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 o
Blood Specimen Collection from Basic to Advanced
Diana Garza
Kathleen Becan-McBride
VI Contents

Competency Assessment 244 Case Study 276

References 246 Action in Practice 276
Resources 246 Competency Assessment 276
References 277
Resources 277
PART III Phlebotomy Equipment
and Procedures CHAPTER 9 Preexamination/Preanalytical
Complications Causing Medical
CHAPTER 8 Blood Collection Equipment
Errors in Blood Collection 278
for Venipuncture and Capillary
Chapter Objectives 278
Specimens 247
Key Terms 278
Chapter Objectives 247 Categories of Preanalytical Variables 279
Key Terms 247 Basal State 279
Introduction to Blood Collection Equipment 248 Diet 280
Venipuncture Equipment 248 Turbid or Lipemic Serum 280
Blood Collection Tubes and Additives 251 Obesity 281
Anticoagulants and Preservatives 252 Damaged, Sclerosed, or Occluded Veins 281
Yellow-Topped Tubes and Vacuum Culture Vials 253 Thrombosis 281
Light-Blue-Topped Tubes 254 Allergies 281
Serum Separation Tubes (Mottled-Topped, Speckled- Exercise 281
Topped, and Gold-Topped Tubes) 254 Stress 282
Rapid Serum Tubes (RST) 254 Diurnal (Circadian) Rhythms and Posture 283
Red-Topped Serum Tubes 254 Travel Issues Affecting Laboratory Results 283
Clear-Topped Tubes, White-Topped Tubes, and RedfLight Age 283
Gray Tubes 255 Mastectomy 284
Green-Topped Tubes and Plasma Separation Tubes (Light- Edema 284
Green, Mottled Gray/Green-Topped Tubes) 255
Menstrual Cycle 284
Purple (Lavender)-Topped Tubes 256
Medications 284
Pink-Topped Tubes 256
Interference of Drugs and Other Substances in Blood 284
Gray-Topped Tubes 256
Infections 286
Royal-Blue-Topped and Tan-Topped Tubes 257
Vomiting 286
Black-Topped Tubes 257
Other Factors Affecting the Patient 286
Molecular Diagnostics Tubes 257
Complications Associated with Test Requests and
Tube Organizer 257 Identification 286
Safety Syringes 258 Identification Discrepancies 286
Safety Needles/Holders 259 Time of Collection 287
The Butterfly Needle (Blood Collection Set) 261 Requisitions 287
Needle and Other Sharps Disposal 262 Complications Associated with the Specimen Collection
Tourniquets 264 Procedure 287
Venoscope, the Vein Finder 265 Tourniquet Pressure and Fist Pumping 287
AccuVein 265 Failure to Draw Blood 287
Gloves for Blood Collection 266 Backflow of Anticoagulant 288
Antiseptics, Sterile Gauze Pads, and Bandages 266 Fainting (Syncope) 289
Microcollection Equipment 267 Hematomas 289
Lancets and Tubes 267 Petechiae 290
Blood-Drawing Chair 272 Excessive Bleeding 290
Specimen Collection Trays 273 Nerve Complications 291
Self Study Seizure during Blood Collection 291
Study Questions 275 Hemoconcentration 291
 Contents vii

Intravenous Therapy 291 Procedure 10-8 Syringe Method 340

Hemolysis 292 Failure to Collect Blood after a Puncture 342
Collapsed Veins 293 Order of Draw for Blood Collection Tubes 343
Improper Collection Tube 293 Manufacturers of Blood Collection Tubes 345
Self Study Specimen Identification and Eabeling 345
Study Questions 295 Caringfor the Puncture Site 347
Case Study 296 Disposal of Used Supplies and Equipment 347
Action in Practice 1 296 Patient Assessment at the End of the Venipuncture
Action in Practice 2 296 Procedure 348
Competency Assessment 297 Other Issues Affecting Venipuncture Practices 348
References 297 Self Study
Resources 298 Study Questions 353
Case Study 1 354
CHAPTER 10 Venipuncture Procedures 299 Case Study 2 354
Action in Practice 354
Chapter Objectives 299
Competency Assessment 355
Key Terms 299
References 358
Blood Collection 300
Resources 358
Health Care Worker Preparation 300
Procedure 10-1 Preparing for the Patient Encounter 302
Procedure 10-2 Hand Hygiene and Gloving CHAPTER 11 Capillary Blood
Technique 305
Specimens 359
Precautions 307
Needlestick Prevention Strategies 307 Chapter Objectives 359
Approaching, Assessing, and Identifying the Patient 309 Key Terms 359
Initial Introduction and Patient Approach 309 Indications for Skin Puncture 360
Physical Disposition of the Patient 309 Composition of Capillary Blood 361
Positioning of the Patient and the Health Care Basic Technique for Collecting Diagnostic Capillary Blood
Worker 312 Specimens 362
Test Requisitions 314 Preparation for Skin Puncture 362
Patient Identification Process 314 Supplies for Skin Puncture 362
Procedure 10-3 Basics of Patient Identification 315 Skin Puncture Sites 364
Special Considerations 317 Improving Site Selection 364
Identity Errors are Preventable 318 Cleansing the Skin Puncture Site 366
Equipment Selection and Preparation 319 Skin Puncture Procedure 366
Supplies for Venipuncture 319 Procedure 11-1 Acquiring a Capillary Blood Specimen
Venipuncture Site Selection 319 (Skin Puncture) Using a Retractable Safety
Tools to Make Difficult Veins More Prominent 325 Device 367
Tourniquet Application 326 Order of Collection 370
Procedure 10-4 Use of a Tourniquet and Vein Blood Films for Microscopic Slides 372
Palpation 326 Procedure 11-2 Blood Smears/Films for Microscopic
Procedure 10-5 Decontamination of the Puncture Site 328 Slides 372
Decontamination of the Puncture Site 329 Other Considerations for Capillary Blood Samples 375
Venipuncture Methods 329 Differences in Venous Specimen Test Results 375
Evacuated Tube System and Winged Infusion System, or Microhematocrit and Other Hematology
Butterfly Method 329 Specimens 375
Procedure 10-6 Performing a Venipuncture Using the Blood pH and Blood Gas Determinations 375
Evacuated Tube Method 330 Completing the Interaction 375
Procedure 10-7 Hand Vein Venipuncture Using a Disposal 375
Winged Infusion/Butterfly Set 336 Eabeling 375
Syringe Method 339 Completing the Patient Interaction 376
VIII Contents

Self Study Room Location 410

Study Questions 377 Equipment Preparation for a Friendlier
Case Study 1 378 Environment 410
Case Study 2 378 Positions for Restraining a Child 410
Action in Practice 378 Combative Patients 411
Competency Assessment 378 Decreasing the Needlestick Pain 412
References 380 Oral Sucrose 412
Resources 380 Precautions to Protect the Child 413
Latex Allergy Alert 413
CHAPTER 12 Specimen Handling, Pediatric Phlebotomy Procedures 413
Transportation, and Microcapillary Skin Puncture 413
Procedure 13-1 Heel Stick Procedure 415
Processing 381
Capillary Blood Gases 419
Chapter Objectives 381 Procedure 13-2 Collection for Capillary Blood Gas
Key Terms 381 Testing 420
Specimen Handling After the Venipuncture 382 Neonatal Screening 422
Specimen Delivery Methods 388 Procedure 13-3 Collection of Capillary Blood for
Hand Delivery 388 Neonatal Screening 423
Pneumatic Tube Systems 389 Fingerstick on Children 425
Transportation by Automated Carrier 390 Venipuncture on Children 426
Processing the Specimen on Arrival at the Clinical Collecting Bloodfrom TV Fines 428
Laboratory 390 Procedure 13-4 Procedure for Heparin or Saline Lock
Shipping Biohazardous Specimens 390 Blood Collection 429
Reporting Laboratory Results 399 Procedure 13-5 Procedure for Central Venous Catheter
Written Reports 399 Blood Collection 430
Verbal Reports 400 Geriatric Patients 432
Computerized Reports 400 Considerations in Home Care Blood
Collections 433
Self Study
Self Study
Study Questions 401
Study Questions 436
Case Study 1 402
Case Study 437
Case Study 2 402
Action in Practice 437
Action in Practice 402
Competency Assessment 437
Competency Assessment 403
References 438
References 404
Resources 439
Resources 404

CHAPTER 14 Point-of-Care
PART IV Point-of-Care Testing and Special
Collections 440
Procedures
Chapter Objectives 440
CHAPTER 13 Pediatric and Geriatric Key Terms 440
Procedures 405 Glucose Monitoring 442
Procedure 14-1 Obtaining Blood Specimen for Glucose
Chapter Objectives 405 Testing (Skin Puncture) 444
Key Terms 405 Quality in Point-of-Care Testing and Disinfecting POCT
Pediatric Patients 406 Analyzers 446
Age-Specific Care Considerations 406 Blood Gas and Electrolyte Analysis 448
Preparing Child and Parent 406 Point-of-Care Testing for Acute Heart Damage 449
Psychological Response to Needles and Pain 409 White Blood Cell Count System 449
Distraction Techniques 410 Blood Coagulation Monitoring 449
Hematocrit, Hemoglobin, and Other Hematology Collection of Donor's Blood 480
Parameters 450 Autologous Transfusion 481
Cholesterol Screening 451 Therapeutic Phlebotomy 481
Other POCT Tests and Future Trends 451 Self Study
Self Study Study Questions 483
Study Questions 452 Case Study 484
Case Study 453 Action in Practice 484
Action in Practice 453 Competency Assessment 484
Competency Assessment 453 References 485
References 454 Resources 486
Resources 454

