UNDERSTANDING PHLEBOTOMY

The phlebotomist is a member of the healthcare team and must demonstrate professional behavior at all times .

I. Evolution of Phlebotomy in Healthcare

Phlebotomy
 the drawing of blood
 has been practiced for centuries and is still one of the most common invasive procedures in health care
 each step in the process of phlebotomy affects the quality of the specimen and is thus important for preventing
laboratory error, patient injury and even death
 practice varies considerably between countries, and between institutions and individuals within the same
country

Stone Age
 Crude tools used to cut vessels & drain blood from body

Egypt (1400 BC)

 Tomb painting shows leech applied to patient for bloodletting

Hippocrates (460-377 BC)

 Health depended on balance of the body. Thought disease was due to excesses like blood, phlegm, black/yellow
bile
 Bloodletting was used to rid the body of evil spirits, cleanse the body.
o Venesection: cutting vein to bleed patient

Middle Ages
 Barber-surgeons performed bloodletting & leeching
o Barber pole (red & white): represented blood of patient
o Bleeding bowl: used to collect blood from patient

17th & 18th Centuries

 Phlebotomy became a major therapy
 Lancets & fleams were used to cut veins & arteries
 Cupping & leeching were used
 Art of Cupping
o Process
 Application of heated suction device, the cup
 Incision with a fleam (lancet)
 Single or double-edged blade
 Multiple fleams attached & folded for ease of carrying
 Blades wiped clean with a rag, therefore disease was spread from something that was suppose
to help.
 Leeching
o Process
 Place drop of milk or blood on the patient’s skin
 Introduce Hirudo medicinalis to the site that injects:
 Local vasodilator
 Local anesthetic
 Hirudin, an anticoagulant – Allow the leech to engorge and fall off
o Present day – Used in microsurgical replantation

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A. Staffing Strategies

Before the 1970s Through the 1970s The 1990s

and 1980s
Laboratorians Phlebotomists New management mantra:
(Medical Technologist (specimen collection a. convert one-skill phlebotomists to multiskilled “patient care
and their assistants) personnel) honed assistants”
were responsible for their skills a.1. vital signs
drawing blood a.2. ambulate patient
specimens Technical personnel a.3. bathe patients
sharpened their a.4. perform other patient care functions
The mantra: focus on analysis
a. keep higher-paid Effects of additional responsibilities to the phlebotomists:
testing personnel a. dissatisfied
b. conducting b. deterioration of specimen quality (increase in
technical aspects of unacceptable specimens)
laboratory medicine c. deterioration on the quality of venipuncture performed to the
c. create lower-paying patient
positions to draw and
prepare the Action done:
specimens a. phlebotomy
a. 1. bringing blood collection practices back within the control
of the laboratory
a.2. reinstituting laboratory-based phlebotomy positions or
decentralized phlebotomy
b. clinical technician
b.1. laboratory-based
b.2. responsible for specimen collection, IV insertion, Holter
monitor application, and ECGs

B. Phlebotomy in a Multiskilled Work Force

“Phlebotomy expertise is directly proportional to the frequency of performance and length of training .”

 Adequate training helps ensure accurate results and minimizes the negative outcomes
o Patients are less likely to suffer direct injuries or treatments based on inaccurate results
 Establish and maintain high standards for specimen collection personnel
 Fully understand the impact that inadequately trained staff can have on patient care
 In 2002, the State of California formally recognized the importance of a comprehensive phlebotomy training
program
o phlebotomists become certified
o those without expertise undergo 80 hours of training followed by 50 supervised venipunctures

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Risks of Phlebotomy
i. Preanalytical Errors
Failure to properly identify the patient
or label the specimen
Underfilling collection tube
Additive carry-over due to
incorrect order of draw
Specimen was not protected
from light
Underfilling blood culture bottles
Failure to properly cleanse
venipuncture site
Prolonged tourniquet application
Failure to inquire about patient
allergies to latex
Failure to label the specimen at the
patient’s side
Pouring contents of one tube into another
Delay in transporting / testing
coagulation specimens
Patient allowed to pump fist
Specimen drawn above IV
Inadequate discard volume drawn when
collecting blood through vascular
access device
ii. Errors That Injure Patient
Arterial nick and/or inadequate pressure
applied to venipuncture site
Lack of knowledge of the anatomy of the
antecubital area
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Negative Patient Outcome
Transfusion or medication-related death. Patient mismanagement
Coag tube: Stroke/ hemorrhage due to unnecessary modification of
blood thinner dosage
EDTA tube: Patient mismanagement from falsely decreased results
Cardiac arrhythmia
Seizure and death due to falsely elevated potassium serum
Falsely lower result prevents physician intervention. Newborn suffers
irreversible brain damage
Death from septicemia due to false-negative result
False-negative blood culture leads to unnecessary administration
of antibiotic / extended length of hospitalization
Seizure and death due to falsely elevated potassium level
Cardiac arrhythmia
Undetected anemia
Sensitization / Anaphylactic shock
Transfusion or medication – related death. Patient mismanagement
Stroke / hemorrhage due to unnecessary modification of blood thinner
dosage. Patient mismanagement from altered results
Stroke / hemorrhage due to modification of blood thinner dosage
based on inaccurate aPTT result
Cardiac arrhythmia
Seizure and death due to falsely elevated potassium level
Patient mismanagement
Patient death / mismanagement
Stroke / hemorrhage due to modification of blood thinner dosage
based on inaccurate coagulation results. Patient mismanagement
from altered results
Hemorrhage that leads to nerve injury, compartment syndrome or
limb amputation
Permanent, disabling nerve injuries
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Bandage applied to heelstick Newborn choking death

