PHLEBOTOMY 1.
Localized stasis
Objectives
● Improves knowledge and awareness of
risks associated with phlebotomy to the
health care workers.
● To reduce blood borne exposure and
develop safe practices.
● Improve quality of lab tests by reducing
pre analytical errors
● Improve patient confidence
Types of Phlebotomy
1. Closed or evacuated systems
- It is preferable because the have
been proven to be safer than open
systems and provide better
specimen quality
- Blood comes directly in contact
with anticoagulants avoiding many
pre-analytical issues such as
micro-clot formation.
- Reduces the risk of direct
exposure to blood
- It is easier to take multiple
samples from a single
venipuncture
- Vacuum extraction systems are
safe, training and skill is required
for their correct use
- Safer than open system
- Better specimen quality
- Blood comes directly into tubes
- Reduce risk of infections
2. Open system
- Use of a hypodermic needle and
syringe is the most common
means of blood sampling
Standard Precautions at sample collection
a. Assume all patients are potentially
infectious
b. Practice effective hand hygiene
procedures
c. Personal protective equipment
i. Gloves
ii. Gowns
iii. Masks
iv. Other PPE
VENIPUNCTURE
Application of tourniquet for greater than
1 mins can cause:
2. Formation of partial filtrate of blood
3. Hemoconcentration
4. Platelet activation may lead to
coagulation test error
5. High values of cellular elements
SPECIMEN REJECTION
1. Unlabelled
2. Incorrect container
3. Insufficient or overfilled tube volume
4. Hemolyzed sample
5. EDTA with clot
6. Contaminated samples
7. Delayed transport time and processing
Prevention and Management of needlestick
injury
● Incase of needle stick injury follow the
protocol which includes:
1. Allow the wound to bleed freely for a
moment and then wash thoroughly with
water
2. Apply disinfectant and first aid dressing.
3. Note down the details of the patient along
with the patient ID
4. Report the incident to authority
immediately whose contact number is
displayed
5. If injury is caused by a sharp having come
in contact with a potentially infectious
material consult a physician as directed
by your HOD, as post-exposure
prophylaxis (PEP) may be required.
Management of spillage of blood/body fluids
● Disposable gown
● Gloves
● Face/eye protection
● Biohazard bags
● Disposable absorbent material
● Disposable cloths/paper towels
● Disinfectant
● Forceps
Choice of Gauge of Needle
- It is important to select the right gauge of
the needle
- Age of the patient
- Amount of blood
- Types of sample
 - Thicker gauge needles are ○ a face shield or goggles,
used for coagulation ○ a pair of disposable patient
studies examination gloves.
- Commonly used gauge are 23G, 22G, 1. Perform hand hygiene by using
21G alcohol-based hand sanitizer or washing
Patient Population your hands with soap and water for at
Needle Adult Pediatric, Neonatal least 20 seconds.
Gauge elderly, 2. Put on shoe cover
small veins
3. Put on the isolation gown.Tie all ties or
snap all snaps. You may need assistance
21 (1-1.5 inch NA NA from another healthcare provider.
or 2.54 4. Put on the N95 respirator. When using a
cm) respirator with a nosepiece, fit it to your nose using
both hands. Do not bend or tent the respirator.
22 (1 inch or (1 inch or NA
Extend the respirator under your chin, protecting
2.54 cm) 2.54 cm)
both your mouth and nose. Pull the top strap over
your head, placing it on the crown, then pull the
23 (1-1.5 inch Winged Winged
or 2.54 set set bottom strap over your head, placing it at the base
cm) butterfly butterfly of your neck. Perform a user seal check. Do this by
0.5 inch or 0.5 inch or using your hands to cover the surface of the
0.75 cm 0.75 cm respirator and gently exhale, checking that the
facepiece bulges slightly. Then, while keeping your
hands over the respirator, take in a quick, deep
➔ The higher the gauge number, the smaller breath, checking that the facepiece collapses
the needle width. On the other hand, slightly.If air escapes through the edges, readjust
the fit of your respirator and perform another user
smaller numbers denote a larger diameter
seal check. Do this each time you put the respirator
or width. Larger diameter gauges have on. If a respirator is not available, put on a
thicker needle walls and are stronger and facemask.Extend the facemask under your chin,
more durable. protecting both your mouth and nose. If the mask
has loops, hook them around your ears. If it has
ties, secure them at the base of your neck and
crown of your head.