CHAPTER 16 Urinalysis, Body Fluids,

CHAPTER 15 Blood Cultures, Arterial, and Other Specimens 487
Intravenous (IV), and
Chapter Objectives 487
Special Collection
Key Terms 487
Procedures 455 Urine Collection 488
Chapter Objectives 455 Single-Specimen Collection 490
Key Terms 455 Procedure 16-1 Clean-Catch Midstream
Blood Cultures 456 Urine Collection Instructions
for Women 492
Possible Interfering Factors 456
Procedure 16-2 Clean-Catch Midstream Urine
Procedure 15-1 Site Preparation for Blood Culture
Collection Instructions for Men 493
Collection 457
Timed Urine Collections 493
Procedure 15-2 Safety Syringe Blood Culture
Collection 459 Procedure 16-3 Collecting a 24-Hour Urine
Specimen 494
Procedure 15-3 Safety Butterfly Assembly Blood
Culture Collection 461 Urine Cytology 495
Procedure 15-4 Evacuated Tube System for Blood Cerebrospinal Fluid 495
Culture Collection 462 Fecal Specimens 496
Procedure 15-5 After Blood Culture Collection by the Seminal Fluid 497
Previous Methods 463 Amniotic Fluid 497
Glucose Tolerance Test (GTT) 464 Synovial Fluid 497
Postprandial Glucose Test 467 Other Body Fluids 497
Modified Oral Glucose Tolerance Test 467 Culture Specimens 498
Lactose Tolerance Test 467 Buccal Swabs 498
Arterial Blood Gases 468 Sputum Collection 498
Radial Artery Puncture Site 468 Procedure 16-4 Collecting a Sputum Specimen 499
Brachial and Femoral Artery Puncture Sites 468 Nasopharyngeal Culture Collections 500
Procedure 15-6 Radial ABG Procedure 470 Throat Swab Collections 500
Therapeutic Drug Monitoring (TDM) 473 Procedure 16-5 Collecting a Throat Swab
Collection for Trace Metals (Elements) 475 for Culture 501
Genetic Molecular Tests 475 Skin Tests 502
Intravenous Line Collections 475 Gastric Analysis 503
Collecting Blood Through a Central Venous Breath Analysis for Peptic Ulcers 504
Catheter 476 Sweat Chloride by Iontophoresis 504
Procedure 15-7 Collecting Blood through a CVC 476 Self Study
Cannulas and Fistulas 479 Study Questions 505
Donor Room Collections 479 Case Study 506
Donor Interview and Selection 479 Action in Practice 506
Contents

Competency Assessment 506 Appendix 2 Finding a Job 534

References 507 Appendix 3 International Organizations 539
Resources 507 Appendix 4 The Basics of Vital Signs 540
Procedure A4-1 Taking Oral Temperature 541
CHAPTER 17 Drug Use, Forensic Procedure A4-2 Taking Aural Temperature 542
Toxicology, Workplace Procedure A4-3 Taking Axillary Temperature 543
Testing, Sports Medicine, Procedure A4-4 Assessing Peripheral Pulse
Rate 544
and Related Areas 508
Procedure A4-5 Taking Blood Pressure 546
Chapter Objectives 508 Procedure A4-6 Assessing Respiration Rate 550
Key Terms 508 Appendix 5 Centers for Disease Control and
Overview and Prevalence of Drug Use 509 Prevention (CDC) Guideline for Hand
Drug Analysis: Rationale, Methods, and Hygiene in Health Care Settings 551
Interferences 513 Appendix 6 Common Laboratory Assays, Tube
Forensic Toxicology Specimens 515 Requirements, and Reference
Intervals 555
Chain of Custody 517
Appendix 7 Guide for Maximum Amounts of Blood
Workplace Drug Testing 517
to Be Drawn from Patients Younger than
Tampering with Specimens 522 Age 14 561
Drug Testing in the Private Sector 523 Appendix 8 Standard Operating Procedures (SOPs)
Drug Use in Sports 524 for Donor Phlebotomy 562
Blood Doping and the Use of Erythropoietin (EPO) 524 Appendix 9 Units of Measurement and
Neonatal Drug Testing 524 Symbols 573
Blood Alcohol and Breath Testing 525 Appendix 10 Formulas, Calculations, and Metric
Future Trends 527 Conversion 575
Self Study Appendix 11 Military Time (24-Hour Clock) 578
Study Questions 528 Appendix 12 Basic Spanish for Specimen Collection
Case Study 1 528 Procedures 579
Case Study 2 529 Appendix 13 Competency Assessment Tracking
Sheet 582
Action in Practice 529
Appendix 14 Answers to Study Questions,
Competency Assessment 529
Case Studies, and Competency
References 530 Checklists 589
Resources 530
Glossary 606
Appendix
Appendix 1 NAACLS Phlebotomy Competencies Index 620
and Matrix 532
About the Authors

Diana Garza received her Bachelor of Science degree in Biology from Vanderbilt
University in Nashville, Tennessee, followed by an additional year to complete her
Medical Laboratory Science certification requirements at Vanderbilt University Medical
Center. Her interest in laboratory sciences and in teaching led her to earn a Masters
in Science Education at the Peabody School of Vanderbilt University. She worked at
Vanderbilt Medical Center in the Microbiology Department while a graduate student.
A move back to her home state of Texas led her to a collaborative graduate program
with Baylor College of Medicine at the University of Houston, and resulted in her
Doctorate of Education in Allied Health Education and Administration, all while she
worked in the Microbiology Laboratory at the University of Texas M. D. Anderson
Cancer Center (MDACC). Her laboratory and teaching experience continued at the
University of Texas Health Science Center at Houston and for many years at MDACC,
where she later became the Administrative Director of the Division of Laboratory Med­
icine. While in Houston, Drs. Garza and Becan-McBride were involved in numerous
courses for technologists, nurses, and physicians to teach phlebotomy techniques. As
young faculty members, they began to develop curriculum materials for their own
use, and in 1984 collaborated in publishing one of the first comprehensive textbooks
focused solely on phlebotomy pracitices. Their successful coauthoring partnership has
endured for over two decades. In 1990, Dr. Garza joined the faculty of Texas Woman's
University-Houston Center, where she taught Internet-based quality improvement
courses and became editor of several journals and continuing education publications.
She has taught extensively; been a reviewer /inspector in many regulatory processes;
participated in accreditation procedures; and authored, edited, and published numer­
ous manuscripts in the field of phlebotomy, health care, and quality management. She
has been on numerous health care advisory boards and nationwide committees, includ­
ing those for certification examinations, and served as a consultant for companies and
health care organizations. She continues her writing and editorial pursuits primarily
in the field of phlebotomy.

Kathleen Becan-McBride is Director of Community and Educational Outreach at The

University of Texas Health Science Center at Houston (UTHealth) and tenured Medical
School Professor in the Department of Family and Community Medicine at UTHealth.
She received her Bachelor of Science degree in Biology from University of Houston
with completion of her medical laboratory science education at St. Luke's Episcopal
Hospital in Houston, Texas, and national board certification as a Medical Laboratory
Scientist. While working at St. Luke's Episcopal Hospital Clinical Laboratory, she
received a full scholarship to the University of Houston/Baylor College of Medicine
collaborative Masters in Allied Health Education and Administration Program. This
inspired her to continue her studies and she completed her Doctorate in Higher Edu­
cation and Administration while teaching in the Medical Laboratory Science program
and Physician Assistant program at University of Texas Medical Branch Galveston and
Medical Laboratory Technician program at Houston Community College. She then
became a faculty member and Chair of the Clinical Laboratory Science Department at
the University of Texas Health Science Center at Houston (UTHealth). And in more
recent years, she has become the Director of Community and Educational Outreach,
Director of Workforce and Resource Development, and Professor in the Medical School
Department of Family and Community Medicine.
xii A bout th e Authors

She has published 24 books and more than 55 articles and has been on numerous
national and international health care advisory boards and several editorial boards for
health care journals. Dr. Becan-McBride has had research projects related to the medi­
cal laboratory sciences and also community (i.e., UV/TB Prevention Research Project
in Homeless Shelters in Houston). Most recently, she has received a National Institute
of Health (NIH) grant in research on new point-of-care (POC) technology as defined
through blood collection techniques. She is on educational advisory boards for medical
laboratory science educational programs and community outreach programs. She has
had invitational medical laboratory science presentations nationally and internationally
to countries including Singapore, China, Russia, France, South America, New Zealand
and more recently, Croatia. She was the elected Chair of the ASCP Board of Certification
Board of Governors from 2008 to 2010 and received the ASCP Mastership Award in 2012
and ASCP Board of Certification Distinguished Service Award in 2012.
During her years at UTHealth, she has been fortunate to have the opportunity to
receive several grants for phlebotomy training programs. Drs. Becan-McBride and Garza
became involved in developing curricular materials to teach phlebotomy students as well
as nursing and other health professional students. These two faculty developed one of
the first comprehensive textbooks devoted strictly to phlebotomy and its importance in
the health care settings. Drs. Becan-McBride and Garza have been collaborators for over
31 years on numerous phlebotomy textbooks and curricular materials and as presenters
at national and international meetings.
Phlebotomy Handbook: B lood Specimen Collection from Basic to Advanced,
9th edition, is designed for health care students and practitioners who are responsi­
ble for blood and specimen collections (i.e., nurses, phlebotomists, medical laboratory
technicians, medical laboratory scientists, respiratory therapists, and others). The pri­
mary goal of this book is to link the phlebotomist (blood collector) to the latest safety
information, techniques, skills, and equipment for the provision of safe and effective
collection procedures, for the improvement of diagnostic and therapeutic laboratory
testing, for enhancement of customer satisfaction, and ultimately, for the promotion
of better health outcomes. This award-winning textbook provides the most up-to-date
comprehensive compilation of information about phlebotomy available. It covers a
wide range of competencies, including communication, clinical, technical, and safety
skills that any health care worker will use in the practice of phlebotomy and other
specimen collection procedures. The equipment chapter (ch. 8) emphasizes the most
recent and comprehensive safety features of phlebotomy supplies and equipment.
This edition also includes the latest information about standards from the Clinical
and Laboratory Standards Institute (CLSI), error reduction, patient and worker safety,
updates linked to needlestick prevention, and The Joint Commission National Patient
Safety Goals. The content also addresses generational traits, age-specific considera­
tions, transcultural communication, and patients with special needs. In addition, the
chapters provide extensive information and insights about quality issues to support
and improve technical skills.
This book highlights the professional role that phlebotomists play as essential
members of the health care team. Part of being an effective member of the health care
community is learning to communicate effectively, so this edition has a greater focus
on medical terminology, roles of other health care providers, and health literacy. The
scope of work for the blood collector has expanded to encompass additional patient
care duties and clinical responsibilities, a more patient-sensitive role, and improved
interpersonal communication skills to deal effectively with patients, treat their families
with respect, handle any special needs, and establish effective collaborations with other
members of the health care teams. These roles and responsibilities are important and
applicable around the world.
The order in which the material is presented generally follows the way in which
a phlebotomist approaches the patient (i.e., beginning with important communication
skills, knowledge of ethical behavior and legal implications, and a basic understand­
ing of physiologic aspects, then moving to safety and infection control considerations
in preparation for the phlebotomy procedure, preparation of supplies and equipment,
actual venipuncture or skin puncture, and potential complications). Specialized speci­
men collection procedures, point-of-care testing, pediatric care, and considerations for
the elderly are included. Problem-solving cases. Action in Practice cases, and Check
Yourself sections integrate the information into real-life situations. The Competency
Assessments provide a Check Yourself feature or can be used by instructors for evalu­
ation. And the Glossary has been updated and expanded to include key words and
other words important to phlebotomists. The appendices provide useful procedures
(such as taking vital signs) and important terms, phrases, and symbols.
 The content is divided into four major parts:

