: Paclted Cells Packed cells are used ent in bone and teeth. Increased levels may reflect
to carry oxygen to tissues and as mass for volume hyperparathyroidism or metastatic bone disease.
replacement. This is the product of choice for patients Decreased levels may re fleet hypoparathyoi dism or a
with cardiac disease or chronic anemia and for those malabsorption syndrome.
requiring restricted sodium or citrate in liver or kidney
Cercinoembtyonic Antigen (CEA) CEA testing can have
disease.
significant value in monitoring treatment of patients
Blood Cross—match: lashed Pecked Cells Washed red with diagnosed malignancies. Persistent elevation
cells have approximately 85 percent of the leukocytes in circulating CEA following treatment or surgery
and 99 percent of the plasma remoi'ed. This prod- is indicative of acute metastatic or residual disease.
uct is indicated in patients who experience febrile or Declining CEA value generally indicates a favorable
alle rgenic reactions and patients with antibodies to prognosis in treatment of colorectal, breast, lung,
immunoglobulin A (IgA) or immunoglobulin E (IgE) prostatic, pancreati c, and ovarian carcinoma. Not
or other conditions requiring transfusion of red blood recommended as a screening procedure to detect
cells with minimal amounts of plasma. cancer in the general population.

Blood Cross-match: Wltole Blood Whole blood pro— Caiecholamines Catecholamines can be detected in
vides a source of red blood cells for carrying oxygen either the plasma or urine. Catecholamines are hor-
to tissues, blood volume expansion, and proteins mones that maintain impulses to parts of the body to
with coagulation properties. This product is used maintain equilibrium. Abnormal levels can be an indi-
in patients wi t h blood volume deficit and massive cation of tumors.
transfusion.
Celiac Disease Tests These are tests to detect autoanti-
Blood Gases Arterial whole blood analyzed for pH, bodies produced by the body in response to wheat,
oxygen, and carbon dioxide content. Abnormal let els rye, and/or barley. Also known as gluten-sensitive
reflect respiratory ailments or improper 'entilation. enteropathy tests.
Blood gases are normally done on arterial blood.

Cell Conut (Cerebral Spinal Fluid) Routine examination
Blood Product: Fresh Frozen Plnsmo Fresh frozen of cerebral spinal fluid (CSF) or any type of body fluid
plasma is the anticoagulated clear liquid portion of the that consists of a red and white cell count. Spinal fluid
blood that is separated and frozen within a few hours should have no red blood cells (RBCs) and fewer than
of whole blood collection. It is a source of coagulation 10 white blood cells (WBCs) per cubic millimeter.
factors. Increase in RBCs may indicate hemorrhage. Increase
in WBCs may indicate many abnormal conditions
Blood Product: Platelet Concentrate Platelets are used such as meningtis, tuberculosis, and encephalitis.
to treat patients with decreased numbers of platelets Body fluids differ in their normal cell counts. As a
(thrombocytopenia) or functionally abnormal plate- general statement, an increased WBC count usually is
lets. May be useful in selected cases of postoperative indicative of some kind of infection, and it is generally
bleeding. caused by bacteria.

Blood Type: ABO rind Rfi Determines the ABO Rh anti Chloride An important negatively charged electrolyte.
gens present on a patients red blood cells. Chloride has two main bodily functions: to help to


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GLOSSARY
Additive Any material placed in a tube that maintains or facilitates the integrity and
function of the sample.
Advance Directive Document stipulating the kind of life-prolonging medical care
permitted for a patient.
Aliquot Part of the whole sample that has been taken off for use or storage.
Anabolism Process of the bod) using simple substances to build complex substances.
Analgesic A drug that is used to give relief from pain.
Anatomy Study of the shape and structure of the body and the relationship of one body
part to another.
Antccubital Fossa The portion of the arm that is in front of the bend of the elbow.
The most prominent veins for venipuncture are located in this area.
Anticoagulant Chemical substance that prevents blood from clotting.
Appendicu lar Skeleton Skeletal system that provides an anchor for muscles.
Arteriospasm Reflex condition of the anery in response to pain or anxiety
Autoclave Instrument for sterilising that uses steam under pressure.
Autogenous Infection Infection from one’s ohm fiora.
Axial Skeleton Skeletal system that provides protection for parts of the body.
Basilic Vein The vein on the little finger side of the arm that runs the length of the arm.
Best Practices The most efficient and effective way of accomplishing a task, process, or
activit)' based on repeatable procedures that have proven themselves over time for large
numbers of people.
Biohazard Anything that is potentially hazardous to humans, living organisms, or the
environment.
Blood-Borne Pathogen A pathogen that is spread by blood and body fluids containing
blood. Typically, the pathogens are hepatitis and human immunodeficiency virus (HIV).
Body Substance Isolation tBSI) The type of isolation that expanded universal precautions
to require glo›'e use when contacting all body substances.
Buffy Coat Layer of cells in an anticoagulant tube of blood t hat is positioned between the
red blood cells and the plasma layers. The bully coat consists of white blood cells and
platelets.
Can n ula Device used for access for dialyzing and fot blood drawing in patients Auth
a kidney disorder.
Capillary Action Adhesive molecular forces between liquid and solid materials that draw
liquid into a narrow-bore capillary tube.
Catabolism Process of producing energy by breaking down complex compounds into
simple compounds.
Category-Specific Isolation Isolation based on the category (strict, respirator)' etc.) of
isolation
Centralized Phlebotomy Sample collection where the phlebotomist is part of the
laboratory team and is dispatched to hospital units to collect blood samples.
Centrifuge Instrument that spins and separates blood into layers depending on the weight
of each layer. The heavier elements are pushed to the bottom due to centrifugal force.

367

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APPENDIX C
BLOOD VOLUME AND
MAXIMUM DRAW

MAXIMUM ALLOWABLE BLOOD DRAW VOLUME

Patient‘s Weight Total Blood Maximum mL in Maximum mL in
Volume One Draw a 30-day Period
kg lb. mL 2.596 of total 5S of total
blood volume blood volume
(mL) (mL)
Preterm Infant 1 2.2 100 2.5 5
2 4.4 200 5 10
infant to 3 8.6 240 d.25 12
Preteen 4 8.8 320 8 16
5 11 400 10 20
6 13.2 480 12 24
7 15.4 560 14 28
8 17.d 640 16 32
9 19.8 720 18 3d
10 22 800 20 40
11-15 23-33 801-1,200 21-30 41—60
16—20 34-44 1,201—1,d00 31—40 d1—80
21—25 45—SP 1,d01—2,000 41—50 81—100
2d-30 5d-dd 2,001-2,400 51-60 101-120
31—35 d7—77 2,401—2,800 d1—70 121—140
Teen to Adult 36—40 78—88 2,520—2,800 62—70 126—140
41—45 89-99 2,801-3,150 71-79 142-158
46—50 100—110 3,151—3,500 80—86 162—172
51—75 111—165 3,570—5,250 87—131 174—282
7d-100 16d-220 5,251-7,000 132-175 264-350
101—125 221—275 7,001—8,750 176—219 351—438
126—150 276—330 8,751—10,500 220—263 439—526

Calculations based on blood volume of:

1 to 2 kg (preterm infant) 100 mL/kg
>2 kg to 35 kg (infant to preteen) 80 mL/kg
>35 kg (teen to adult) 70 mL/kg
0.454 kg - 1 lb.
information is from the autt›or’s research and experience and adapted from information from Searle Children’s
Hospital and Children’s Hospital Boston.