5. Put on Hair cap/net
6. Put on a face shield or goggles.
7. Put on your gloves. Pull the gloves
down so that they cover the wrist of the
gown.

Proper Doffing of PPE

1. Before leaving the room, remove and
discard your gloves. Gloves can be
removed using more than one technique.
a. For the glove-in-glove
technique. Pinch the outside of
the glove near the wrist. Peel
downwards, pulling the glove
inside out With your ungloved
hand, slide your finger under the
Proper Donning of PPE wrist of your remaining glove
● Identify and gather the proper PPE to Again, peel downwards, turning
don, including: the glove inside out. Discard the
○ Isolation gown, gloves.
○ N95 filtering respirator or surgical b. For the beaking method, Pinch
mask the outside of the glove near the
 wrist. Using your finger, pull the
glove inside out and over the
fingers and thumb to form a beak.
With the beaked hand, pinch the
opposite glove at the wrist, and
pull downwards, turning the glove
inside out. With the ungloved
hand, pull the beaked glove off
touching only the inside of the
glove.
2. Remove your gown (shoe cover if an).
Untie all ties or unsnap all snaps.
a. Some gown ties can be broken
rather than untied. In that
instance, break the ties gently,
avoiding a forceful movement.
Reach up to the shoulders and
carefully pullor roll the gown down
and away from the body. Dispose
of the used gown.
b. You may now exit the laboratory
or the patient’s room.
3. After leaving the patient;s room, perform
hand hygiene by using alcohol-based
hand sanitizer or washing your hands with
soap and water for at least 20 seconds.
Be sure to clean your wrists where the
edge of the glove was located.
4. Carefully remove the face shield or
goggles by grabbing the strap and pulling
upwards and away from your head. Do
not touch the front of the face shield or
goggles.
5. Hair cap/ net (if any)
6. Remove and discard the respirator or
surgical mask If you are wearing a
respirator, remove the bottom strap by
grabbing only the strap and bringing it
carefully over your head. Grasp the top
strap and bring it carefully over your
head, and then pull the respirator away
from your face without touching the front
of the respirator.
a. If you are wearing a facemask,
carefully untie the straps or
unhook them from your ears and
pull the mask away from your face
without touching the front of the
mask.
7. Lastly, once again perform hand
hygiene after removing the respirator or
facemask.
BIORISK MANAGEMENT
● An effective procedure of risks posed by
working with infectious agents and toxins
in laboratories
● It includes a range of practices and
procedures to ensure the biosecurity,
biosafety and biocontainment of those
infectious agents and toxins.
BIOSAFETY
● A prevention mechanism that includes
conduction of regular reviews of the
measures to ensure safety in laboratory
settings, as well as strict guidelines to
follow.
● It is employed to protect from harmful
incidents.
● Example: PPE, Handwashing, proper
disposal
BIOSECURITY
● Refers to measures aimed at preventing
the introduction and/or spread of harmful
organisms (e.g. viruses, bacteria, etc.) to
animals and plants in order to minimize
the risk of transmission of infectious
disease.
● Measures employed to protect
biohazardous materials, or critical
relevant information, against theft or
diversion, of those who intend to pursue
intentional misuse.
BIOCONTAINMENT
● A component of biorisk management with
the overall objective to confine an
infectious organism or toxin, thereby
reducing the potential for exposure to
laboratory workers or persons outside the
laboratory, and the likelihood of accidental
release to the environment.
● Example: Waste management
● White - sharp objects like syringe
● Red - contaminated pathogen affected
like IV
● Blue - bottles of medicines
● Yellow - bandages, cotton, paper or the
general waste)
PHLEBOTOMY
- The process of making a puncture in a
vein, usually in the arm, with a syringe or
cannula for the purpose of drawing blood.
- The procedure itself is known as
venipuncture, which is also used for
intravenous therapy.