■ PART I: Overview, Safety Procedures, and Medical Communication—provides a

knowledge base of the roles and functions of a phlebotomist in the health care indus­
try and presents information about safety and infection control in the workplace.
■ PART II: Anatomy and Physiology of the Human Body—provides the basics of
anatomy and physiology with an emphasis on the circulatory system.
■ PART III: Phlebotomy Equipment and Procedures—provides comprehensive coverage
on the latest equipment and supplies, the most updated information and comprehen­
sive description of the actual techniques used in phlebotomy, and documentation and
transportation procedures needed for safe handling of biohazardous specimens. Clinical
and technical complications that may occur during the procedure are also reviewed.
■ PART IV: Point-of-Care Testing and Special Procedures—provides information
about pediatric phlebotomy procedures, blood culture collections, arterial and IV
collections, and special considerations for the elderly, homebound, and long-term
care patients. In addition, topics such as donor phlebotomy and drug and forensic
laboratory testing are reviewed.

Key Features of the Ninth Edition

■ Objectives at the beginning of each chapter list the important concepts discussed in
the chapter.
■ Key Terms list the vocabulary introduced and defined in the chapter. These terms also
appear in boldface type within the body of the chapter so that they are easier to find.
■ Clinical Alerts indicate procedures or concepts that have vitally important clinical
consequences for the patient. Each Clinical Alert! indicates that extra caution should
be taken by the health care worker to comply with the procedure, thereby avoiding
adverse outcomes for the patient.
■ Procedures throughout the text provide step-by-step instructions with an "on-the-
job" perspective.
■ Colorful photographs illustrate important concepts and show procedural steps and
equipment.
■ Study questions at the end each chapter help test your knowledge of the chapter
content.
■ Case Studies help you develop problem-solving and troubleshooting skills.
■ Action in Practice presents an additional case study with questions to test your criti­
cal thinking skills.
■ Check Yourself presents a brief description of a procedure to be performed along
with questions to test your knowledge of the requirements and steps to perform to
complete the procedure.
■ Competency checklists provide a list of competencies you should master relevant
to the chapter content and the National Accrediting Agency for Clinical Laboratory
Sciences (NAACLS) competencies.
■ References correlate to the endnotes in the chapter.
■ Resources provide additional readings and websites related to the chapter content.
■ The Glossary has been updated to include more terms as a valuable reference.
■ A full-color Tube Guide chart provides a list of the types of blood collection tubes
and shows the appropriate color codings with additives.
■ The Appendices include a guide to NAACLS phlebotomy competencies coverage in
the text, essential elements for finding a job, basic procedures for taking vital signs,
hand hygiene recommendations, laboratory tests and blood requirements, blood
 donation procedures, units of measurement and symbols, formulas and calculations
used in laboratories, military time, Spanish phrases, and several other topics.

Video Program
A four-hour DVD video library is available for separate purchase, serving as the most
complete skills collection of its kind. The series contains 38 segments demonstrating a
wide array of blood specimen collection procedures and patient interactions (includ­
ing pediatrics and adults in both clinic and hospital settings). The video is based on
current Clinical and Laboratory Standards Institute (CLSI) guidelines and standards,
and emphasizes safety, infection control, effective communication, quality assessment,
and avoiding errors. The footage correlates directly with the procedures shown in
Phlebotomy Handbook, 9th edition, and was filmed in collaboration with the authors.
The video series is ideal for independent self-study or review for those aiming to enhance
their understanding and performance. It is also an excellent classroom teaching tool for
instructors who wish to supplement their teaching with dynamic footage of experts in
action. The series helps fulfill National Association for Accreditation of Clinical Labora­
tory Sciences competencies for accredited programs in Phlebotomy. Educators should
contact their Pearson sales representative to learn about special offers and institutional
pricing.

Additional Resources for Educators

This ninth edition has digital companion resources that are cross-referenced to the text.
The Instructor's Resource Manual contains a wealth of material to help faculty plan and
manage their course. It includes a detailed lecture outline, a complete test bank, teaching
tips, and more for each chapter. For instructors, log on to www.pearsonhighered.com
to access the complete test bank and PowerPoint lectures that contain discussion points
with embedded color images from the book.

An Accompanying Guide
for Examination Review
Available for separate purchase is Pearson's SUCCESS! in Phlebotomy: Q&A Review, 7th
edition. This is an aid to students and health care workers preparing for a certifica­
tion examination. It has over 850 exam-type questions and an accompanying access to
www.myhealthprofessionskit.com multiple-choice questions, flashcards, and an audio
glossary.
In summary, the authors have created a book with several audio and visual learning
tools that health care professionals and students will use as a central authority on blood
collection practices. Instructors can also use this as the central text for teaching specimen
collection skills.
We are grateful to many generous individuals, product suppliers, manufacturing com­
panies, professional organizations, and health care organizations for their assistance
in preparing the previous editions of this text. The first edition was conceptualized in
the 1980s, when phlebotomy was learned in an apprentice-type situation and teaching
materials were scarce. As licensing, credentialing, manufacturing of new products,
procedures, competencies, hazards, and safety regulations expanded, so did our text.
Each edition used previous editions as a framework for updating, redesigning, and
improving the next. In 2006, Phlebotomy Handbook, 7th edition, won a first-place Book
Award from the American Medical Writers Association in the Allied Health Category,
and we are proud to continue the tradition of excellence in this ninth edition with the
participation of so many talented people. Thus, we thank many phlebotomists, medical
technicians and technologists, artists, photographers, and educators who have given us
countless editorial tips and practical advice over the years. We also thank health care
workers around our country and the world who have taken the time to read about new
and better ways of improving the practice of phlebotomy.
We are particularly grateful to BD Vacutainer Systems, Greiner Bio-One, Marketlab,
the American Society for Clinical Pathology, The University of Texas M. D. Anderson
Cancer Center (MDACC), Memorial Hermann Health Care System, and The University
of Texas Houston Health Science Center for their support throughout many stages
of our previous and current editions. We thank Donna Hermis and Dr. Passion
Lockett for their assistance and expertise as contributing authors. We also thank the
many students, faculty, and staff of the Diagnostic Center at the University of Texas
M. D. Anderson Cancer Center who were models for the photographs and technical
experts, especially Dr. Brandy Greenhill, Program Director, Clinical Laboratory Science
Program; Kimberly Murray; and Peter McLaughlin, MD. Thanks also go to photogra­
pher Patrick Watson for his patience, efficiency, and organizational skills.
We greatly appreciate our positive working relationships with editors and copyedi­
tors, past and present, who have encouraged us and improved our writing through
eight editions. Special thanks go to Jane Licht, Cheryl Mehalik, Lin Marshall, Mark
Cohen, Melissa Kerian Bashe, Cathy Wein, and Amy Peltier.
Last, and most important, we gratefully acknowledge our families, who have
proudly grown up with this text as part of their lives. They have continued to encour­
age us and have supportively tolerated the thousands of hours over many years that
we have spent writing the previous and current edition of this textbook. They will
always hold a special place in our hearts.
D iana Garza
Kathleen Becan-McBride
Thank you to the following reviewers for their valuable contributions:

Pamela Audette, MBA, MT, RMA
Program Chair, Medial Assistant
Program
Finlandia University
Hancock, Michigan
Jerry Barton, MLS (ASCP)
Phlebotomy Program Director
Cape Fear Community College
Wilmington, North Carolina
Doris Beran, MPH, MT (ASCP)
Allied Health Instructor
Coconino Community College
Flagstaff, Arizona
Jennifer Elenbaas
Instructor
Davenport University
Grand Rapids, Michigan
Penny Ewing, BS, CM A (AAMA)
Instructor
Gaston College
Dallas, North Carolina
Michelle Mantooth, MSc., MLS
(ASCP)CM, CG(ASCP) CM
Instructor
Trident Technical College
North Charleston, South Carolina
Margaret Oliver, MT (ASCP)
Instructor
Neosho County Community College
Ottawa, Kansas
Evelyn Paxton, MS, MT (ASCP)
Program Director
Rose State College
Midwest City, Oklahoma
Pam Tully, MHS, MT (ASCP), PBT
(ASCP)
Phlebotomy Program Director
Bossier Parish Community College
Bossier City, Louisiana

Jimmy Boyd, MLS (ASCP) Kimberly Meshell

Program Director Instructor
Arkansas State University Beebe Angelina College
Beebe, Arkansas Lufkin, Texas
This page intentionally left blank
Phlebotomy Practice
and Quality Assessment
KEY TERMS