Failure to anticipate syncope Fractures, contusions, concussions, paralysis

Failure to inquire about patient Sensitization / Anaphylactic shock

Drawing from the side of a mastectomy Lymphedema

Excessive needle manipulation Permanent, disabling nerve injuries / arterial laceration

Failure to survey both arms for Impaling median nerve while attempting to access basilic vein
medial vein when safer vein was available / permanent nerve injury

Failure to use a tourniquet Permanent nerve injury while attempting to access basilica vein
when safer vein was available, but not made evident

Excessive angle of the needle insertion Needle penetrates through vein, into nerve or artery
Permanent, disabling nerve injuries / arterial puncture

Failure to remove needle upon Permanent, disabling nerve injuries

shooting pain sensation

iii. Errors That Cause Employee Injury

Accidental needlestick Acquiring HIV, hepatitis, or any of 20 of disease known to be
transmitted by blood exposure

Exposure to breaks in skin from drawing Acquiring HIV, hepatitis, or any of 20 of disease known to be
or processing blood without gloves transmitted by blood exposure

Repeated use of latex gloves / tourniquets Sensitization / Anaphylactic shock

Improper ergonomics when Back injuries

positioning patient

II. Phlebotomy’s Role in Healthcare

 seventy percent (70%) of the objective information the physician receives on the patient’s status comes from
results of tests performed
 the quality of the test result is partially dependent on precise laboratory instrumentation and highly sensitive
test methodologies
 diligently adhere to the standards and facility’s policies to ensure that testing personnel can extract an accurate
result from the specimen
 vital in the medical field
o safety monitoring: conform to precautionary and sterile procedures in dealing with blood and needles,
injuries, and dissemination of blood borne illnesses
o patient relation: entrusted in assuring the patient gets through the process in calm and painless manner
o blood extraction: follow a standard operating procedure such as identifying a patient by full name, date
of birth, and cross-checking work order details with information in the hospital bracelet
o records retention: maintain patient and laboratory records updated
o supplies management: monitor, organize, and retain supplies and equipment use in good condition
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III. Traits that Form the Professional Image of the Phlebotomist
A. Best practices in phlebotomy involve the following factors:
 planning ahead
o most important part of carrying out any procedure
o done at the start of a phlebotomy session

 using an appropriate location

o should work in a quiet, clean, well-lit area, whether working with outpatients or inpatients

 quality control
o an essential part of best practice in infection prevention and control
o helps to minimize the chance of a mishap

Elements of quality assurance in phlebotomy

Element Notes
Education and training understanding of anatomy, awareness of the risks from blood exposure, and
the consequences of poor infection prevention and control
Standard operating required for each step or procedure (should be written and be readily
procedures (SOPs) available to health workers)
For blood donation, the identity of the donor should be accurately matched
to the results of screening tests.
Correct identification of the
patient For blood sampling, after samples have been taken from a patient or donor,
a system of identification and tracking is essential to ensure that the sample
is correctly matched with the result and with the patient or donor.
The condition of the sample the quality of the results is satisfactory
Safe transportation improve the quality of results from laboratory testing
A system is required for reporting all adverse events. A log book or register
An incident reporting system should be established with accurate details of the incident, possible causes
and management of adverse events.

 standards for quality care for patients and health workers, including:
o availability of appropriate supplies and protective equipment
o availability of post-exposure prophylaxis (PEP)
o avoidance of contaminated phlebotomy equipment
o appropriate training in phlebotomy
o cooperation on the part of patients

 quality of laboratory sampling

o Factors that influence the outcome of laboratory results during collection and transportation include:
 knowledge of staff involved in blood collection
 use of the correct gauge of hypodermic needle to prevent haemolysis or abnormal results
 the anatomical insertion site for venipuncture
 the use of recommended laboratory collection tubes
 patient–sample matching (i.e. labelling)
 transportation conditions
 interpretation of results for clinical management

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B. Key Qualities of a Good Phlebotomist
 Hand-eye coordination
o need to focus and draw blood right the first time
 When doesn’t happen, may cause the patient a lot of anxiety
 Compassion
o be very empathetic, speaking kindly to patients and reassuring them that everything will be ok
 Detail oriented
o involves identifying the patient correctly, following the right venipuncture procedures, using the correct
labels and accurate database entry
 Team player
o works with other medical staff to ensure that each patient gets the right treatment
 Patience
o some of the patients may not be very easy to work with

IV. The Different Types of Healthcare Settings

Types of Health Care Facilities
Hospital
Ambulatory Surgical Center
Doctor’s Office
Urgent Care Clinic
Nursing Home
Services offered and description
- primary task is to provide short-term care for people with severe health issues;
- bring together healthcare providers
- offer a safe environment for the surgery and basic monitoring during the initial
post-operation hours;
- less expensive
- focused on one type of medicine
- provide routine care as well as treatment for acute conditions
- walk-in clinics that offer outpatient care immediately
- designed for patients who require constant care but do not need to be hospitalized
and cannot be cared for at home
- often associated with seniors who require custodial care
-offers help with basic tasks that can be challenging for individuals with health issues
(e.g. feeding, bathing, and dressing)

V. Basic Concepts of Communication to Healthcare Settings

 Communication
o The means by which information is exchanged or transmitted
o Components
 Verbal
 Active listening
 Nonverbal (body language)
 Kinesics: study of nonverbal communication
 Proxemics: study of an individual’s concept and use of space
 Appearance
 Touch: special type of nonverbal communication
o Elements of Effective Healthcare Communication
 Empathy
 Control: patient’s sometimes need to feel in control of their situation.
 Respect & confirmation
 Trust

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