- Vital part of modern medicine, drawing
vital uncontaminated blood for the blood
tests which remain the bedrock of
diagnostic science
CLINICAL ASSISTANCE
- Duties and responsibilities:
- Receives, screens, interviews, and
registers patients or clinical/laboratory
test specimen (as well as collection)
- Takes and records results and provide to
physicians to aid in the diagnosis or rule
out medical conditions.
OBJECTIVES OF GOOD PHLEBOTOMY
PRACTICES include:
- Improve knowledge and awareness of
risks associated with phlebotomy to the
health care workers
- To reduce blood borne exposure and
develop safe practices
- improve quality of lab tests by reducing
pre analytical errors
- Improve patient confidence
COMMON SITES
1. Ante cubital area
a. Median cubital vein
i. Most preferred site, large
and well anchored, least
painful and least likely to
bruise
b. Cephalic vein
i. Large but not well
anchored, more painful
than median cubital vein,
lies near brachial artery
and median nerve with risk
of getting punctured
c. Basilic vein
i. Large, easy to palpate but
not well anchored, lies
near brachial artery and
the median nerve with risk
of getting punctured
2. DORSUM OF THE HAND
a. Veins on the dorsum of hand
i. Higher tendency to bleed
ii. Easier to access in fat
persons
ALTERNATE SITES
1. Phlebotomists will not collect blood
except under special circumstances from:
a. Arm or hand from the side of a
mastectomy unless all other sites
have been ruled out and onl with
written permission from the
physician or nurse
b. Limbs with indwelling artificial
access devices unless all other
sites have been ruled out and only
with written permission of primary
care physicians
UNACCEPTABLE SITES
1. Arterial lines or locks
2. Shunts
3. Fistulas
4. Palmar region of wrist
5. Varicose veins
6. Femoral vein
YELLOW PLASTIC CONTAINER
- Blood-stained swabs, bandages
RED PLASTIC CONTAINER
- All infected plastics like IV infusion lines,
catheters
1% SODIUM HYPOCHLORIDE SOLUTION
- Used syringe before disposal
LIST OF BASIC PHLEBOTOMY MATERIALS
- Scrubs
- Non sterile gloves
- Request course information
- Alcohol pad
- Tourniquet
- Needles
- Blood collection tubes
- Labels
- Gauze or bandages
- Waste bins
SPECIMEN COLLECTION PROCEDURE
● (1) Receive, review and accession of test
request.
 ● (2) Approach, greet and identify the
patient
● (3) Explain the procedure and obtain
consent
● (4) Verify collection requirements, and
identify sensitivities and potential
problems
● (5) Sanitize hands and put on gloves
● (6) Position patient, apply tourniquet, and
ask the patient to make a fist
● (7) Select a vein, release the tourniquet,
and ask the patient to open the fist
● (8) Clean and Air-dry the site
● (9) Prepare the collection equipment
● (10) Reapply tourniquet, and uncap and
inspect the needle
● (11) Ask the patient to remake a fist,
Anchor the vein and insert the needle
● (12) Establish blood flow, release the
tourniquet, and Ask the patient to open
the fist
● (13) Fill, remove and mix tubes in order of
draw, or fill syringe
● (14) Withdraw the needle, Place gauze,
activate the needle safety feature, and
apply pressure
● (15) Discard needle, attach transfer
device, transfer blood, and discard
syringe and transfer device unit
● (16) Label and prepare tubes for handling
and transport
● (17) Check the patient’s arm, and apply a
bandage
● (18) Dispose of used materials, and
reposition moved items
● (19) Thank the patient, remove gloves,
and sanitize hands
● (20) Transport specimen to the Lab
promptly
TYPES OF PHLEBOTOMY
1. Arterial sampling
2. Venipuncture sampling
3. Fingerstick sampling
PHLEBOTOMY : PATIENT CENTERED CARE
EFFECTIVE COMMUNICATION
● Effective communication is a key
component of successful phlebotomy
procedures.
● It is important to prepare the patient
adequately for the blood collection
procedure, not just physically, but also
mentally.
● Educating the patient about the process is
respectful to the patient and will improve
sample integrity.
● Allow time:
○ For patients to ask questions
○ To share information that is
important to the sample collection
process
○ To describe post-venipuncture
self-care information
○ Use simple vocabulary and not complex
medical terms when explaining
procedures or answering patients'
questions.