Chapter Objectives accuracy

acute care
Upon completion of Chapter 1, the learner is responsible aliquot
for doing the following: ambulatory care
American Society for Clinical
1. Define phlebotomy and identify health professionals who perform phlebotomy
Laboratory Science (ASCLS)
procedures.
American Society for Clinical Pathology
2. Identify the importance of phlebotomy procedures to the overall care of the patient. (ASCP)
3. List professional competencies for phlebotomists and key elements of a performance anatomic pathology
assessment. Centers for Medicare & Medicaid

4. List members of a health care team who interact with phlebotomists. Services (CMS)
clinical decisions
5. Describe the roles of clinical laboratory personnel and common laboratory
clinical pathology
departments/ sections.
competency statement
6. Describe health care settings in which phlebotomy services are routinely performed. continuing education (CE)
7. Explain components of professionalism and desired character traits for phlebotomists. continuous quality
improvement (CQI)
8. Describe healthy behaviors, fitness, and coping skills to reduce stress in the workplace.
examination (analytical phase)
9. List the basic tools used in quality improvement activities and give examples of how a Food and Drug Administration (FDA)
phlebotomist can participate in quality improvement activities. home health personnel
10. Define the difference between quality improvement and quality control. hospital- or health care-acquired
infections (HAIs)
inpatients
International Organization for
Standardization (ISO)
long-term care
nanotechnology
National Phlebotomy
Association (NPA)
personal protective equipment (PPE)
phlebotomist
phlebotomy
CONTINUED
 Phlebotomy Practice and Definition
Clinical decisions are based on medical standards of practice, diagnostic testing (e.g.,
laboratory tests and x-rays), a patient's history, and observation of signs and symp­
toms. Therefore, before physicians can make clinical decisions, they need laboratory
test results for the patient. The development of modern diagnostic techniques, clini­
cal laboratory automation, computer technology, standardization, globalization, and
changes in the delivery of health care services have increased the variety and number
of laboratory test options available for clinical decisions. Since laboratory test results
influence the majority of medical decisions and play such an important role in the clini­
cal management of patients, many health care workers are taking greater roles in the
specimen collection process. Among those who perform phlebotomy tasks are clinical
or medical laboratory personnel (including certified phlebotomists), nurses and nurse
aides, respiratory therapists, medical assistants, home health personnel, and others.
Regardless of specific job backgrounds, common elements about the practice of phle­
botomy should be known by all who are responsible for blood specimen collections.
The term phlebotom y is derived from the Greek words, phlebo, which relates to
physician's office laboratories veins, and tomy, which relates to cutting. In ancient times, phlebotomy was practiced to
(POLs) withdraw blood using various means, including knives, crude lancets, leeches, blood
cups or bowls, pumps, and glass syringes. In some cultures, phlebotomy was thought
point-of-care (POC)
to cleanse or purify the body and/or get rid of unwanted spirits. However, today, m od­
postexamination (postanalytical ern phlebotomy equipment and practices are very advanced. The current definition of
phase) phlebotomy can be summarized as the incision of a vein for collecting a blood sample
preexamination (preanalytical (a portion of blood removed that is small enough so as not to cause harm) for labora­
phase) tory testing or other therapeutic purposes (e.g., blood donations). Synonymous words
professionalism are venesection or venisection, and the phlebotomist, or blood collector, is the individual
who performs phlebotomy. The term phlebotomist will be used throughout this text even
quality
though it is interchangeable with blood collector. Phlebotomists often assist in the collec­
quality control (QC) tion and transportation of specimens other than venous blood (e.g., arterial blood, urine,
quality improvement tissues, sputum) and may perform clinical, technical, or clerical functions. However, the
reliability primary function of the phlebotomist is to assist the health care team in the accurate, safe,
Six Sigma and reliable collection and transportation of specimens for laboratory analyses.
stakeholders In this text, numerous phlebotomy procedures and practices are covered, ranging
from the most basic to more advanced procedures. However, the two most common
standards of practice
phlebotomy techniques are extensively covered and are the essence of all phlebotomy
practices:

■ Venipuncture—Withdrawing a venous blood sample (from a vein, not an artery)

using a needle attached to an evacuated tube system or other collection devices
(covered in Chapters 8 and 10).
■ Skin Puncture—Puncturing a finger with a specially designed safety lancet to with­
draw a smaller amount of capillary blood (covered in Chapters 8 and 11).
■ Advanced and/or specialized procedures are covered in Chapters 13,15, 16, and 17.

Patients' blood specimens are discrete portions of blood taken for laboratory analysis
of one or more characteristics to determine the character of the whole body.1Laboratory
analyses of a variety of specimens are used for three important clinical purposes:

■ Diagnostic and Screening Tests—To figure out what is wrong with the patient (e.g.,
tests that detect abnormalities) or to detect irregularities that require more extensive
follow-up testing.
 C hapter 1 Phlebotomy Practice and Quality Assessment 3

■ Therapeutic Assessments—To develop the appropriate therapy or treatment of the

medical condition (e.g., tests that predict the most effective treatment or the drug of
choice)
■ Monitoring—To make sure the therapy or treatment is working to alleviate the dis­
ease or illness (e.g., tests to confirm that the abnormality has returned to normal or
that the drug is reaching its effective dosage)

Thus, the requirement for a high-quality specimen that is correctly identified, collected,
and transported is vital to the overall care of a patient. Phlebotomists' duties vary in scope
and range, depending on the setting. They may have duties related to all phases of labora­
tory analysis or may be assigned to only specimen collection duties in one area of a hospi­
tal. Technology has enabled laboratory testing to be performed closer to the point-of-care
(POC); for example, at the patient's bedside, at ancillary or mobile clinic sites, in the home,
or even in an ambulance (BOX 1-1). Phlebotomists' duties have become more coordinated
with other health care processes. In some cases, health professionals—such as nurses, res­
piratory therapists, patient care technicians, medical assistants, and others—have been
cross-trained to assume phlebotomy duties; in other cases, traditional laboratory-based
phlebotomists have been cross-trained to assume expanded clerical or patient care duties—
for example, performing electrocardiograms and low-risk laboratory procedures. Whatever
the case, the workplace settings and roles and responsibilities of the health care professional
who performs phlebotomy procedures will continue to evolve and change.

HEALTH CARE SETTINGS AND HEALTH CARE TEAMS

Health care organizations in the United States vary widely but most fit into two categories:
inpatient, where patients are in a hospital for more serious conditions and care and out­
patient or ambulatory care, where patients's conditions are less critical and can be treated
without hospitalization. Traditional hospitals are organized into departments according

BOX 1-1

Potential Job Sites for Phlebotomists

Hospital (In p a tie n t) Settings
Acute-care hospitals (urban or rural) Hospital-based clinics
Specialty hospitals (cancer, Hospital-based emergency centers
psychiatric, long-term care, pediatric)

A m bulatory Care (O u tp a tie n t) Settings

Health department clinics Health maintenance organizations (HMOs)
Community health centers (CHCs) Insurance companies
Rural health clinics Physician group practices
Community-based mental health centers Individual or solo medical practices
School-based clinics Specialty practices
Prison health clinics Rehabilitation centers
Dialysis centers Mobile vans for blood donations
Screening centers Mobile vans for primary care delivery
Home hospice Free-standing surgical centers
Durable medical equipment suppliers Reference laboratory collection sites
Physician's office laboratories (POLs) Drug screening sites
(in medical clinics) Mobile mammography units
Hom e health care (provided in the
patient's home)
4 C hapter 1 Phlebotomy Practice and Quality Assessment

to medical /surgical specialties and/or around organs systems as shown in TABLE 1-1.
Sometimes, departments are organized by therapy services or procedures offered to the
patient. Phlebotomists should become knowledgeable about these areas of the hospital and
the personnel who work there because patients spend time in them prior to, during, and/or
after their phlebotomy procedures. Some factors that relate to these departments may affect
the outcome of the laboratory test, and they all involve members of the health care team.

HOSPITALS IN THE UNITED STATES

There are over 5,700 hospitals in the United States. They vary according to the follow­
ing factors:

■ Mission (patient care, education, research)

■ Number of staffed beds (over 920,000 beds in the United States)2
■ Admissions (a total of over 37 million per year)2
■ Ownership (public or nonprofit, governmental, for profit [investor owned or
proprietary])
■ Length of stay (short term [e.g., less than 30 days] or long-term [e.g., greater than
30 days])
■ Type of care (e.g., acute care [short term treatment for an urgent injury or medical
condition], cancer center, psychiatric, long-term care [treatment for chronic condi­
tions], pediatric, rehabilitation, etc.)
■ Location (urban or rural)
■ Relationship to other health facilities (e.g., hospital system-managed by a central
organization or a network of providers that work together to coordinate care and
may or may not be affiliated with each other)

TABLE 1-1

Medical, Surgical, and Ancillary Service Departments in Large Health Care Facilities
Health care professionals make up one of the largest workforce segments in the United States. For every one physician, there are approxi­
mately 16 health care workers who provide direct and support services to the patient and physician. The following list is only a partial
listing of common clinical departments and personnel. There are many levels of education, experience, credentialing processes, and
licensing requirements for the health care industry, and it is beyond the scope of this text to cover all the important individuals. There are
also a variety of specialties and subspecialties for physicians (medical doctors, MDs), scientists, biomedical engineers, nurses, physician
assistants (PAs), social workers, pharmacists, therapists, technical individuals, and spiritual support personnel who are valuable members of
the health care team but too numerous to mention here.