365

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 364 Appendix B

sample. Either sample ha ing a large concentration of Specific gravity: indicator of the concentrating and diluting
the antibiotic indicates the antibiotic may be toxic to ability of the kidney
the patient. A low concentration of the antibiotic may
be inadequate to suppress the growth of the bacteria. pH: acid—base balance

rricfiomonos Prep (Wet Mount Jor Trichomonas) Protein: indicator of kidney function

Method for the examination of vaginal or urethral
Glucose: indicator of carbohydrate metabolism
discharge for the presence of the urogenital
protozoan Trichomonas vnginalis, which is identified Ketones: indicator of carbohydrate metabolism
microscopically by its characteristic shape and
movement. If found, a diagnosis of trichomonas Bilirubin: indicator of liver function
infection of the site is confirmed.
Blood: indicator of kidney function or physical damage
Triglyceride Triglyceride is the main form of stored fat
Urobilinogen: indicator of liver function
in humans. Elevated triglycerides increase the risk of
heart disease. Nitrite: indicator of urinary tract infection

T-3 TriiodothJronine (T-3); ThJroxine (T-4) Harmories Leukocyte esterase: indicator of the presence of white
of the thyroid gland. Abnormal levels reflect increased blood cells (WBCs)
or decreased ilyioid activity.
Vonromycin Level: Predose (Trough); Vancomycin Level:
Troponin A cardiac-specific marker that is elevated within Postdose (Penh) This test determines the concentration
several hours of a hean attack. of the antibiotic vancomycin in various body fluids (usu-
ally blood) at a specific time. A blood sample collected
Uric Acid Nucleic acid end product excreted by the kid 5 minutes before the antibiotic is given is called the pre-
neys. Increased levels are found in gout, chronic renal dose sample, and the sample collected 60 minutes after
disease, ieukemia, and various malignant conditions. a ñ0-minute infusion of the antibiouc is called the post-
Urinalysis end Microscopic £xnm Microscopic exam dose sample. Either sample having a large concentration
is performed on a urine sample only when the of the antibiotic may indicate the antibiouc is toxic to
chemical screen welds a positive result for any of the patient. A low concentration of the antibiotic may be
ihe following: protein, blood, nitrite, and leukocyte inadequate to suppress the growth of the bacteria.
esterase. lnvolves noting the different types of cells,
microorganisms, and other sYrvciures present in a BIBLIOGRAPHY
centrifuged sediment.
Lab Tests Online. (2016). Retrieved july 2016 from lab-
Urinolysis: RoWine Serves as an excellent screening test. testsonline.org
Consists of a physical examination and a chemical
screen. Physical exam entails recording the color and Moisio, M. A., 6r Moisio, E. W (1998). Understanding
clarity of the urine. Chemical screen includes the laboratory and diagnostic tests. Clifton Park, NY: Delmar
following tests: Cengage Learning.
















 Appendix B

pregnancy autoimmune disease, narcotic addiction, and constrict blood vessels. It can be present in high
and diseases due to treponemes other than Treponemo concentrations when there are carcinoid tumors.
palliJum. A high or rising titer is used to aid in the
diagnosis of syphilis. Reactives must be confirmed 5C•OT—Also renown as AST (Aspartete Aminotransfer-
with an FTA-ABS (fluorescent treponemal antibody, ase) Enzyme of the heart and liver. Increased in myo-
absorbed) tesi. cardial infarction or liver disease.

Renal Panel Consists of sodi um, potassium, chlo ride, SGPT—Also known us ALT (Alanine AminoironsJerase)
carbon dioxide (CO 2), glucose, blood urea nitro- Enzyme of the liver. Increased in hepatitis and liver
gen (BUN), calcium, creatinine, phosphorous and disease.
albumin.
5 ichle Cell Screen Used to detect levels of hemoglobin S
Reticu Docyte Count Reticulocytes (retics) are immature of 10 percent or more. Does not distinguish between
nonnucleated red blood cells (RBCs). Daily about sickle cell disease and sickle cell trait. Sickle cell dis-
I percent of the RBC population dies and I percent ease is often fatal before adolescence without medical
new cells are normally delivered into the bloodstream management. Under certain conditions that bring
from the bone marrow A special staining procedure about low oxygen tension, such as surgery, sickle cell
must be done to count these retics. Retic count is one trait can result in serious clinical complications. Con-
method of es'a1uaiing effective RBC product ion. firmatory test of hemoglobin electrophoresis should
be run not only to distinguish between the disease
Rheumatoid A rth rims (RA) Factor Detects the presence and the trait, but to rule out other false-positive and
of an antibody called the rheumatoid factor (RF) in false-negative results.
serum or joint fluid. Elevated le›'els may indicate
a diagnosis of rheumatoid arthritis. Low titers may fiodium Sodium primarily controls the distribution of
occur in other disease conditions, such as systemic body fluid between intracellular and extracellular
lu pus erythematosus (SLE), tuberculosis, syphilis, or fluid.
x•iral in fections.
Teiciioic Acid Antibody Detects antibodies to the cell wall
RJiogam This product is given to Rh-negative individuals teichoic acid or the bacterium Staphylococcus aureus.
exposed to Rh-positive red cells to present the formation This test can be used to detect deep-seated staphylo-
of Anti-D antibodies. Product should be given to coccal infections, such as endocarditis, bacteremia,
Rh-negative women who deliver an Rh-positive or and osteomyelitis, and to monitor therapy.
D-positive infant within 72 hours of delivery. Rh-negative
women who abort or miscarry after 12 weeks of gestation Theophylfine/Aminophylline Drug used in the treatment
should receive a full dose of immune globulin. of asthma. Periodic monitoring of its amount in the
blood is made to determine the dose to be gii'en.
Rubella Screen Detects the presence of antibody to the Blood levels too low may be ineffective; levels too high
rubella (German measles) virus. Positive test indicates may lead to harmful side effects.
immunity to the virus. If a pregnant woman is not
immune, infection with the virus during the first tri- throat Strep Sc reen Lniex slide agglutination test for the
mester may cause congenital abnormalities, abortion, detection of a group A streptococcal antigen directly
or stillbirth. horn throat swabs.

Sedimentation Rate (5ed Rate) Measures the rate, Thyroid-Stimul‹iting Hormone (TSH) TSH levels are
expressed as the number of millimeters per hour, at measured to identify and differentiate primary and
which the red blood cells settle out of blood when secondary hypothyroidism.
the blood is placed in a vertical tube. An elevated
Tohramj7cin Level: Predose (Troug h); TobramJctn Level:
sedimentation rate is a nonspecific response to tissue
Postdose (Pea Ii) This test determines the concentra-
damage but does precisely rehect the seventy of the
tion of ihe antibiotic tobramycin in various body fluids
damage. Its greatest value is in detecting the inflamma-
(usually blood) at a specific time. The blood sample
tory process.
collected 5 minutes before the antibiotic is given is
Serotonin A chemical produced by the nervous system called the predose sample, and the sample collected
and the brain. Serotonin helps transmit nerve impulses after the antibiotic is given is called the postdose

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 Glossary

Trough Level (Predose) Drug level in the blood collected when the lowest serum
concentration is expected, which is usually 30 minutes before administering the next dose.
Universal Precautions A principle to protect health care associates from infections as
a result to exposure to body fluids. A term now replaced by standard precautions.
Vasoconstriction Constriction of vessel(s) that limits blood how.
Venipuncture Collection of blood from a vein by penetrating the vein with a needle.
Yiscosity Degree of thickness or resistance to flow of a substance.
Wheal A whitish raised bump produced by the fluid from an intradermal injection.







