CASE STUDY 1
● If an error does occur during the
venipuncture procedure ---- a blood tube
was not collected for a particular test ----
and is realized by the phlebotomist, what
is the appropriate action to be taken?
RESPONSE
● The phlebotomist should explain the error
to the patient and perform a second
venipuncture to collect the required tube.
○ Ignoring an error or taking
inappropriate actions can put a
patient at risk.
SAMPLE INTEGRITY
● If there is a problem with the sample, then
test results are meaningless. It can lead
to:
○ Patients experience wasted time
in addition to anxiety and loss of
faith in the expertise of the
phlebotomy staff.
○ Patients may also experience
harm, if harm is defined as delay
in diagnosis, therapy, hospital
admission or discharge.
○ Threats to sample integrity include:
■ Collection of a sample from the
wrong patient
 ■ Collection of the wrong blood
sample (eg, a blue top tube when
a green top is needed)
■ Missed venipuncture (multiple
attempts)
■ Multiple venipunctures due to
improper or inadequate sample
collected
■ Mislabeled and unlabeled samples
■ Improperly performed
venipuncture or skin puncture
CASE STUDY 1
● A phlebotomist asks an outpatient, “Are
you Piolo Pascual?” After the patient
answers yes, the phlebotomist proceeds
by labeling the tubes and drawing the
blood. What is wrong with this scenario?
● APPLICATION OF THE TOURNIQUET
CASE STUDY 2
● A patient must have blood drawn for a
complete blood count (CBC), potassium
level, prothrombin time (PT), and type
and screen. The phlebotomist draws
blood into the following tubes in this
order:
1. Serum separation tube
2. Light blue stopper tube for PT
3. Lavender stopper tube for CBC
4. Green stopper tube for the potassium
● Which of the results will be affected by
the incorrect order of draw? Explain.
PATIENT AGE CONSIDERATIONS
CHILDREN / NEONATES
● Use a wrist or foot band only if it is
attached to the patient;
● DO NOT use the bed number or a wrist
band that is attached to the bed or cot.
● If a parent or legal guardian is present,
ask that person for the child’s first and
last names, date of birth and hospital or
file number are written on the laboratory
form, and match them to the identity of
the patient.
● Venepuncture is the preferred method of
blood sampling for term neonates, and
causes less pain than heel-pricks
● Use a winged steel needle, preferably 23
or 23 gauge, with an extension tube (a
butterfly)
● Ask whether the parent would like to help
by holding the child.
● Immobilize the child
● Use a transilluminator or pocket pen light
to display the dorsal hand veins and the
veins of the antecubital fossa if necessary
● If not confident, seek assistance from an
experienced co-phlebotomist.
ELDERLY / GERIATRICS
● ARM VEINS: A smaller 22-gauge straight
needle (black cap) is best for small or
difficult arm veins.
● HAND VEINS: A winged blood collection
set with a 23-gauge needle
● Elderly patients are prone to bruising
when applying the tourniquet. Less than
one minute.
● To make these veins more prominent
● Apply a heat compress to the site for
three to five minutes.
● Stimulate the site with alcohol to make
the veins more prominent.
● Briefly hang the arm in a downward
position.
● Do NOT tap the veins. This could bruise
the patient.
● Massage the arm upward from the wrist
to the elbow if selecting arm veins.
PERFORMING THE VENIPUNCTURE
SUCCESSFULLY
● Elderly patients’ veins have a tendency to
move or “roll” very easily.
● Use your thumb to gently pull the skin taut
and anchor the vein
● Avoid drawing from sclerosed or
“hardened” veins that have poor blood
flow.
APPLYING PRESSURE AT VENIPUNCTURE
SITE
● Apply pressure on the site for three to five
minutes or until the bleeding has stopped.
BANDAGING THE SITE
● Older patients also have thin, fragile skin
and thus an increased sensitivity to
standard adhesive bandages.
● Avoid using adhesive bandages.
 ● The preferred method is to apply paper
tape over folded gauze to make a
pressure bandage.
PATIENTS WITH SPECIAL NEEDS
Mentally and Physically Disabled Patients
● The phlebotomist should assess the
needs of the patient and employ others to
assist if necessary.