D ep a rtm en t F u n c t io n s P erson n el

Allergy Diagnosis and treatment of persons who have allergies or "reactions" Physicians, nurses, medical assistants
to irritating agents.
Anesthesiology Pain management before, during, and after surgery. Anesthesiologist, nurse anesthetist
Cardiology Medical diagnosis and treatment of conditions relating to the heart Cardiologist (MD)
and circulatory conditions.
Cardiovascular Surgical diagnosis and treatment of heart and blood circulation disorders. Cardiovascular surgeon (MD),
surgical nurse
Dermatology Diagnosis and treatment of skin conditions. Dermatologist (MD), nurse, medical
assistant
Diagnostic Imaging or Radiology Uses ionizing radiation for treating disease, fluoroscopic and radiographic x-ray instru­ Radiologist, radiologic technician/
mentation and imaging methods for diagnosis, and radioisotopes for both diagnosing technologist
and treating disease. Sometimes patients are injected with dye that might interfere with
some laboratory tests. The phlebotomist should document the circumstances as appro­
priate. In addition, the phlebotomist should be aware of applicable safety requirements.
Electroca rdiog rap hy Uses the electrocardiograph (ECG or EKG) to record the electric currents produced Cardiologist, nurse, medical assistant,
by contractions of the heart. This assists in the diagnosis of heart disease. EKG technician
Electroencephalography Uses the electroencephalograph (EEG) to record brain wave patterns. Neurologist (MD), nurse
Endocrinology Diagnosis and treatment of disorders in the organs and tissues that produce Endocrinologist (MD), nurse
hormones (e.g., estrogen, testosterone, cortisol).
Family medicine/General practice Care of general medical problems of all family members. Family practice or primary care
physician (MD)
 C hapter 1 Phlebotomy Practice and Quality Assessment

TABLE 1-1

Medical, Surgical, and Ancillary Service Departments in Large Health Care Facilities (continued)
D ep a rtm en t F u n c t io n s P erson n el

Gastroenterology Diagnosis and treatment of conditions relating to esophagus, Gastroenterologist

stomach, and intestines.
Geriatrics/Gerontology Diagnosis and treatment of the elderly population. Gerontologist
Hematology Diagnosis and treatment of conditions relating to the blood. Hematologist
Immunology Diagnosis and treatment of conditions relating to the immune system Immunologist
Internal Medicine General diagnosis and treatment of patients for problems of one Internist (MD) or doctor of osteopathic
or more internal organs medicine (DO), nurse, physician
assistant (PA)
Laboratory Medicine/Pathology Uses sophisticated instrumentation to analyze blood, body fluids, and tissues for Pathologist, pathology assistant,
pathological conditions. Laboratory results are used in diagnosis, treatment, and laboratory personnel (Box 1-2)
monitoring of patients' health status.
Neonatal/Perinatal Study, support, and treatment of newborn and prematurely born babies Neonatologist
and their mothers.
Nephrology Kidneys. Urologist
Neurology Nervous system. Neurologist, neurosurgeon
Nuclear Medicine Uses radioactive isotopes or tracers in the diagnosis and treatment of patients and Radiotherapist (MD)
in the study of the disease process. The radioactive substance is injected into the
patient and emits rays that can be detected by sophisticated instrumentation.
Phlebotomists should be knowledgeable of special safety requirements for entering
this area. Also, the radioisotopes may interfere with laboratory testing, so
documentation of this therapy may be required.
Nutrition and Dietetics Perform nutritional assessments and patient education, and design special diets for Nutritionist, dietician
patients who have eating-related disorders (e.g., diabetes, obesity, anorexia).
Obstetrics/Gynecology Diagnosis and treatment relating to the sexual reproductive system of females, Obstetrician, gynecologist (MD)
using both surgical and nonsurgical procedures.
Occupational Therapy Assists the patient in becoming functionally independent within the limitations Occupational therapist (OT)
of the patient's disability or condition. Occupational therapists (OTs) collaborate
with the health care team to design therapeutic programs of rehabilitative activities
for the patient. The therapy is designed to improve functional abilities or activities
of daily living (ADLs).
Oncology Diagnosis and treatment of malignant (life-threatening) tumors (i.e., cancer). Oncologist (MD)
Ophthalmology Diagnosis and treatment of the eyes and vision-related medical problems. Ophthalmologist (MD),
optometrist (DO)
Orthopedics Care of medical concerns related to bones and joints. Orthopedic Surgeon (MD), physical
therapist
Otolaryngology Diagnosis and treatment of medical problems related to ears, nose, Otolaryngologist, speech pathologist,
and throat (ENT). audiologist
Pathology See Laboratory Medicine/Pathology
Pediatrics General diagnosis and therapy for children. Pediatrician (MD)
Pharmacy Dispenses medications ordered by physicians. Pharmacists also collaborate with the Doctor of Pharmacy (Pharm. D),
health care team on drug therapies. Phlebotomists may collect blood specimens at pharmacist
timed intervals to monitor the level of the drug in the patient's bloodstream.
Physical Medicine Diagnosis and treatment of disorders of the neuromuscular system. Physical therapist (PT), occupational
therapist (OT)
Physical Therapy Assists in restoring physical abilities that have been impaired by illness or injury. PT and OT
Rehabilitation programs often use heat/cold, water therapy, ultrasound or
electricity, and physical exercises designed to restore useful activity.
Plastic Surgery Cosmetic surgery or surgical correction of the deformity of tissues, including skin. Plastic surgeon (MD)
Proctology Diagnosis and treatment of diseases of the anus and rectum. Proctologist (MD)
Psychiatry/Neurology Diagnosis and treatment for people of all ages with mental, emotional, and nervous Psychiatrist/Neurologist (MD)
system problems, using primarily nonsurgical procedures.
Pulmonary Diagnosis and treatment of conditions relating to the respiratory system. Pulmonologist (MD)
Radiotherapy Uses high-energy x-rays, such as from cobalt treatment, in the treatment of Radiotherapist (MD), nuclear medicine
disease, particularly cancer. Safety precautions are important to avoid unnecessary technician
irradiation.
Rheumatology Diagnosis and treatment of joint and tissue diseases, including arthritis. Rheumatologist (MD)
Surgery Diagnosis and treatment in which the physician physically alters a part of the General surgeon, specialty surgeon
patient's body. (orthopedic, cardiovascular, etc.) (MD)
Urology Diagnosis and treatment of medical conditions related to sexual/reproductive Urologist, nephrologist (MD)
system in men, and renal system for men and women.
6 C hapter 1 Phlebotomy Practice and Quality Assessment

BECOMING A PART OF THE HEALTH CARE TEAM

All health care workers are expected to be valuable members of a health care team
(FIGURE 1 -1 ). Even though there are many levels and types of health care teams (self-
directed work groups, manager-led group, etc.) and roles/responsibilities that are
assigned to each, there are important questions to ask in each situation:
What do I need to do to maximize team/group effectiveness?
How can I be a better team member?
In high-performance teams, every team member should:

■ Understand the mission of the organization, the goals of the group, and/or the
project
■ Know basic skills for group processes (listening skills, setting norms for the team,
etc.)
■ Show reliability and dependability in work assignments
■ Communicate one's own ideas and feelings
■ Actively and respectfully participate in decision making
■ Learn how to be flexible in decision making (give and take)
■ Constructively manage conflicts
■ Contribute to the cohesion of the team
■ Contribute to problem-solving strategies
■ Support and encourage other team members

Individuals should reflect on this list periodically as they go through this text and
through their careers. To make it a self-assessment, simply add the words "Do I ..."
to each phrase in the list. Professional growth and maturity occur if one can honestly
answer these questions and strive for improvement if there are deficits. Additional
resources for team development and communication are listed at the end of this chapter
and in Chapter 2.

FIGURE 1-1
Health Care Team

Daily com m unication w ith a health care team is part of

the job. Discussions th a t occur w ith in a patient's hearing
range m ust be highly professional.
 C hapter 1 Phlebotomy Practice and Quality Assessment

The Clinical Laboratory and Specimen

Collection Services
A typical hospital-based clinical laboratory has two components: clinical pathology and
anatomic pathology. In the clinical pathology area (also called the clinical laboratory or
medical laboratory), blood and other types of body fluids and tissues are analyzed (e.g.,
urine, cerebrospinal fluid [CSF], sputum, gastric secretions, and synovial fluid). In the
anatomic pathology area, autopsies are performed, histologic and cytologic procedures
are utilized for tissue and fluid specimens, and fine-needle aspirates and surgical biopsy
tissues are analyzed.
Laboratories can also be independently owned and operated outside the hospital
setting i.e., physicians office laboratories. Large hospital laboratories typically have
organizational structures that have an administrative/management hierarchy, a central
specimen processing area, and divisions or sections for the testing processes (FIGURE 1-2).
Each section may have a pathologist as the director and supervisors who oversee the
technical procedures and troubleshoot issues that arise in that section.

FIGURE 1 -2
Example of an Organizational Chart for a Clinical Laboratory

This figure shows an overview of the major sections of a hypothetical hospital-based clinical laboratory.

Regardless of the type or size of the clinical laboratory, it is important to under­

stand that the phlebotomist plays a vital role early in the process of producing labora­
tory results/reports. Reliability (reproducibility and consistency) and accuracy (the
degree of correctness) of all patient test results depend on the preexamination pro­
cess (preanalytical phase) of specimen collection—that is, the part of the process that
occurs from the time laboratory tests are ordered through the time that specimens
are actually delivered to the laboratory and then processed and/or transported to a
referral laboratory (i.e., before the actual testing and analysis is performed). The pre­
examination process is the fundamental and crucial domain of every phlebotomist.
FIGURE 1 -3 depicts the functional phases of laboratory testing, the preexamination
(preanalytical phase), the examination (analytical phase), and the postexamination
(postanalytical phase).1
8 C hapter 1 Phlebotomy Practice and Quality Assessment

Preexamination Examination Postexamination

What happens before testing What happens during testing What happens after testing

Preexamination Process Examination Process Postexamination Process

(Preanalytical Phase) (Analytical Phase) (Postanalytical Phase)

EXAMPLES EXAMPLES EXAMPLES

Laboratory examination requests/orders Using appropriate testing methods Reporting the final test result

Patient preparation and precollection Using appropriate equipment Notifying appropriate providers of critical
assessment (identification, values when appropriate
hand hygiene, etc.)
Performing quality control Defining and adhering to turnaround times

