PRE-ANALYTICAL CONSIDERATION AND

VENIPUNCTURE COMPLICATIONS

• Venipuncture – most frequent method

PRE-ANALYTICAL CONSIDERATION (for venipuncture):

- According to the CLSI, a standardized venipuncture
procedure can reduce or eliminate errors that can affect
sample quality and patient test results.
➢ 5 FACTORS TO CONSIDER:
1. Requisition form
- All phlebotomy procedures begin with the receipt of a
test requisition form that is generated by or at the
request of a health-care provider
- The requisition becomes part of the patient’s medical
record and is essential to provide the phlebotomist with
the information needed to correctly identify the patient,
organize the necessary equipment, collect the
appropriate samples, and provide legal protection
- Phlebotomists should carefully examine all requisitions
for which they are responsible before leaving the
laboratory
- Requisitions from outpatients may be hand carried by
the patient
▪ INFORMATION REQUIRED:
a. Patient’s first and last names
b. Identification number (In-patient:
hospital generated; in an outpatient
setting it may be a laboratory-assigned
number.)
c. Patient’s date of birth
 d. Patient’s location
e. Ordering health-care provider’s name
f. Tests requested
g. Requested date and time of sample
collection
h. Status of Sample (STAT, Timed,
Routine)
▪ OTHER INFORMATION:
a. Number and type of collection tubes
b. Special collection information (fasting
sample or latex sensitivity)
c. Special patient information (areas that
should not be avoided)
d. Billing information
2. Greeting the patient
- A phlebotomist’s professional demeanor instills
confidence and trust in the patient, which can
effectively ease patient apprehension about the
procedure
- When approaching patients, phlebotomists should
introduce themselves, say that they are from the
laboratory, and explain that they will be collecting a
blood sample
- The procedure must be explained in nontechnical terms
and in a manner the patient can understand
- The more relaxed and trusting your patient, the greater
chance of a successful atraumatic venipuncture
- Observe any signs on the patient’s door or in the
patient’s room relaying special instructions, such as
Allergic to Latex, Nothing by Mouth (NPO), Do Not
Resuscitate (DNR), Do Not Draw Blood from (a
particular) arm, Infection Control Precautions, orPatient
Expired.
 SPECIAL SITUATION
Sleeping Patients
Unconscious Patients
Psychiatric Units
• Should be gently
awakened and given time
to become oriented and
have their IDENTITY
VERIFIED before the
venipuncture is
performed and secure
their INFORMED
CONSENT.
• Blood collection from a
SLEEPING PATIENT may
result in identification
errors or physical injury
to the patient and result
in a charge of assault and
battery (Informed
Consent).
• Unconscious patients
should be greeted in the
same manner as
conscious patients.
• In this circumstance,
nursing personnel are
often present and can
assist with the patient, if
necessary.
• It is usually preferable to
have a nurse assist with
patients on the
psychiatric unit.
• These patients are often
anxious about the

Physicians, Clergy, Visitors
Unavailable Patient
venipuncture procedure
and feel more
comfortable when a
caregiver with whom
they are familiar is
present.
• Be sure to place blood
collection equipment
away from the patient.
• Physicians, members of
the clergy, and visitors
may be present when the
phlebotomist enters the
room.
• When the physician or
clergy member is with
the patient, it is
preferable to return at
another time, unless the
request is for a stat or
timed sample.
• Patients are not always in
the room when the
phlebotomist arrives.
• The phlebotomist should
attempt to locate the
patient by checking with
the nursing station.
• If the sample must be
collected at a particular
time, it may be possible
to draw blood from the
patient in the area to
 which he or she has been
taken.
• If this is not possible, the
nursing station must be
notified, and the
appropriate forms
completed so that the
test can be rescheduled.
• The requisition form is
usually left at the nursing
station.