● For patients that do not understand you
when you try to explain the procedure, the
patient's caregiver can be asked to assist
by helping explain the procedure to the
patient in terms that the patient will
understand.
● The patient's caregiver is someone who
the patient trusts and someone who
knows how the patient will react.
● The phlebotomist should be as
non-threatening as possible when
communicating with special needs
patients.
● For a patient with physical disabilities, the
phlebotomist should try to modify the
environment to accommodate the
patient's needs.
● This may include lowering or heightening
the draw chair to accommodate patient
height and/or size or locate a more
appropriate collection place.
COMMUNICATION & INTERACTION WITH
PATIENTS
● communicating well could look like
keeping patients and donors calm while
drawing their blood, obtaining correct
information, and confirming that all patient
info is accurate
● Language Barrier (take necessary
translation assistance
INTERACTION WITH PATIENTS
1. Assess your body language.
2. Make your interactions easier for them..
3. Show them the proper respect.
4. Have patience.
5. Monitor your mechanics.
● Speak clearly and slowly, louder than you
usually do, but without yelling. Enunciate
complex words carefully, but use simple
language as much as possible.
6. Provide simple written instructions when
necessary; use graphics where possible.
7. Give your patients ample time to respond
or ask questions.
● This will strengthen your ability to provide
the best possible care for your patients
and make them feel like the valued
partners in their own care that they are.
● It will also improve their experience with
you and the nursing services provided by
your facility, which can be beneficial to
your patient satisfaction scores.
PHLEBOTOMY : 5 Common Mistakes
1. Drawing Blood from the Wrong Patient
2. Labelling Errors
3. Medical Lab Techs Should Know How to
Use Equipment Properly
4. Poor Phlebotomy Techniques
● drawing blood from the wrong vein,
● from an area that is prone to infection,
● shaking the tube too hard,
● not transferring blood using the proper
transfer devices.
● Shaking the blood tube too hard can lead
to inaccurate test results
5. Avoid Collection Problems as a
Phlebotomy Technician
● getting the order of the blood draw wrong
● collecting blood too late or too early
● not drawing enough blood so that an
accurate lab test can be run
PHLEBOTOMY : Adverse Reactions Handling
Hematoma:
● As soon as a hematoma is noted, remove
the needle and tourniquet and apply
pressure at the site for a minimum of 3
minutes put on a bandage or gauze with
tape and inform the patient of the
hematoma.
Arterial puncture
● Let the patient know there may be more
discomfort at the site than if the draw was
a venipuncture draw. C
Pain
● If the patient will complain that he/she
feels an electric shock going up his/her
 arm, immediately remove the needle
from the patient’s arm and put pressure
on the site.
● Ask the patient if the sensation has
stopped. If so, try to redraw at another
site if the patient is willing. Explain.
Nerve Damage:
● If the patient continues have these
symptoms, ask for one of our on-site
pathologists to meet with the patient or
get the patient to ED (Emergency
Department) and ask the staff there to
examine the patient for nerve damage.
● Comfort the patient and let them know we
cannot feel for nerves and this is a rare
out-come of venipuncture. E
Re-Bleed:
● Patients with some liver disease, vascular
diseases, clotting disorders, or
medications may complicate normal
clotting post a blood collection.
● Hot temperatures outside may cause a
site to re-bleed because the veins dilate
to cool the body.
● If the bleeding has not stopped, continue
to apply pressure. If bleeding still
continues, the patient may need to be
taken to ED
● He/she may need to see his/her own
doctor to evaluate the bleeding.
Allergy:
● Some patients may have itching or
burning at the collection site. Rashes or
hives may form near the site.
● If the patient passes out or stops
breathing call and get emergency care to
the patient.
● Phlebitis is inflammation of a vein.
● Thrombophlebitis is due to one or more
blood clots in a vein that cause
inflammation.
● causes pain and irritation and may block
blood flow in the veins.
● Superficial phlebitis affects veins on the
skin surface.
● This area may feel hard, warm, and
tender. The skin around the vein may be
itchy and swollen.
● The area may begin to throb or burn.
A low-grade fever may occur.
● If an infection is present, symptoms may
include redness, fever, pain, swelling, or
breakdown of the skin.