Collection of specimen (venipuncture or Troubleshooting equipment and reagents Entering critical laboratory data
capillary puncture)
Troubleshooting erroneous results and Correcting erroneous results
quality control errors
Labeling the specimen
Reviewing and verifying results Storing specimens appropriately
Post-puncture care
Interpreting other information that Obtaining information needed for follow-up
Transporting the specimen correlates with the test results or repeat testing

Specimen receipt, handling, and storage
Evaluating condition of the specimen
Communicating when the specimen is
unacceptable
Reconciling discrepancies in laboratory Troubleshooting delays or failures to
findings communicate critical/alert values
Maintaining turnaround times for this
phase of testing

Processing the specimen

Expediting urgent specimens

FIGURE 1 -3
The Clinical Laboratory's Workflow Pathway

The Clinical and Laboratory Standards Institute (CLSI) describes the basic workflow of a clinical laboratory as beginning with a request
for a laboratory test and ending with laboratory examination results and their interpretation by a health care provider. The workflow
concept is depicted here in general terms and in reality involves many steps and actions; only a few examples are listed under each
heading. The importance of these processes cannot be overstated because any failure to perform them correctly or completely can
result in harm to patients, medical errors, waste of resources, and repeated work. All steps in each of these domains must be done
according to standards of practice and must be traceable to the individual who performs the tasks. Standards o f practice are
procedural guidelines set by governmental, accreditation, certification agencies; professional organizations; and/or manufacturing
and equipment requirements.
 C hapter 1 Phlebotomy Practice and Quality Assessment 9

Smaller clinical laboratories can be located in remote locations or in clinics, physi­

cians' offices, and mobile vans. Health care workers who perform the testing must main­
tain the same high standards of quality as are found in larger, high-volume laboratories.
The federal government has several agencies that regulate and oversee all clinical
laboratories; they include the U.S. Food and Drug Administration (FDA), the Centers
for Medicare & M edicaid Services (CMS) in the federal Department of Health and
Human Services, the Occupational Safety and Health Administration (OSHA) in the
Department of Labor, and the Department of Transportation (DOT). Some of these will be
discussed more extensively in later chapters. Other regulatory agencies also have over­
sight of clinical laboratories, depending on the health care setting, the type and complex­
ity of the testing they do, and employee certification. Among these are the International
Association of Blood Banks, the American Society for Clinical Pathologists (ASCP), the
College of American Pathologists (CAP), and The Joint Commission.
Also, some states (including California, New York, and Florida) have licensure/certi­
fication regulations and/or testing requirements for laboratory personnel. Phlebotomists
should be knowledgeable about the licensure requirements when applicable because
they may be allowed to perform certain procedures in one state but not in another. For
example, many phlebotomists are allowed to perform basic point-of-care tests in most
states, but they are not allowed to do so in California. Also, in California, the Department
of Public Health requires specific proficiency areas for three different levels of licensed
phlebotomists: Limited Phlebotomy Technician, Phlebotomy Technician I, and Phlebot­
om y Technician II. Refer to the Resources at the end of the chapter for more information.

CLINICAL/MEDICAL LABORATORY DEPARTMENTS

Clinical laboratories, especially those that are hospital based, typically have an adminis­
trative office headed by a pathologist and/or a director who oversees the many financial
and operational aspects of the laboratory. Administrative responsibilities include all
financial matters, such as cost accounting and budgeting, as well as human resources,
strategic planning, operational issues, and regulatory issues. Depending on the size of
the organization, the laboratory may have multiple supervisory/management person­
nel and/or physicians or scientists overseeing specific areas of the clinical laboratory.
Large clinical laboratories usually cluster similar testing processes according to the
sections listed in the organizational chart in Figure 1-2.

CLINICAL/MEDICAL LABORATORY PERSONNEL

Laboratory personnel work as a team to provide essential clinical data to physicians
for diagnosing, treating, and monitoring patients. They provide the many pieces of
a complex puzzle that make up a patient's condition. Laboratory professionals have
some com m on characteristics: They like to solve problems, they strive for accuracy
and reliability in their job tasks, they communicate well, they work under pressure and
follow through on complex tasks, and they set high-quality standards for themselves
and their work. Regardless of the level of education, health care workers involved with
phlebotomy should familiarize themselves with various members of the clinical labora­
tory team (BOX 1-2).

Competencies, Certification, and

Professionalism for Phlebotomists
The requirements for a phlebotomist vary across health care settings and regions of
the country. A high school diploma or its equivalent is most often required to enter a
phlebotomy training program in hospitals, community colleges, or technical schools.
Typically, the length of training ranges from a few weeks to months, depending on
the location, size of the facility, and the complexity of patients being served. Prior to
10 C hapter 1 Phlebotomy Practice and Quality Assessment

BOX 1-2

Clinical/Medical Laboratory Personnel

■ Pathologists— Physicians (medical doctors, MDs) who have extensive training in pathology
(the study and diagnosis of disease).
■ Administrative/Management Staff— Individuals who may have a graduate degree in
health care administration or business.
■ Technical supervisors— Medical laboratory scientists with additional experience and
education in a laboratory specialty area, such as hematology, microbiology, or clinical
chemistry.
■ Medical Laboratory Scientists (MLS)— Certified professionals with a bachelor's degree in
a biological science. Educational requirements include one or more years of study in an
MLS program. Licensing is required in some states. Roles and responsibilities include per­
forming chemical, microscopic, microbiologic, or immunologic tests pertaining to patient
care; recording and reporting test results; participating in research and development of
new test methods; performing preventive maintenance, troubleshooting, and quality con­
trol of instruments and reagents; maintaining safety in the clinical laboratory; and teaching
residents and fellows in pathology and laboratory sciences.
■ Medical Laboratory Technicians (MLT)— Individuals who have a two-year certificate or
associate's degree. The MLT may perform designated tests and procedures, prepare speci­
mens for testing and transport, prepare reagents, perform quality control measures, and
assist the MLS in numerous preanalytic and postanalytic processes and in performing lim­
ited analytical processes.
■ Phlebotomists or Phlebotomy Technicians— Individuals with a high school diploma and
specialized phlebotomy educational and clinical training; most phlebotomists take a certifi­
cation examination. More information is presented in the next section.
■ Medical Assistants (M A)— Individuals who have completed a medical assisting certificate,
often in conjunction w ith an associate's degree. The MA in a laboratory setting may per­
form phlebotomy procedures, specified low-risk laboratory tests, basic patient assessments
(blood pressure, etc.), specimen processing and handling, and clerical duties.
■ Certified Specialists— Individuals who complete required experiences and a certification
examination in a specified area of the laboratory such as blood banking, hemapheresis,
microbiology, clinical chemistry, hematology, laboratory safety, or laboratory management.
■ Other Laboratory Personnel— Doctoral-level scientists who specialize in specific areas such
as immunology or microbiology, laboratory information systems (LIS) operators and pro­
grammers, clerical staff, quality management staff, infection control officers, and biomedi­
cal equipment specialists.

acceptance and/or employment, screening requirements may be requested, including a

criminal background check, a drug screen, and/or evidence of specific immunizations,
including the Hepatitis B vaccination series. Employers often require phlebotomy cer­
tification, which is accomplished by passing a national certification examination and/
or attending continuing education (CE) programs in the field. Certification provides
career advantages through job opportunities, career advancement, and portability (i.e.,
recognized from state to state). Since some state requirements vary, double-checking
the educational requirements in a specific area prior to beginning the curriculum will
prevent any misunderstandings.
Professional organizations that recognize phlebotomists include those listed in
BOX 1-3. Many of these organizations have developed com petency statements to
describe the entry-level skills, ability level, aptitude, tasks, and/or roles performed
 C hapter 1 Phlebotomy Practice and Quality Assessment

BOX 1-3

Professional Organizations for Phlebotomists

The organizations listed here have an interest in prom oting and improving the practice of
phlebotomy. They differ slightly in their membership requirements, fees, member benefits, con­
tinuing education courses, availability of certification examinations specifically for phlebotomists,
and their profit motives (some are nonprofit and others are for-profit or proprietary; i.e., com­
mercial, private ownership). The eligibility requirements and documentation for each certification
also differ among these groups. Before applying for one or more of the certification examinations,
double-check to see which ones are more reputable, secure, and accepted in the local com­
munity or state. Sometimes health care organizations have preferences for specific certifications
and will adjust salaries accordingly. Likewise, local community colleges and universities can also
provide recommendations about which certification examination to take. Since some states have
credentialing or continuing education requirements for phlebotomists, it is important to know
which organizations are approved by the state health departments to provide the examination
or CE programs. Keep in mind that this is not an exhaustive list; in addition to the organizations
listed here, there are other groups that market phlebotomy-related products and may offer
continuing education programs as well.

N o n p ro fit O rganizations
The Am erican Society fo r Clinical Laboratory Science (ASCLS)
1861 International Drive, Suite 200
McLean, VA 22102
(571) 748-3370
www.ascls.org
ASCLS has recognized clinical laboratory personnel for more than 50 years. Several types of
memberships are available, depending on the education and experience of the individual. Phle­
botomists may join ASCLS as associate members in the Phlebotomy Section.
Am erican Society fo r Clinical Pathology (ASCP)
33 W. Monroe Street, Suite 1600
Chicago, IL 60603
(312) 541-4999; (800) 267-2727
(312) 541 -4998 (fax)
www.ascp.org
ASCP offers many levels of certification for laboratory personnel through the Board of Certi­
fication (BOC), including a Phlebotomy Technician Examination (PBT), a Donor Phlebotomy
Technician (DPT), and an international certification examination for PBT (ASCP'). It also provides
educational programs, teleconferences, webinars, workshops, phlebotomy scholarships, and
online CE for phlebotomists. The certification exam covers the entry-level skills of a phlebotomist
and uses taxonomy levels that assess recall (recognize facts), interpretive skills (use knowledge
to interpret numeric data), and problem-solving skills (use applications of specific information to
solve problems). Over 13,000 phlebotomists have been certified by ASCP since 1989.
Am erican Society o f Phlebotom y Technicians (ASPT)
P.O. Box 1831
Hickory, NC 28603
(828) 294-0078
(828) 327-2969 (fax)
www.aspt.org
ASPT offers a CPT (ASPT) certification examination. It also offers certification examinations for
point-of-care technician, EKG technician, drug collection specialist, paramedical insurance exam­
iner, and patient care technician.