3. Patient identification
- The most important procedure in phlebotomy is correct
identification of the patient.
- Serious diagnostic or treatment errors and even death
can occur when blood is drawn from the wrong patient.
- The Clinical and Laboratory Standards Institute (CLSI)
recommends two identifiers for patient identification.
- To ensure that blood is drawn from the right patient,
identification is made by comparing information
obtained verbally and from the patient’s wrist ID band
with the information on the requisition form.
- Discrepancies between the patient’s ID band the
requisition must be verified before blood is drawn. It is
estimated that 16 percent of ID bands contain
erroneous information.
- CLSI requires that a caregiver or family member must
provide information on a cognitively impaired patient’s
behalf before collecting the sample. Document the
name of the verifier.
 ➢ BAR CODE TECHNOLOGY
- Positive patient identification can be
made using barcode technology.
- Using a wireless hand-held computer,
the phlebotomist positively identifies
the patient by scanning the bar code on
the patient’s hospital ID band.
- The system, which is interfaced with the
laboratory information system (LIS).
SPECIAL SITUATION
Missing ID Band • The phlebotomist must
contact the nurse and
request that the patient
be banded before the
drawing of blood.
• The nurse’s signature on
the requisition form
verifying identification
should be accepted in
only emergency
situations or according to
hospital policy.
• Patients in psychiatric
units often do not wear
an identification band.
Unidentified Emergency • Both the temporary and
Department Patients permanent identification
band must be attached to
the patient and
confirmed before blood
may be collected.
Identification of Young, • Ask the patient’s nurse,
Cognitively Impaired, or relative, or a friend to
Patients Who Do Not Speak identify the patient by
the Language name, address, and
identification number or
date of birth.
• Document the name of
the verifier.
• This information must be
compared with the
information on the
requisition and the
patient’s identification
band.
• Any discrepancies must
be resolved before
collecting the sample.

4. Patient preparation
- The pre-examination stage of laboratory testing involves
processes that occur before testing of the specimen.
- Errors that occur during this stage often happen during
blood collection and are primarily controlled by the
phlebotomist.
- The phlebotomist should also be able to recognize
various patient conditions and complications that may
occur during or after blood collection.
- Numerous pre-examination variables associated with
the patient’s activities before sample collection can
affect the quality of the sample.
- Variables: Diet, Posture, Exercise, Stress, Alcohol,
Smoking, Time of Day, Medications, Fever, Age,
Dehydration, Pregnancy, Altitude, Gender, Malnutrition
 ➢ BASAL STATE
- It refers to an early morning condition
before the patient has eaten or become
physically active.
- This is a good time to draw blood
specimens because the body is at rest and
food has not been ingested during the
night.
- Normal values (reference ranges) for
laboratory tests are determined from a
normal, representative sample of
volunteers who are in a basal state.
MAJOR TESTS AFFECTED BY PATIENT PRE-EXAMINATION VARIABLES
VARIABLES INCREASE VALUES DECREASE
VALUES
Non-fasting Glucose,
Triglycerides, AST,
Bilirubin, BUN,
Phosphorus, Uric
Acid, Growth
Hormone,
Cholesterol, HDL, LDL
Prolonged Bilirubin, Ketones, Glucose, Insulin,
Fasting Lactate, Fatty Acids, Cholesterol
Glucagon, and
Triglyceride
Recent Food Glucose, Insulin, Chloride,
Ingestion Triglycerides, Ionized Phosphorus,
Calcium & Gastrin potassium,
Amylase& ALP
Posture Albumin,aldosterone,
bilirubin, calcium,
cortisol, enzymes,
 cholesterol, TAGs,
RBCs, WBCs
Short-term Creatinine, fatty Arterial pH and
exercise acids, lactate, AST, PCO2
CK, LDH, uric acid,
bilirubin, HDL,
hormones,
aldosterone, renin,
angiotensin, WBCs
Long-term Aldolase, creatinine,
exercise sex hormones, AST,
CK, and LD
Stress Adrenal hormones, Serum iron and
aldosterone, renin, PCO2
TSH, GH, prolactin,
PO2, and WBCs
Alcohol GGT, Glucose, Testosterone
aldosterone,
prolactin, cortisol,
cholesterol, TAGs,
LH, catecholamine,
AST, ALT, Mean
Corpuscular Volume
(MCV), HDL, and iron
Caffeine Fatty acids, hormone
levels, glycerol,
lipoproteins, and
serum gastrin
Smoking Glucose, BUN, TAGS, Immunoglobulins
cholesterol, ALP, IgA, IgG, IgM
catecholamines,
cortisol, hemoglobin,
 hematocrit, RBCs,
and WBCs
Altitude RBCs, hemoglobin,
and hematocrit
Age Cholesterol and Hormones
triglycerides
Pregnancy Protein, ALP,
estradiol, free fatty
Dehydration Calcium, coagulation
factors, enzymes,
iron, RBCs, and
sodium
Diurnal ACTH, Cortisol, iron Eosinophils,
Variation (A.M.) & aldosterone creatinine, TAGs
Diurnal ACP, GH, PTH, TSH
Variation (P.M.)
Malnutrition ketones, bilirubin, glucose,
lactate, and cholesterol,
triglycerides thyroid
hormones, total
protein, and
albumin
Fever insulin, glucagon, and
cortisol levels.