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 0
m
Qualitative Analysis The chemical analysis designed to identify the components of a
substance. The results from this analysis are released as a positive (present) or negative
(not present) result.
Quality Assurance Program that strives to have the health care facility guarantee that all
areas are providing the highest quality and most appropriate level of care.
Quality Control Methods to monitor processes and confirm that processes are within the
preestablished limits.
Quality Improvement Review and monitoring of outcomes to strive toward continuous
improvement in performance.
Quality Service Superior professional attention and assistance to customers’ needs.
Quantitative Analysis The analysis of a substance to determine the amount or proportions
of the substance. Results will be released as an amount, such as grams per liter.
Receiver Person who is being given information by a sender.
Recordkeeping Maintaining information and records of any job-related injuries.
Root Cause Analysis of an event to determine the actual reason for the incident and
corrective action needed to prevent a recurrence.
Sender Person communicating to someone else verbally or nonverbally.
Sentinel Event An unexpected occurrence involving death or serious physical and
psychological injury.
Septicemia Condition in which microorganisms (mainly bacteria) are circulating and
multiplying in the patients blood.
Serum Fluid portion of the blood after clotting has taken place.
Sharps Container Specially labeled puncture-resistant containers for the disposal of sharp
items such as needles, scalpels, and syringes.
Skeletal Muscle Muscles attached to the bone.
Smooth Muscle Muscles involved in involuntary movement.
Standard Precautions Assumes that all blood and most body fluids are potentially
infectious. A principle maintaining that personal protective equipment must be worn for
contact with all body fluids whether blood is visible or not.
Systemic Infection An infection aiTecting the entire body.
Systemic 5ystem System circulating blood throughout the body with the exception of the lungs
Systolic Blood pressure when the heart is fully contracted.
Therapeutic Drug Monitoring (TDM) Collection and testing of blood to evaluate and
manage medication therapy effectively and safely.
Therapeutic Range Concentration of medication that is effective and not toxic in patient
management.
Thixotropic Separator Gel A gel material capable of forming an interface between the cells
and fluid portion of the blood as a result of centrifugation.
Threshold Acceptable level of performance.
Thrombocytes Formed blood element: also known as platelets.
Tourniquet Any constrictor used to facilitate vein prominence.
Transmission-Based Precautions Isolation precautions taken for patients diagnosed or
suspected of a specific transmissible disease. The precautions are based on whether the
disease is transmitted by airborne, droplet, or contact.



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 370 Glossary

Median Cubital Vein The vein in the antecubital fossa area of the arm that bridges the
cephalic and basilic veins.
Median Plane Imaginary line equally dividing the right and left sides of the body.
Medical Necessity Service that is reasonable and necessary for the treatment of the patient’s
illness.
Metabolism Process in the body of making substances and breaking down substances so
the body can function.
Mitochondria Serve as sites for cell respiration and energy production.
Muscle Tissue Tissue that has the ability to shorten, thicken, or contract.
Nervous Tissue Tissue consisting of neurons that have the ability to react.
Nosocomial Infection Also known as health care—associated or hospital acquired infection.
Infection that develops in a patient 48 hours or more after admission to a hospital or
health facility.
NPO Nothing by mouth. From the Latin term nulla per os.
Nucleus Part of cell that controls cell division and other activities of the cell.
Occluded Blocked; the normal How of blood is prevented.
OIG U.S. Office of the Inspector General.
Other Potentially Infectious Material (OPIM) Human body fluids, unfixed tissue or blood,
and organs or other tissues from experimental animals infected with HIV or HBV
Palpate To search for a vein with a pressure-and-release touch.
Papoose Board with Velcro® straps to hold a child.
Pathology Study of the nature and cause of disease.
Peak Level (Postdose) Drug level in the blood collected 15 to 30 minutes after the
dosage has been administered or when the highest serum concentration of the drug is
expected.
Personal Protective Equipment (PPE) Equipment that is used to protect the health care
associate from exposure to blood and body huids.
PHI Protected health information.
Phlebotomy Act or practice of bloodletting as a therapeutic or diagnostic measure.
Physiology Study of the function of each body part and how the functions of the various
parts coordinate to form a living organism.
Plantar Sole of the foot.
Plasma Fluid portion of the blood when no clotting has taken place.
Platelet Adhesion The process of platelet clumps adhering to an injured area to stop
bleeding.
Platelet Aggregation The process of platelets clumping together during hemostasis.
Postexamination (Postanalytical) Process in which t he results of the testing are
communicated to the health care provider.
Postprandial After a meal.
Prcexamination tPreanalytical) All processes that it takes to collect the sample and get to
the point in which the testing of the sample can occur.
Psychosocial Involving aspects of social and psychological behavior.
Pulmonary System System circulating blood through the lungs.



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Failure A case when the system does not meet user or customer expectations.
Fasting Having had nothing to eat for at least 8 to 12 hours.
Fibrin Degradation Products (FDPs) Fragments of the fibrin/clot found in the bloodstream
Fibrinolysis Process at the end of the clotting process that breaks down fibrin into small
fragments, called fibrin degradation products, that lead to disintegration of the clot.
Fistula Artificial shunt connection done by surgical procedure to fuse the vein and artery
together. Used for dialysis only.
Flea Metal rod used for mixing the blood sample that fits inside a capillary tube.
Gestational Diabetes Diabetes that develops during pregnancy.
Golgi Apparatus Layers of membranes within a cell that synthesize carbohydrates and
combine with protein molecules.
Hematoma Leakage of blood out of the vein during or after venipuncture that causes a
bruise.
Hemoconcentration Concentrating the constituents of blood by leaving the toumiquet on
too long.
Hemodialysis Process for puri lying blood by passing it through a dialyzer.
Hemopoiesis (Hematopoiesis) Formation of blood cells.
Hemostasis Process of the formation of a blood clot when an injury occurs and then lysing
of that blood clot when the injury has been repaired.
HHS U.S. Department of Health and Human Services.
HIPAA U.S. Health Insurance Portability and Accountability Act.
Homeostasis Occurs when all parts of the body work together to form a steady state.
ICD-10 fnternotional Statistical ClnssJication oJ Diseases and Refuted 1-iealtñ Problems list of
diagnosis codes for illnesses. Published by the American Medical Association.
Induration A hard, red spot that is the result of lymphocytes migrating to the
injection site.
In-Office Phlebotomist A phlebotomist who works in a physicians office to collect samples
from patients but is an employee of the laboratory.
Interstitial Fluid Fluid located between the cellular components of tissue.
Irritant Contact Dermatitis Irritation and redness of the skin by direct contact with a
chemical irritant.
Keloid Fibrous tumor arising from a cut; results in excessive scar tissue.
Lateral Toward the side of the body.
Latex Allergy An allergy to natural rubber latex. It is an allergy to the latex proteins that
are released in the use of latex-containing products.
Leukocytes Formed blood element; also known as white blood cells.
Local Infection An infection affecting only one area of the body.
Lyse Process of cell destruction; results in nonintact cell structure.
Lysosomes Sphefical bodies in the cell cytoplasm that break down components.
Malpractice Failure of a professional person to offer a standard of care, resulting in injury
or harm to the patient.
Meconium A dark, tarry material passed from the neonate’s rectum in the first days after
birth until milk- or formula-based stool appears.
Medial Toward the midline, or middle, of the body.