(continued)
12 C hapter 1 Phlebotomy Practice and Quality Assessment

BOX 1—3 (continued)

N ational Accrediting Agency fo r Clinical Laboratory Sciences (NAACLS)

5600 N. River Road, Suite 720
Rosemont, IL 60018-5119
(773) 714-8880
(773) 714-8886 (fax)
www.naacls.org
NAACLS accredits educational programs in clinical laboratory sciences, including phlebotomy.
No certification examinations are provided.
N ational Phlebotom y Association (NPA)
1901 Brightseat Road
Landover, MD 20785
(301) 386-4200
(301) 386-4203 (fax)
www.nationalphlebotomy.org
NPA was established in 1978 to recognize the phlebotomist as a distinctive and identifiable part
of the health care team. The association has established professional standards, a code of ethics,
educational opportunities, and an annual certification examination resulting in a CPT (NPA). NPA
has trained and certified approximately 15,000 phlebotomists in all 50 states and abroad and
has accredited 75 teaching programs. Accredited programs must include the following topic
areas: Historical Perspective, Medical Terminology, Anatomy and Physiology, Communication,
Phlebotomy Practical, Cardio-Pulmonary Resuscitation (CPR), Stress Management, Phlebotomy
Techniques, Human Relations, Legal Aspects, Infection Control, and Drug Awareness.

Com m ercial O rganizations

Am erican C ertification Agency (ACA)
P.O. Box 58
Osceola, IN 46561
(574) 277-4538
(574) 277-4624 (fax)
Contact: Shirley Evans, Testing Specialist or Carole Mullins, Director
E-mail: info@acacert.com.
www.acacert.com
The ACA provides certification examinations for phlebotomy technicians and instructors.
Am erican M edical Technologists (A M T)
10700 W. Higgins Road, Suite 150
Rosemont, IL 60018
(847) 823-5169 or (800) 275-1268
(847) 823-0458 (fax)
w w w .am tl .com
AMT offers several certification examinations, including Phlebotomy Technician, Medical Labora­
tory Technician, Medical Laboratory Assistant, Medical Assistant, Medical Administrative Special­
ist, Allied Health Instructor, and Clinical Laboratory Consultant.
N ational C enter fo r Com petency Testing (N C C T/M M C I)
7007 College Boulevard, Suite 385
Overland Park, KS 66211
(800) 875-4404
(913) 498-1243 (fax)
www.ncctinc.com
The NCCT provides certification and CE for phlebotomy technicians and instructors.
 C hapter 1 Phlebotomy Practice and Quality Assessment

BOX 1—3 (continued)

N ational H ealthcareer Association (NHA)

National Headquarters
7 Ridgedale Avenue, Suite 203
Cedar Knolls, NJ 07927
(973) 605-1881 or (800) 499-9092
(973) 644-4797 (fax)
Established in 1989, NHA was formed to create a network for health care professionals. NHA
provides a certification examination for phlebotomists, CPT.

by designated health care workers. Some offer convenient continuing education

opportunities via conferences, online coursework, webinars, or podcasts. In addi­
tion, som e professional organizations require CE to maintain certification and/or
states may have specific CE licensure requirements through their respective public
health departments.
The following list identifies competencies for entry-level phlebotomy technicians
adapted from the American Society for Clinical Pathology and the National Accrediting
Agency for Clinical Laboratory Sciences. In general, phlebotomists should have basic
knowledge of anatomy of the arms and hands, physiology related to the circulatory sys­
tem and basic body systems, specimen collection, specimen processing and handling (for
blood and non-blood specimens), quality assessment tools, and laboratory operations
related to phlebotomy. At career entry, a phlebotomist should be able to accomplish the
tasks listed here. Also refer to Appendix 1 for a more detailed list of competencies from
the National Accrediting Agency for Clinical Laboratory Sciences (NAACLS).

Fundamental knowledge of:

■ principles of basic and special blood collection procedures

■ basic anatomy and physiology and biological aspects of the human body
■ preanalytic (preexamination) variables
■ standard operating procedures (SOPs) for laboratories
■ medical terminology
■ regulatory requirements
■ patient and personal safety
■ infection control

Decision-making skills related to:

■ the correct course of action

■ selecting equipment/methods/reagents/samples
■ applying quality control procedures
■ selecting the most appropriate site for blood collection

Ability to prepare the follow ing for a phlebotomy procedure:

■ patients
■ phlebotomy supplies and equipment
14 C hapter 1 Phlebotomy Practice and Quality Assessment

Evaluation skills related to:

■ specimen and patient situations

■ care of the patient after the procedure
■ quality control procedures
■ actions during adverse patient reactions
■ sources of preanalytic (preexamination) variables
■ common procedural/technical problems
■ corrective action

At minimum, BOX 1 -4 shows the types of competencies that an employer might

assess for the phlebotomises performance evaluation. Competency statements describe
the entry-level skills and tasks performed by phlebotomy technicians and measured
on certification examinations. However, professional practice, experience, and continu­
ing education contribute to a well-rounded, successful career in phlebotomy. Employee
performance evaluations are important to both the employee and the employer because
they provide feedback, identify problems early on, encourage employees to improve
their skills and knowledge of policies, target specific improvements, and document that
employees are competent in their job duties. Evaluations play a key role in determining
who gets a raise or promotion when those opportunities are present. Box 1-A describes
examples of typical job duties for phlebotomists.

BOX 1-4

Typical Clinical, Technical, and Clerical

Duties and Attributes of Phlebotomists
W h a t are th e clinical duties o f phlebotom ists?
■ Communicate professionally with patients and coworkers.
■ Identify the patient correctly.
■ Assess the patient before blood collection.
■ Prepare the patient accordingly.
■ Perform the puncture.
■ Withdraw blood into the correct containers/tubes.
■ Assess the degree of bleeding and pain.
■ Assess the patient after the phlebotomy procedure.
W h a t kind o f technical duties do phlebotom ists have to perform ?
■ Manipulate small objects, tubes, and needles.
■ Select and use appropriate equipment.
■ Perform quality control functions.
■ Transport the specimens correctly.
■ Prepare/process the sample(s) for testing/analysis.
■ Assist in laboratory testing procedures, washing glassware and cleaning equipment.
W h a t clerical duties are expected o f phlebotom ists?
■ Print/collate/distribute laboratory requisitions and reports.
■ Work on secure computers, faxes, printers, and telephones.
■ Answer all queries as appropriate.
■ Demonstrate courtesy in all patient encounters.
■ Always respect privacy and confidentiality (on and off the job).
 C hapter 1 Phlebotomy Practice and Quality Assessment

BOX 1—4 (continued)

W h a t kinds o f policies m ust a phlebotom ist adhere to?

■ Safety in the laboratory and in patients' rooms.

■ Infection control, gowning/gloving, and hand hygiene.
■ Fire prevention and control.
■ Dress codes.
■ Attendance, sick leave, and vacation.

W h a t kind o f com m unication skills do phlebotom ists need?

■ Verbal skills.
■ Nonverbal skills.
■ Listening skills.
■ Telephone etiquette.
■ Written communication.
■ Use of medical terminology appropriate for patients and coworkers.
■ Management of angry or difficult patients.

How is th e q u ality and productivity o f a phlebotom ist's w o rk measured?

■ Quality can be measured by waiting times, lack of complications or mistakes, contamina­

tion rates, etc.
■ Workload metrics are often used to evaluate efficiency such as the amount of work pro­
cessed in a given period of time.
■ Productivity is also measured by the time and attention given to patients and to detailed
procedures, and by the throughput of work based on how much work is completed during
specified amounts of time.

Professionalism is the skill, competence, or character expected of an individual in a

trained profession. It is hard to describe without sounding like one must achieve perfec­
tion. However, health care workers can use four categories to "frame" their concept of
professionalism.3Refer to FIGURE 1-4.

FIGURE 1 -4
RESPECT Four Categories of Professionalism

This health care worker is the "picture of professionalism." Each side of the frame is an important
aspect of her career:

■ Respect— For others, in personal appearance and in organizational policies/procedures such

as patient confidentiality; for coworkers; and of cultural and/or racial differences
■ Service— Shift focus from oneself to others; com m it to one's job duties and to effective
communication
■ Support — Maintain a clean workspace; report errors and damaged equipment or supplies;
exhibit courteous behavior; engage one's employer by respectfully disagreeing and offering
solutions to problems
■ Growth— Learning more about one's job and other aspects of the organization and employees
who help run it