● Deep Vein Thrombosis affects the larger
blood vessels deep in the legs. Large
blood clots can form, which may break off
and travel to the lungs. This is a serious
condition called pulmonary embolism and
must be treated immediately by a doctor.
Vasovagal reaction:
● A reflex of the involuntary nervous system
that causes the heart to slow down
(bradycardia) and that, at the same time,
affects the nerves to the blood vessels in
the legs permitting those vessels to dilate
(widen).
● As a result the heart puts out less blood,
the blood pressure drops, and what blood
is circulating tends to go into the legs
rather than to the head.
● The brain is deprived of oxygen and the
fainting episode occurs.
● Stop collection immediately and help
control the patient to prevent injury.
● If the patient is moving to the floor,
verbally call out for help and gently help
the patient to the floor.
Anxiety/fear:
● Patients, especially children under the
age of 12 or mentally disabled person
● Take the time to explain to the patient
exactly what will happen at the patient’s
level of understanding.
● Ask care givers to assist with calming the
patient. Then seek out help to hold the
arm still during collection
● Use a focus point for the patient to look at
while you draw like a caregiver, a stuffed
animal, some stickers, or something else
in the room away from the site of
collection.
● Remain calm and comforting and put
yourself in the patient’s position to help
guide you in the collection.
● If the patient refuses, notify medical staff
immediately and wait for their direction
before trying to draw the patient. Seek out
caregiver/family member helps as
possible.
Patient Blood Volumes
 ● a. blood collections should be at minimal
levels and when large amounts are
required for testing, medical staff must be
made aware of how much the lab may
remove from a patient.
● Blood volume varies with the age of the
patient.
● As a rule of thumb, no more than 3-5% of
a patient’s total blood volume should be
drawn in one day.
● Always work with medical staff if there is
any question about how much blood
should be taken.
In summary, appropriate actions include:
1. Check the tourniquet is providing
sufficient venous engorgement
2. Removing collection system and starting
again at a different site
3. Obtaining support from a more
experienced practitioner.
4. Ask for help if you are unsure and keep
the patient’s safety foremost in your
decision making.
● Always work with doctors and nursing
staff who are directly caring for our
patients if there are any adverse reactions
or risk of overphlebotomizing a patient.
Responsibility of the phlebotomist in
infection control
● A phlebotomist’s primary role is to draw
blood as ordered by a physician.
Roles and Responsibilities
● Helping to check in patients when they
arrive
● Identifying the best needle size and
location for each blood draw
● Following proper infection control
procedures before drawing blood
● Ensuring the correct use of collection
tubes and containers for the requested
lab work
● Taking collected blood to the lab
● Keeping blood drawing supplies
well-stocked and organized
● Reporting any patient distress or
concerns to nursing staff
● Documenting information in patient
records
● Keeping medical records organized
● For Blood Bank Phlebotomy, drawn blood
shall be kept in designated,
temperature-controlled areas.
INFECTION CONTROL IN PHLEBOTOMY
● hand hygiene
● glove use / PPE
● skin antisepsis
● sterile, single-use blood-sampling devices
● sharps containers
● disinfection of surfaces and chairs
● cleaning and disinfection of tourniquets
● transportation of laboratory samples in
labeled, washable containers
BLOOD SPILLAGE
● Wear a pair of non-sterile gloves / PPE
● Use tongs or a pan and brush to sweep
up as much of the broken glass (or
container) as possible. Do not pick up
pieces with your hands.
● Discard the broken glass in a sharps
container .
● If this is not possible due to the size of the
broken glass, wrap the glass or container
in several layers of paper and discard it
carefully in a separate container. Do not
place it in the regular waste container.
● Use disposable paper towels to absorb as
much of the body fluids as possible.
● Wipe the area with water and detergent
until it is visibly clean.
● Saturate the area again with sodium
hypochlorite 0.5%. This is a 1:10 dilution
of 5.25% sodium hypochlorite bleach,
which should be prepared daily.
● Rinse off the tongs, brush and pan, under
running water and place to dry.
● Remove gloves/ PPE and discard them.
● Wash hands carefully with soap and
water, and dry thoroughly with single-use
towels.
● Record the incident in the incident book if
a specimen was lost, or persons were
exposed to blood and body fluids.