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 368 Glossary

Cephalic Vein The vein on the thumb side of the arm that runs the length of the arm.
Chemical Hazard Any element, chemical compound, or mixture of elements and/or
compounds that causes physical or health hazards.
Circadian Cyclical changes throughout the day.
Circannual Seasonal changes over the course of a year.
C UA Clinical Laboratory Improvement Act.
Communicable Disease Disease that is spread from person to person.
Compatible Substances that can be mixed without reacting with one another.
Competency Ability to correctly perform a task according to a standard procedure.
Compliance The formalized monitoring of an organizations adherence to laws and
regulations.
Connective Tissue Tissue that supports and connects organs and tissues of the body.
CPT Current Procedural Terminology manual listing a coding of procedures and services
performed by physicians. Published by the American Medical Association.
Cyclical Occurring in cycles.
Cytoplasm Semifluid inside of the cell membrane.
Decentralized Phlebotomy Sample collection where all members of the health care team
share responsibility to collect blood samples.
Demeanor The outward behavior of an individual.
Dermis Skin layer underneath the epidermis.
Diastolic Blood pressure when the heart is at rest.
Diplomatic Skill in handling affairs without raising hostility.
Disease-Specific Isolation Isolation based on the type of disease infecting the patient.
Diurnal Daily ›'ariation in blood levels at a particular time of day.
Edema Abnormal accumulation of fluid in the tissues, resulting in swelling.
Employee Input Involvement of nonmanagerial, frontline employees in decisions for the
use of needle safety devices.
Endocarditis Infection of the inner membrane of the heart.
Endoplasmic Reticulum Channel for transport of material in and out of the nucleus.
Engineering Controls Controls that isolate or remove blood -borne pathogens hazardous
for the workplace.
Epidermis Outermost covering of the skin.
Epithelial Tissue Tissue that protects the body by covering surfaces.
Erythrocytes Formed blood element; also known as red blood cells.
Esoteric Type of laboratory tests that are not routinely done. These tests are often sent to
another laboratory that specializes in a specific test.
Ethics Professional code of conduct in the treatment of patients. Ingrained in this is a
moral philosophy of how the phlebotomist treats the patient.
Etiologic Agent Viable microorganism or its toxin that causes or may cause human disease.
Examination All processes that are done to perform the test(s) on the sample to achieve
a result.
Exposure Control Plan A plan that identifies those tasks and procedures in which
occupational exposure may occur and identdies the positions whose duties include those
tasks or procedures.


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 Bibliography

Cengiz, M. Ulker, fi Meiselman, H. j. Baskurt, O. K. (2009). Influence of tourniquet appli-
cation on venous blood sampling for serum chemistry hematological parameters, leu-
kocyte activation and erythrocyte mechanical properties. Oinical Chemistry Laboratory
Medicine, 47(6), 769—776. dot: 10.1515/CCLM.2009. page 157.
Clinical Laboratory Standards Institute (CLSI). (2007). Procedures Jor the collection of
âia$nostic blood specimens by venipuncture: AppoveJ slanJard (6th ed.) (CLSI Document
GP4l-A6). Wayne, PA: Author.
Clinical Laboratory Standards Institute (CLSI). (2010). Accurac y in patient and somp!e idcnti-
Jication: Ayprored guide Iines (CLSI Document GP33-A). Wayne, PA: Author.
Clinical Laboratory Standards Institute (CLSI). (2010). Procedures for the handling and pro-
cessing oJ blood specimens Jor common laboratory tests: Approved standard (Cth ed.) (CLSI
Document GP4i-A4). Wayne, PA: Author.
Grenache, D. G. (2004, March). Imprecision and physiological variation: Impact on
uncertainty of clinical laboratory results. Clinical Laboratory News, American Associa-
tion of Clinical Chemistry, https://www.aacc.org/publications/c1n
Paxton, A. (1999, May). Stamping out specimen collection errors. CAP Todoy: College of
American Pathologists.

Chapter 11
Davis, B. K. (2011). PhJeboiom : From student to proJessionnl (3rd ed.). Clifton Park, NY:
Delmar Cengage Learning.
Eeland, K., fi Bailey, K. (2006). Customer sewice for dummies: A reference for the rest oJ us
(3rd ed.). Boston: IDG Books.

Chapter 12
American Medical Association. (2016). Current procedural terminology (CPT). Chicago, IL:
Author.
Centers for Medicare and Medicaid Services. (2010, December). Hroith Insurance Portabiiit
rind Accou ntabilit y Act. Retrieved March 2016 from http://www.cms. hhs.gov
OiTice ot the Inspector General. (1998, February). OIGs compliance program guidance for
hospitals. Federal Registe r 8987.
U.S. Department of Health and Human Services, Health Care Financing Administration.
(1992, February 28). Clinical Laboratory Improrement Amendments, 1988 (Federal
Register No. 069-001-00042-4). Washington, DC: U.S. Government Printing Office.

Chapter 13
American Society for Clinical Pathology (ASCP). ( 2016). CertJication maintennncr program.
Retrieved March 2016 from http://wwwascp.org/bor
Clinical Laboratory Standards Institute (CLV I). (2013). Development rind control: Approved
standard (6th ed.) (CLSI Document QMS02A2). Wayne PA: Author.
Clinical Laboratory Standards Institute (CLSI). (2009). Training verbfication rind competence
assessment: Approved standard (3rd ed.) (CLSI Document QMS03A3). Wayne, PA:
Author.

Appendix B
Lab Tests Online. (20 l6). Understanding You r Tests. Retrieved june 2016 from labtestsonline
.org
Moisio, M. A., 6r Moisio, E. Vi (l99fi). UnJersiariling laboratory and diagnostic tests. Clifton
Park, NY: Cengage Learning.




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 376 Bibliography

Chapter 8
Iturñage, G. S., Unceta-Barrenechea, A. A., Zarate, K. S., Olaechea, I. Z., N unez, A. R., fi
Rivero, M.M. (2009, June). Analgesic effect of breastfeeding when taking blood by
heel-prick in newborns. Annals Pediatric, 310—313.
Kalanick, K. A. (201 2). Phlebotomy trrhnician specialist (2nd ed.). Clifton Park, NY: Cengage
Learning.
Liaw, J. J., Yang, L. , Ti, Y., Blackbur n, S. T., fr Sun, L. W. (2010, October). Non nutritive
sucking relives pain for preterm infants during heel-stick procedures in Taiwan.
Journal of Clinical Nursing, 2741—275 1.
McMurtry C. M., Chambers, C. T., fi McGrath, P j. (2010, july). When “don’t worry”
communicates fear: Children’s perceptions of parental reassurance and distraction
during a painful medical procedure. Porn, 150(1), 52—58.