MAJOR TESTS AFFECTED BY PATIENT MEDICATION

MEDICATION AFFECTED TEST
Acetaminophen and certain Elevated liver enzymes and
antibiotics bilirubin
Cholesterol-lowering drugs Prolonged PT and APTT
Certain antibiotics Elevated BUN, creatinine,
and electrolyte imbalance
Corticosteroids and estrogen
diuretics
Diuretics
Chemotherapy
Aspirin, salicylates, and
herbal time supplements
Radiographic contrast media
Fluorescein dye
Oral contraceptives
Prolonged Tourniquet
Application
Hemolysis
IM Injection
Cleansing Agents (Betadine)
Elevated amylase and lipase
Increased calcium, glucose,
and uric acid and decreased
sodium and potassium
Decreased RBCs, WBCs, and
platelets
Prolonged PT and bleeding
Routine urinalysis
Increased creatinine, cortisol,
and digoxin
Decreased apoproteins,
transcortin, cholesterol,
HDL, triglycerides, LH, FSH,
ferritin, and iron
Albumin, Enzymes, Lactate,
Cholesterol, K, TP, AST,
Bilirubin
K, Ammonia, Phosphate,
Iron, Mg, ALT, AST, LD, ALP,
CK
Creatinine Kinase, LDH
Phosphorus, Uric Acid &
Potassium

5. Site selection
- The preferred site for venipuncture is the antecubital
fossa located anterior and below the bend of the elbow.
- Three major veins—the median cubital, the cephalic,
and the basilic—are located in this area and, in most
patients, at least one of these veins can be easily
located.
- Vein patterns vary among individuals. The most often
seen arrangement of veins in the antecubital fossa are
referred to as the “H-shaped” and “M-shaped” patterns.
 SPECIAL SITUATIONS IN PHLEBOTOMY
SITUATION APPROPRIATE COURSE OF
ACTION
IV Use opposite arm or
perform fingerstick, if
possible; otherwise, have
nurse turn off IV for 2 min,
apply tourniquet below IV,
use different vein (if
possible). Document
location of IV &
venipuncture, type of fluid
Fistula Draw from opposite arm
Indwelling lines & catheters, Usually not drawn by lab,
heparin locks, cannulas first 5 mL drawn should be
discarded. Lab may draw
heparin, lock, if nothing is
being infused
Sclerosed veins Select another site
Hematoma Draw below
Streptokinase/tissue
plasminogen activator (TPA)
Edema
Scars, burns, tattoos
Mastectomy
Patient refuses
Unidentified patient
Minimize venipuncture.
Hold pressure until bleeding
has stopped
Select another site
Select another site
Draw from opposite arm
Try to persuade. If
unsuccessful, notify nurse.
Never draw without
consent; could lead to
charges of assault & battery
Ask nurse to ID before
drawing

SPECIAL SITUATIONS IN PHLEBOTOMY

IV Line on both Arms - Discontinue IV for 2
minutes
- Collect sample below the
IV site
- Initial sample (5mL)
→discard
IV Fluid Contamination - Increased: Glucose (10%
contamination w/ 5%
dextrose →I
Increased blood glucose
by 500 mg/dL) Chloride,
Potassium, Sodium
- Decreased: Urea,
Creatinine