Chapter 9
American Association of Blood Banks. (20 li). Technical manuiql 18th ed.). Philadelphia:
J. B. Lippincott.
American Diabetes Association. (2010). Di«hetes. Retrieved March 2016 from http:// www
.diabetes. org
Bates, D. Vi, Goldman, L., fi Lee, T. H. (1991). Contaminant blood cultures and resource
utilization: The true consequences of false-positive results. Journal of the Anne ricon
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Chapter 10
Becton Dickinson White Paper VS539l. (200 I, April). Evaluation of somple quilt If anJ
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Chapter 6
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Chapter 3
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Chapter S
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f*44—G 51.
McDowell, J. (2005, March). Getting the fat out of labs. Clinical Laboratory News, American
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Nelson, K. (2002). Recer trali zing phlebotomy seances ir the clinical laboratory Advance
[or Medical Labor atoIy Professionals, 19(2 1), 21—24.
Polansky, V (2003). Growing your own: A long-term solution to your staffing needs.
Clinical Laboratoi yG Management Review, 17, 178—181.
Tamparo, C. D., 6r Lindh, W. Q. (2017). Therayeutit communication.s Jor allied Health
proJcssions (4th ed.). Clifton Park, NY: Cengage Learning.
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Chopter 2
Centers for Disease Control and Prevention (CDC). (2007). lsolotion guidelines. Retrie›'ed
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Health cci e settings. National Institute for Occupational Safety and Health, U.S. Depan-
ment of Health and Human Services, Public Health Service. Retrieved December 18,
201 5 from http://www.cdc.gov/niosh, or by calling 1 800 35 NIOSH.
Centers for Disease Control and Prevention (CDC). (2011). Heolflicn rr -nssocinted infections
(HAIs). Retrie›'ed December 18, 2015 from http://wwwedc.gov/haJ
Clinical Laboratory Standards Institute (CLSI). (2005). Protection of laboratory worhe rs
from occuyationafly orqui red infections A yyroved guidelines (3rd ed.) fCLSl Docu ment
M29-A3). Wayne, PA: Author.
HIV Clinical Response. (Updated October 2014). HIV ptophylaxis Jollowing orcupntionnl
exposure. Retrieved December 24, 2015 from www.hivguidelines.org




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 Index

HHS (Health and Human Services Inferior, 78 consent and, 336
Depanment), 326, 331, 332 Intenor vena cava, 111 in exposure, 338—339
High-complexity tests, 27 Infertility, 91 fainting and, 33C›—337
HIPAA (Health Insurance Portability Information hematoma and, 337—338
and Accountability Act), 326, protected health, 326, 329, 330 labeling and, 338
329, 330, 334 release of, 334—335 lawsuit prevention, 339
Histologic technician (HT), 17 In-office phlebotomist, 312, 319 nerve damage and, 338
Histotechnologist (HTL), 16 Integu mentary system, 81—82 in transport, 306—308
Home glucose monitoring, 260 Intensive Care Unit (ICU), 7 Legs, veins of, 11 7
Home health care, 7 Interstitial fluid, 93, 212, 215 Length, 123, 124
Homeostasis, 7d, 79 Intravenous lines, l9fi—199 Leukocytes, 98, 99, 102
Hospital-acquired infection, 39 Iodine, 45, 2fi7—2fi8 Light
Hospital laboratory; 24 Iron-deficiency anemia, 194 exposure, 300—301
Housekeeping, 46 Irritant contact dermatitis, 38, 69 for vein location in children,
Human body, 77 Isolation 237—238
Hybrid phlebotomy 6 blood collection in, 226 Limited phlebotomy technician, 16
Hydrogen peroxide, 45 body substance, 38, 43 Lipemia, 195
Hyperinsulinemia, 259 category-specific, 38, 56—57 Lipid panel, 10
contact, 57 Listening, 313—31a
I disease-specific, 38, 56 Local infection, 38, 39
latrogenic anemia, 194 respiratory, 57 Luer adapter, 134—135
ICD-9CM, 341 strict, 57 Lymphatic system, 92—93
Identification techniques, 56—38 Lyse, 248
hazard, 66 tuberculosis, 57 Lysosomes, 76, 79
patient, 157-159, 163-164, 294 Isopropyl alcohol, 45
sample, 162—1 65 Ivy method, 262 M
Immunohematology 9 Malaria, 255—256
Immunology, 9 J Malpractice, 326, 336
Incineration, 69 jaundice, 194 Manual requisition form, 160—161
lndirect contact, 40 joint Commission, 24—26 Marketing, 332
Indirect inoculation blood culture Masks, 49—50, ñ2—55
collection, 272 Material safety data sheets, fi5-6fi
Induration, 248, 273 Keloid, 248 Maximum draw volume, 365
Indwelling lines, 196—199 Kilogram, 124 Meconium, 248, 290—291
Infants. Ser also Pediatric patients drug detection in, 290—29 1
age-specific care competency Medial, 212, 218
for, 347 Labeling, 162—165, 338 Median cubital vein, 98, 116
blood volume in, 363 Laboratory, 7, 13—14 Median plane, 76, 77
heel collection in, 220—222 Laboratory organizational chart, Medical laboratory scientist (MLS),
pain in, 233 18—19 15, 16, 17
papoose for, 242 Laboratory staff, 15—18 Medical laboratory technician
preterm, blood volume in, 3O5 Laboratory standards, 24—28 (MLT), 16, 17
psychosocial needs of, 232 Laboratory techniques, 65 Medical necessity, 326, 327, 331
sample collection in, 23a›—239 Lateral, 212, 218 Medical records, 7
lnfection Latex allergy, 38, 68—69 Medical technician, 17
autogenous, 38, 40 Laws, compliance, 327—330 Medicolegal problems, 335—339
chain of, 40 Lawsuit prevention, 339 Medicolegal transport, 306—308
control, 39—43 Leeches, 4 Mega-, 124
local, 38, 39 Legal considerations Metabolism, 76, 79
nosocomial, 39 accidental arterial puncture and, Meter, 124
systemic, 39 335, 338 Metric conversion table, 123—124
vehicle, 41 in compliance, 327—330 Metric system, 123—124



 Index

Direct contact, 40 Evacuated blood collection system Glycosolated hemoglobin, 260, 261
Direct-draw blood culture collection, needle, 128 Goggles, 55
268 Evacuated collection tubes, 132— Golgi apparatus, 76, 79
Disease 134, 1 70—184, 185—188, Gowns, 52—55
communicable, 38, 39 297—298 Gram, 124
-specific isolation, 38, 56 Evacuated sysiem, 127—129 Greeting, 158, 169—170
Disease-related anemias, 194 reuse of holder, 130—131 Grooming, 23
Disease-specific isolation, 38, 56 Examination, 2, 11
Disposable needles, 125—126 Exercise, as variable, 295—297 H
Disposal of used materials, 69—70 Exposure, as legal consideration, Hand positioning, syringes, 172—173
Distal, 78 338-339 Hand vein venipuncture, l88-191
Diurnal, 248, 249, 294, 297 Exposure control plan, 38, 62, 63 Handwashing, 46—48
Dorsal, 78 Exposure incident, 62 Hazard(s)
Dorsal hand vein, 238—239 Exposure to light, 30O—301 arterial punctures, 200
Drainage/secretion precautions, 57 biohazard, 38
Droplet precautions, 57 F chemical, 38
Droplet transmission, 41 Face shields, 55 compliance and, 333
Drug detection Failure, 2, 29 identification, 66
in meconium, 290—29t Fainting, 192, 336—337, 346 Hazard Communication Act, 66
in umbilical cord tissue, 290—291 False Claims Act, 328, 330 Health care—associated infection, 39
Duke method, 262 Fasting, 248 Health care practitioner, 8
Fasting glucose, 257, 261 Health care, role of phlebotomy in, 4—
E Fasting samples, 249, 297 6
Edema, 154, 167 Fear, in children, 230—231 Health care setting, 6—12
EDTA white-stoppered tubes, Fecal sample, 287-290 Health information. See PHI
139—140 Feet, veins of, 1 1 7 (protected health information)
Elderly patients, 348 Fibrin degradation products (FDPs), Health maintenance organizations
Electrical safety, 68 122, 136 (HMOs), 13
Electrocardiograms (EKG), 6, 7 Fibrinolysis, 122, 136 Hean, 109—115
Electroencephalograms fEEG), 6, 7 Fire safety, fi6—67 chambers, 110
Electrolyte panel, 10 Fistula, 154, 199 conduction system of, 1 l4
Emergency department, 7 Flea, 122, 146 cross-section of, 111
Employee input, 38, 63, 64 Food services, 7 Heart disease, tests for. 1 14
Endocarditis, 98, 113 Form Heavy metals, 253
Endocardium, 113 chain of custody, 306—307 Hecto—, 124
Endocrine disorders, tests for, 91 practical evaluation, 349, 351 Heel, 220—222
Endocrine glands, 90 Fraud alerts, 332 Hematology 9
Endocrine system, 89—90 Frequently ordered tests, 357—364 Hematoma, 154, 193, 337—338, 346
Endoplasmic reticulum, 7fi, 79 Frontal plane, 78 Hemochromatosis, 253
Engineering controls, 3fi, 44, 62, 63 Hemoconcentration, 122, 143
Enteric precautions, 57 Hemodialysis, 76, 86
Environmental services, 7 Gastrointestinal (GI) laboratory, 7 Hemogard tube, 132—133
Epicardium, 113 Genetic anemias, 194 Hemoglobin Alc, 260, 261
Epidermis, 76, 81 Gentamicin, 231 Hemolysis, 194, 219
Epithelial tissue, 76, 80 Geriatric, 7 Hemolytic anemia, 194
Erythrocytes, 98, 99 Geriatric patients, 347 Hemopoiesis (Hematopoiesis), 76,
Esoteric, 2, 14 Gestational diabetes, 24fi, 259 83, 98, 99, 101
Ethics, 2, 23, 326, 339—340 GIoves, 48—49, 50—51, 52—55 Hemostasis, O, 122, 135
Ethylenediaminetetraacetic acid Glucose testing, 256—261 Heparin, 139
(EDTA), 139 Glucose tolerance test (GTT), Hepatic function panel, 10
Etiologic agent, 294, 304 257—258, 261 Hepatitis B vaccination, 46




 380 Index

Capillary puncture, 213—2 17, Civil Monetary Penalties Law, 328, Consent, 336
220—222 330 Contact isolation, 57
Cardiac arrest, 193 Clerical skills, 156 Contact precautions, 58
Cardiac cycle, 11 2 CLIA. See Clinical Laboratory Continued bleeding, 193
Cans, sample collection, 149—150 Improvement Act Continuous quality improvement
Catabolism, 76, 79 Clinical Laboratory Improvement (CQI), 29
Category-specific isolation, 38, Act (CLIA), 25, 26—27 Control(s)
56—57 Clinical Laboratory Improvement engineering, 38, 44, 62, 63
Caudal, 78 Act of 1988 (CLIA), 326, 329, infection, 39—43
Cell structure, 79—80 334 work practice, 45—46
Centralized phlebotomy, 2, 4 Clinical laboratory scientist (CLS), Controller, 320
Centrifuge, 98, 107, 108 16 Convulsions, 193, 336—337, 346
Centrioles, 80 Clinical Laboratory Standards Coronal plane, 7fi
Cephalic vein, 98, 116 lnstitute (CLSI), 25, 26, 158 Coronary arteries, 113
Certification, 352 CLSt. See Clinical Laboratory Coronary Care Unit (CCU), 7
Chain of custody, 252—2 53, 283, Standards Institute Courier services, 333
306—307 Coagulation, 8, 9, 135—137 Cranial, 78
Chemical hazard, 38 Collaborator, 320 Cubic centimeter, 124
Chemical safety 67 Collapsing veins, 226—227, 346—347 Culture
Chemistry, 9 Collection tubes, 141. See also Tubes blood, 2fi6—272
Children College of American Path o1ogists collection, 286—287
age-specific care competency for, (CAP), 25, 26 nasopharyngeal, 287
347—348 Comatose patient, identification of, throat, 287, 288
blood volume in, 363 158 urine, 276, 279, 283
distraction in, 234 Communicable disease, 38, 39 Cupping, 4
fear in, 230—231 Communication skills, 313—318 Current Procedural Tcrminolo
glucose tolerance test in, 258 Compatible, 2, 10 (CPT), 32fi, 331
involvement of, 234—236 Competency(ies) Customer
pain in, 233—234 assessment, 350—35I external, 312, 319
psychosocial needs of, 232 definition of, 344 internal, 312, 319
reluctance in, 230—231 documentation, 345 Cyclical, 294, 297
restraint of, 24O—243 examination, 349—351 Cytogenetics, 9
role plapng with, 235-236 NAACLS, 353-355 Cytoplasm, 76, 79
sample collection in, 236—239 program, 344—345, 349, 352 Cytotechnologist (CT), 16. 17
supine position for, 242 safety and, 346—347
tips for working with, 243—244 Complete blood cell count (CBC), D
understanding of illness in, 231 10, 103 Damaged veins, 226—227, 346—347
urine collection in, 278, 279 Compliance Death, 340
venipuncture on, 212—2 13 definition of, 32d-327 Decentralized phlebotomy, 2, 5
Chilling, 299 importance of, 327 Demeanor, 2, 15
Chlorhexidine gluconate, 45 laws regulating, 327—330 Dermis, 76, 81
Chromosomes, 80 plan elements, 331—332 Diabetes
Chronic stress, 322 policies, 332—33 5 determination, 258—259
Circadian, 294, 297 Comprehensive metabolic panel, 10 gestational, 248, 259
Circannual, 294, 297 Compromiser, 320 glucose testing in, 256—261
Circulatory system Computer label, 162—163 Diabetic shock, 192
anatomy of, 99—109 Conduction system of heart, 114 Diastolic, 98, 115
arteries of, I 16—117 Con fi ict management, 320—3 21 Digestive system, 88—H9
parts of, 99 Connective tissue, 76, 80 Digestive system disorders, tests for,
physiology of, 99—109 Conscious patient, identification of, 89
veins of, I 16—117 155 Diplomacy, 312, 320




 INDEX


ethylenediaminetetraacetic acid, Bevel, of needle, 127
Accession order, 166 139 Bicuspid valve, 111
Accomodator, 320 heparin, 139 Billing,35l
Accountability, 18 potassium oxalate, 138 Biohazard, 38, 65
Accurac y in Patient and Sample sodium curate, 138—139 Biohazard exposure response,
Jdenti{ic‹ition, 11 sodium fluoride, 13fi 71—72
Activated partial thromboplastin sodium polyanethol sulfonate, Bleeding
time (aPTT) test, 136 139 continued, 193
Acute stress, 322 solution A, 139 times, 2ñ2—2ñ6
Additive, 122, 133 See also solution B, 139 Blood
Anticoagulants trace element iubes, 140 cellular elements, 100—101
Administration, 7 Anticoagulant therapy, 225 OSHA definition of, 61
Administratii'e office, 9 Antikickback law, 327—328, 330 volume, 365
Administrati›'e skills, 1 56 Antise ptics, 45 Blood bank, 9
Advance directives, 2, 23—24 Aorta, 1 1 1 Blood-borne pathogen, 38, 42, 61
Age Aortic valve, 111 Blood collection. See nlso Arterial
skin and, 81 Appendicular skeleton, 7h, 82—d3 punctures; Capillary puncture;
-specific care, 347—34fi Arterial punctures, 199—206 Venipuncture
Airborne precautions, 57 accidental, 335, 33fi in children, 236—239
Airborne transmission, 42 Allen test, 200—202 in isolation room, 226
Alcohol testing, 252 blood gas procedure, 203—206 technique, 155
Aliquot, 154, 162 hazards in, 200 Blood culture, 2G6—272
Allen test, 200—202 sites in, 200 Blood flow, 105
Allergy, 38, 68—69, 193 Arteries, 111, 113, 116—117 Blood flow chart, 110
American Association of Blood Arterioles, 106 Blood gas, 203—206. See also Arterial
Banks, 165 Arteriospasm, 154, 200 punctures
American Osteopathic Association ASAP priority, 199 Blood pressure, 115
(AOA), 24 Assorted evacuated tubes, 132 Blood pressure cuff, 115, 143
Amencan Society (or Clinical Attitude, professional, 22—23 Blood smear, 253—256
Pathology (ASCP), 15, 18 Authority, 18 Blood transfer, 175—17/
Amikacin, 251 Autoclavc, 38, 70 Bluud tubes, I00
Aminoglycosides, 251 Autogenous infection, 38, 40 Blood vessels, 107
Anabolism, 76, 79 Autolysis, 79 Board of health, 26
Analgesic, 230, 234 Avoider, 320 Body language, 3I 3—314
Analysis Axial skeleton, 76, 82—83 Body positions, 77—78
qualitative, 3, 8 Body substance isolation (BSI), 3fi,
quantitative, 3, 8 B 43
Anatomy, 76, 77 Babies, 2I8—224 Body systems, 79
Anemia, 193—194 Bagging, 56 study of different, 93
Angle, of needle insertion, 129 Bag, self-sealing, 44 Brachial artery, 116
Animal cell structure, 80 Bar code, 159, 162 Breathing the syringe, 125
Antecubital fossa, 98, 11fi Basic metabolic panel, 10 Buffy coat, 98, 109
Anterior, 7t3 Basilic ein, 98, 116 Butterfly collection system,
Antibiotic removal device (ARD), 266 Becton Dickinson Eclipse needle, I 34—135, 185—191 , 269—272
Aniicoagulants, 98, 109 130
EDTA white-stoppered tubes, Benzalkonium chloride, 45 C
139—140 Best practices, 326, 336 Cannula, 154, 199
errors, 298, 299 Beta—lactamase, 266 Capillary act ion, 122, 145

379

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 386 Index

V consent for, 336

Vaccination, hepatitis B, 46 definition, 3, 4 “Waiting-to-serve time,” 5

Vacutainer, 127 evacuated tube collection, 17O—184 Waived tests, 27
Valves. 106 failed, 195—196 Warming. 299—300
Vancomycin, 251 greeting patient, 169—170 Washington, George, 4
VanishPoint needle holder. 131 locating vein, 169, 170—172 Waste disposal, 333
Vascular access devices (VAD), order of draw, 177—178 Weight, 123, 124
197—199 order of draw in, 299 Wheal, 248, 273
Vasoconstriction, 122, 136 patient reactions, 184—183, White blood celb (WBCs), 99
Vector transmission, 42 192—195 Winged infusion set,
Vehicle infection, 41 patient restrictions, 169 134—135. 185—188,
Veins, 166—168, 169, 170—172, site selection, 166—168 ISS—191
188—191 supply assembly, 169 Work practice controls,
Vein valves, 106 syringe collection, I 70—184 45—46
Venesection, 3—4 Ventral, 78
Venipuncture Viscosity, 122, 134
angle of needle insertion, 129 Vitamin D, 85 Xylose tolerance, 260
blood collection, 155, 173—175 Volume
blood transfer, 175—177 blood, 365 Z
on children, 212—213 measurements, 123, 124 Zephrin chloride, 45



































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 Index

capillary puncture, 214 Superior, 78 Transponation, of samples,
venipuncture, I66—168 Superior vena cava, 111 302-306,333
Six Sigma, 31 Supine position, for children, 242 Trans 'erse plane, 78
Ske1etaI muscle, 76, 83 Surgicutt method, 262—265 Trays, sample collection, 149—1 50
Skeletal muscle damage, 84 Syncope, 192 Tricuspid valve, 111
Skeletal system, 82—83 Syringe collection, 268, 298—299 Trough level (predose), 248, 250
Skeleton Syringes, 12°›-127, 170—184, T-spot test, 273
appendicular, 76, 82—83 lfi8—191 Tube(s)
axial, 76, 82—83 Systemic infection, 39 assorted evacuated, 132
Skin Systemic system, 98, 99 collection, l4l
allergies, 193 Systolic, 98, I IS defective, 298
layers of, 81 evacuated, 297—298
Sleeping patient, 15fi T evacuated collection, 132—134
Smear, blood, 253—256 Technical skill, 157 Hemogard, 132—133
Smooth muscle, 76, 83 Temperature, 124, 299—300 microcollection, 147
Social skills, 156 Temporary precautions, 57 microhematocrit, 146
Sodium citrate, 138—139 Test(s) trace element, 140
Sodium fluoride, 138 frequently ordered, 357—3h4 Tuberculin skin test, 273—276
Sodium polyanethol sul fonate (SPS), high -complexity, 27 Tuberculosis isolation, 57
139 moderate—complexity, 27
Solution A, 139 physician-performed microscopy, U
Solution B, 139 27 Umbilical cord tissue, drug detection
Special collection techniques, 252— request form, 159 in, 290—291
253 waived, 27 Unconscious patient, identification
Speech therapy, 7 Thalassemia, 194 of, 158
Sphygmomanometer, 1 15, 1 43 Therapeutic drug monitoring Unidenti fied emergency patient, 158
Splattering of blood. 131 (TDM), 248, 249 United States ex rei Dowden v.
Spring-loaded puncture Therapeutic phlebotomy, 253 National 1-halt h Laboratories,
devices, 145 Therapeutic range, 248, 249 I nc., 327
Sputum collection, 2fi7, 289 Thixotropic separator gel, 122, 133 Universal precautions, 39, 42—43
Standard precautions, 39, 43 Threshold, 3, 30 Urinalysis, 9
Standards Throat culture, 287, 288 Urinary disorders, tests for, 87
of conduct, 331 Thrombocytes, 98, 99 Urinary system, 85&6
laboratory, 24—28 Time Urine collection, 276—287
OSHA, 59—69 bleeding, 262—266 cathetcrized, 276, 283
Standing orders, 332 measurements, 124 chain of custody, 283
Stark law, 328, 330 Timed samples, 249—251, 297 in children, 278, 279
State Board of Health, 2fi Tissue for culture, 279, 283
Stat laboratory, 11 connective, 80 delayed testing in, 280—283
Stat samples, 252 epithelial, fi0 double-voided, 27fi, 282
Stool sample, 287—290 muscle, 81 8-hour, 276, 278. 282—283
Stress nervous, 81 female clean-catch midstream,
acute, 322 Tobramycin, 251 279, 283
chronic, 322 Total quality management (TQM), 29 first morning, 276, 278,
coping with, 321—323 Tourniquet, 295 252—253
reduction, 322—323 Toumiquets, 122, 142—144 male clean-catch midstream, 276—
thinking about, 322 Trace element tubes, 140 277
as variable, 295, 296 Transmission-based isolation problems with, 28 I
Strict isolation, 57 precautions, 39, 56—59 routine, 276—280
Superficial veins Transportation timed, 276, 279, 282
of arm, 116 medicolegal, 306—308 24—hour, 280, 281—283
of legs and foot, 117 of samples, 302—30ñ Urine glucose, 260



 Index

Plane Protected health information. Restraint, of children, 240—243
frontal, 78 See PHI (protected health Reuse
median, 76, 77 information) of evacuated system holder,
transverse, 78 Protective precautions, 57 I 30—1 31
Plantar, 212, 218 Prothrombin time (PT) test, 136 of needle holder, 131
Plasma, 98, 106 Proximal, 77—78 of tourniquet, 143
Platelet adhesion, 122, 136 Psychiatric patient, 226 Reverse precautions, 57
Platelet aggregation, 122, 136 Psychosocial, 230 Right atrium, 111
Platelets, 99 Psychosocial needs of children, 232 Right ventricle, 111
Pneumatic tube system, 302, 304 Pulmonary arteries, 111 Risk reduction, 43—56
Point of care testing, 7& Pulmonary semilunar valve, 11 I Root cause, 3, 26
Polycythemia vera, 253 Pulmonary system, 98, 99
Positioning, patient, 166 Pulmonary valve, 111 S
Posterior, 78 Pulmonary veins, 111 Safety
Posterior tibial artery, 218—219 Purified protein derivative (PPD), chemical, 67
Postexamination, 3, 11—1 2 274—276 electrical, h8
Postprandial, 248, 259 fire, 66—fi7
Postprandial glucose test, 239 guidelines, 70—71
Posture, as variable, 295—297 Qualitative analysis, 3, 8 Sagittal plane. See Median plane
Potassium oxalate, 138 Quality assurance, 3, 29—32 Sample(s)
Practical evaluation form, Quality control, 3, 30 chilling of, 299
349, 351 Quality improvement, 3, 31 fasting, 249, 297
Precautions Quality service, 312, 313 identification, 162—165
airborne, 57 Quantiferon test, 273—274 labeling, 162—165, 338
contact, 58 Quantitative analysis, 3, 8 recollection, 301-302
drainage/secretion, 57 Questionable test requests, 334 rejection, 301—302
droplet, 57 stat, 252
enteric, 57 R timed, 249—251, 297
in microcollection, 219 Radial artery, 203—204 transportation of, 333
protective, 57 Radiation exposure, 6fi warming of, 299—300
reverse, 57 Radiology 6, 7 Sample collection trays/carts,
standard, 39, 43 Rapid response laboratories (RRLs), 149—150
temporary, 57 14 Satisfaction, patient, 318-320
universal, 39, 42—43 Reasonably anticipated contact, 62 Secondary hemostasis, 136
Prediabetcs, 257 Receiver, 312, 313—314 Semen collection, 285—286
Preexamination, 3, 11 Re-collection, 301—302 Semiconscious patient, identification
definition of, 294 Recordkeeping, 39, 63, 64 of, 15d
variables, 294—30I Record retention, 332 Semilunar valve, 111
Preferred provider organization Recovery 7 Sender, 312—313
(PPO), 13 Red blood cells (RBCs), 99 Sentinel event, 3, 25
Preschoolers Regional laboratory 14—15 Septicemia, 248
pain in, 233 Rejection, 301—302 Serum, 98, 106
psychosocial needs of, 232 Release of information, 334—335 Sexually transmitted diseases, 91
(See also Pediatric patients) Renal panel, 10 Sharps, 65
Preterm infant, blood volume in, Reproductive systems, 90—91 Sharps containers, 39, 44
365 Requisition design, 332 Sharps with Engineered Sharps
Primary hemostasis, 136 Resistant patient, 225—226, 243 Injury Protections (SESIPs), 63
Prioritization, 199 Respiratory isolation, 57 Shock, diabetic, 192
Privacy, 329 Respiratory system, 84—85 Sickle cell anemia, 194
Private room, 46 Respiratory therapy, 7 Site(s)
Professional attitude, 22—23 Response, biohazard exposure, 71—72 arterial punctures, 200
Professional grooming, 23 Responsibility, 18 in babies, 218—219



 Index

Microbiology, 9 NPO, 248, 249 psychiatric, 226
Microcollection equipment, Nucleus, 76, 79 resistant, 225—226
144—147 Nursing, 7 rights, 19—21
Microcollection tubes, 1 47 satisfaction, 318—3 20
Microhematocrit tube, 146 O types of, 158
Milli—, 123, 124 Obese patient, 226, 346 Patient Care Partnership, 19—22
Millimeter, 124 Obstetrics, 7 Patient care technician, 5
Mitochondria, 76, 79 Occluded, 98, 113 Patient-focused care, 5
Mitral valve, 111 Occupational exposure, 62 Patient service centers (PSCs), 14
Moderate-complexity tests, 27 Occupational Safety and Health Peak level (postdose), 248, 250
Molecular diagnostics, 9 Administration (OSHA), 25, 27, Pediatric patients
Muscle tissue, 76, 81 59—69, 130 age-specific care competency for,
Muscular system, 83—fi4 definitions, 61—63 347—348
Myocardium, 113 standards, 59—69 blood volume in, 365
Occupational therapy, 7 customer service with, 320
N OIG (Ofice of the Inspector distraction in, 234
NAACLS competencies, 353—355 General), 326, 327, 331 fear in, 230—231
Nasopharyngeal culture, 287 Older patients, 348 involvement of, 234—236
National Accrediting Agency for Oncolo 7 pain in, 233—234
Clinical Laboratory Sciences Order of draw, 177—178, 224. 299 psychosocial needs of, 232
(NAACLS), 25, 27 Organizational chart, 18 reluctance in, 230—231
National Accrediting Agency for Onhopedic, 7 restraint of, 240—243
Clinical Laboratory Sciences Other potentially infectious material role-playing with, 235—236
(NAACLS) competencies, (OPIM), 39, 61—62 sample collection in, 23fi239
353-355 Outpatient laboratory, 24 supine position for, 242
Nausea, 192 tips for working with, 243—244
Needle(s) P understanding of illness in, 231
angle of insertion, 129 Pain urine collection in, 278, 279
Becton Dickinson Eclipse, 130 developmental reactions to, 233 venipuncture on, 212—213
bevel of, 127 distraction and, 234 Pediatrics, 7
contaminated, 65 management, 233—234 Penicillinase, 26fi
disposable, 125—126 as patient reaction, 192 Personal protective equipment
evacuated blood collection Palpate, 122. 143 (PPE), 39, 48-55
system, 128 Papoose. 230, 242 Pharmacy, 7
holder for, 129 Parent assistance, with pediai ric PHI (protected health information),
parts of, 126 patients, 241 326, 329, 330
safety device, 127, 128 Pathologist, 16 Phlebotomist, 18
sizes of, 126 Pathology, 3, 17 Phlebotomy
Needleless systems, 62 Patient(s) centralized, 2, 4
Negligence, 336, 33fi—339 approaching skills, 156—15 7 decentralized, 2, 5
Neonatal, 7 conflict management with, definition of, 3
Nephrology, 7 320—321 in health care, role of, 4—6
Nerve damage, 192, 338 with damaged veins, 346—347 history oi, 3—6
Nervous system, 84 fainting or convulsing, 346 hybrid, 6
Nervous system disorders, tests for, geriatric, 347 quality assurance, 29—32
84 greeting, 158, 169—170 therapeutic, 253
Nervous tissue, 7ñ, 81 identification, 157—159, 163—164, Phlebotomy technician I, 16
Nonlatex tou miquet, 142 294 Phlebotomy technician II, 16
Nonspring-loaded lancets, 144 in isolation, 220 Physical therapy, 6, 7
Nonverbal communication, obese, 226, 346 Physician-petformed microscopy
313—314, 315 positioning, 166 tests, 27
Nosocomial infection, 39 with problematic veins, 226—227 Physiology, 76, 77