SERVICE
Another random document with
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"It is very evident," muttered one of the party with a scarcely stifled
groan—"it is very evident, my Diego, that you count amongst the
number of your friends none of those whose names, or position, or
country, place them in jeopardy."
"Ah! indeed," added another, without perceiving the flush that
suddenly deepened on the young noble's cheeks, "and it is easy
enough to discover, even if one had not known it, that Diego has
neither wife nor child for whose sake to feel a due value for his life
and lands."
Again that sudden flush on the handsome face, but Montoro stood in
shadow, and none marked it. The gathering of men, now turned into
a band of conspirators, was more intent on learning from Montoro de
Diego whether he meant to betray their purpose, than in taking note
of his own private emotion, and once assured of his silence they let
him depart, while they remained yet some time longer in secret
conclave, to concert their plans for destroying Arbues and the
Inquisition both together.
"There cannot be much difficulty one would imagine," muttered one
of the conspirators, "in compassing the death of a wretch held in
almost universal odium."
But others of the party shook their heads, while one, more fully
acquainted with the state of affairs than the rest, replied moodily:
"Nay then, your imagination runs wide of the mark. The difficulty in
accomplishing our undertaking will be as great as the danger we
incur. The cruel are ever cowards. Arbues wears mail beneath his
monastic robes, complete even to bearing the weight of the warrior's
helmet beneath the monk's hood. And his person is diligently
guarded by an obsequious train of satellites."
"Then we must bribe the watch-dogs over to our side," was the stern
remark of the haughty Don Alonso, who had been the first to seize
upon the suggestion thrown out by the unknown voice in the crowd.
Immediately after that declaration the noblemen dispersed, for it was
not safe just at that time for men to remain too long closeted
together.
 CHAPTER III.
RIVALS AT DON PHILIP'S HOUSE.
When Montoro de Diego quitted the palace of Don Alonso his face
betokened an anxiety even greater than that warranted by the
conversation in which he had just taken part. To say truth his secret
belief was, that the deadly decision arrived at by his friends was the
frothy result of recent disappointed hopes, and that with the calming
influence of time bolder and more honourable counsels would
prevail. As he left the palace, therefore, he left also behind him all
disquietudes especially associated with the late discussion, and the
settled gravity of his face now belonged to matters of more private
interest.
Don Alonso had declared, that it was easy enough to see that Don
Diego had no friends amongst those looked upon with evil eyes by
the authorities of the Inquisition. But Don Alonso was wrong. The two
friends whom Don Diego valued more highly than any others upon
earth were reputed of the race of Israel. Christians indeed, for two
generations past, but still with a true proud gratitude clinging to the
remembrance that they had the blood in their veins of the "chosen
people of God." They were Don Philip and his daughter Rachel.
Don Miguel had remarked with something of a sneer that it was easy
enough to remember, from his present action, that Don Diego was
unencumbered with family ties. And Don Miguel was so far right that
Montoro de Diego was as yet a bachelor. But he was on the eve of
marriage with Don Philip's daughter, and the words of his fellow-
nobles had rung in his ears as words of evil omen. As he paced
along the streets he tried in vain to shake off his dark forebodings,
and it was with a very careworn countenance that he at length
presented himself at the home of his promised bride.
To his increased disturbance, upon being ushered into the presence
of Don Philip and his daughter, the young nobleman found a stranger
with them; at least, one who was a stranger to him, though
apparently not so to his friends, with whom he appeared to be on
terms of familiar intercourse.
Don Diego at once took a deep aversion to the interloper, for he had
entered with the full determination to press upon Rachel and Don
Philip the expediency of an immediate marriage, in order that both
father and daughter might have the powerful protection of his high
position, and undoubted Spanish descent and orthodoxy. But it was,
of course, impossible to speak on such topics in the presence of a
stranger. So annoyed was he that his greetings to his betrothed bride
partook of his constraint, and the girl appeared relieved when her
father called to her:
"Rachel, my child, the evening is warm; will you not order in some
fruit for the refreshment of our guests?"
As the beautiful young girl left the apartment in gentle obedience to
her father's desire the stranger followed her with his eyes, saying
with studied softness:
"Your daughter is so lovely it were a pity that she had not been
dowered with a fairer name."
The old man sighed before replying: "Perchance, Señor, you are
right. And yet, in my ears the name of Rachel has a sweetness that
can scarcely be surpassed."
"It might sound sweeter in mine," rejoined the stranger still in tones
of studied suavity, "if it were not one of the names favoured by the
accursed race of Israel."
A momentary flash shot from the eyes of Don Philip, but hastily he
dropped his lids over them as he answered with forced quietude:
"Doubtless I should have bestowed another name upon my child had
I foreseen these days, when it is counted for a crime to be
descended from those to whom the Great I Am, in His infinite
wisdom, gave the first Law and the first Covenant."
He ceased with another low, quiet sigh, and a short silence ensued,
during which Don Diego felt rather than saw the sharp, searching
glances being bestowed upon himself by the stranger, who at length
rose, and said coolly:
"Ay, truly, Don Philip, a crime it is in the eyes of Holy Mother Church
to have aught to do, even to the extent of a name, with the accursed
race, and so, to repeat my offer to you for the hand of your fair
daughter. I support my offer now with the promise—not a light one,
permit me to impress upon you—to gain the sanction of the Church
that her old name of Rachel shall be cancelled, and a new and
Christian one bestowed upon her?"
As he finished speaking he turned from Don Philip with a look of
insolent assurance to Don Diego, who in his turn had started from
his seat, and stood with nervous fingers grasping the hilt of his
rapier. As the nobleman met the sinister eyes, full of an impertinent
challenge, he made a hasty step forward with the haughty
exclamation:
"And who are you pray, sir, who dare ask for the hand of one who is
promised to Don Montoro de Diego? Know you, sir, that the daughter
of Don Philip is my affianced bride?"
"I have heard something of the sort," was the reply, in a tone of
indescribable cool insolence. "Yes; I have already learnt that you
have had eyesight good enough to discover the fairest beauty in
Saragossa. But you had better leave her to me, noble Señor. She
will be—" and the speaker paused a moment to give greater
emphasis to his next slowly-uttered words—"she will be safer with
me than with you—and her father also." And with a parting look and
nod, so full of latent knowledge and cruel determination that Don
Diego's blood seemed to freeze in his veins as he encountered
them, the new aspirant for the beautiful young heiress took his leave.
As the great iron-bound outer door clanged to, behind him, the head
of the old man sank forward on his breast with a groan. His daughter
re-entered the apartment at the moment, and the smile which had
begun to dawn on her countenance at the departure of the
unwelcome guest gave way to a cry of dismay. Flying across the
floor she threw herself on the ground beside her father with a pitiful
little cry.
"Oh! my father, are you ill?—What ails you, my father?"
For some seconds the old man's trembling hand tenderly caressing
the soft hair was the only answer. At last he asked with a choked
voice:
"My daughter—couldst thou be content to wed yon Italian?"
The words had scarcely passed his lips when the girl sprang to her
feet, gazing with wild eyes at her questioner.
"Kill me, my father, but give me not to yon awful, hateful man.
Besides—" and with a look of agonized entreaty she turned towards
Don Diego—"besides, am I not already given by you to another?"
"And to another who has both the will and the power to claim the
fulfilment of the promise," exclaimed Montoro de Diego, coming
forward, and clasping the girl's hand in his with an air of iron
resolution.
Once again there was a heavy silence in the darkening chamber,
and when it was broken the hearers felt scarcely less oppressed by
the sound, although the words themselves seemed to speak of
happiness.
"My son," said the old man in low and urgent tones, "it is true, I have
given you my child—my only one. Fetch the good old priest Bartolo
now, at once, and secretly, and let him within this hour make my gift
to you secure."
A faint protest against this sudden, unexpected haste was made by
the young bride, but Don Diego needed no second bidding to the
adoption of a course he considered to be dictated as much by
prudence as affection. Two hours later Montoro de Diego wended his
way to his own palace with his young wife, Rachel Diego, by his
side.
"Do not weep so, my Rachel," entreated the young nobleman as he
led his bride into her new home.
But the tears of the agitated girl flowed as bitterly as ever as she
moaned, "My father—oh! my father! If but my father had come with
us!"
"He has promised to take up his abode with us, if possible, within the
next few weeks, my Rachel," returned Montoro de Diego, in the vain
endeavour to give her comfort. But she dwelt upon the words, "if
possible," rather than upon the promise. She guessed but too well
the fears which had dismissed her thus summarily from her father's
home. She had heard but too much of the hideous tragedies of the
past two months, and her husband himself was too oppressed with
forebodings to give her consolation in such a tone of confidence as
should secure her belief.
Don Philip had offered his life for his daughter's happiness, and his
daughter well-nigh divined the fact.
Had the Christianized Jew consented to give his daughter, and his
daughters princely fortune, to the vile informer of the Inquisition, he
would have escaped harm or persecution, at any rate for that
season. But he counted the cost, and taking his life into his hand, for
the sake of his child's happiness, he committed her henceforth to the
loving charge of the noble-hearted Don Diego. The fulfilment of the
sacrifice was not long delayed.
The days went by, and the weeks—one—two—three. The second
day of the fourth week was drawing to its close, since the group of
Spanish noblemen had muttered their passionate resolves to rid their
Aragon of Arbues de Epila. They had not been idle since then. Time
had not quenched their burning indignation, but rather fanned it
fiercer as they gathered fresh adherents, and gold, that ever needful
aid in all enterprises. But the one adherent Don Alonso and Don
Miguel most longed for still held aloof.
The lengthening shadows of that day belonged also, as the reader
knows, to the second day of the fourth week since Don Diego's
marriage, and his new ties made him but increasingly anxious to
keep in the most careful path of rectitude, for the sake of expediency
now as much as honour.
The name of Montoro de Diego was hitherto so unblemished, his
rank was so important, that he might well believe himself a safe
protector for his young bride, and for his new father-in-law, even
though it was not wholly unmixed, pure Spanish blood that flowed in
their veins. And he was firm in his refusal to have any part in
schemes of danger. His wife was safe, hidden up in the recesses of
his palace; and his father-in-law, he trusted, had secured safety in
flight.
On the day succeeding that on which Don Philip had refused to
purchase peace at the price of his daughter's welfare, Rachel Diego
had received a few hurried lines of farewell from him, saying that he
was going into exile until safer times for Saragossa, and bidding her
be of good cheer, as all immediately concerning themselves now
promised to go well.
Under these circumstances Don Diego might be pardoned, perhaps,
if for a time he forgot the miseries surrounding him—forgot his hopes
to infuse a bolder, nobler spirit of upright resistance to evil, into his
comrades, and rested content with his own happiness.
But there came a dark awakening.
The day had been one of dazzling heat; and as the sun's rays grew
more and more slanting, and the shadows longer, Don Diego bid his
gentle young wife a short adieu, and sauntered forth to draw, if
possible, a freer breath out-of-doors than was possible within.
He had been more impatient in seeking the evening breeze than
most of his fellow-citizens, for the streets were still almost deserted.
There was but one pedestrian besides himself in sight, and Montoro
de Diego was well content to note that that one was a stranger, for
he was in no mood just then for parrying fresh solicitations from his
friends by signs, and half-uttered words, to join their secret counsels.
He was sufficiently annoyed when he perceived at the lapse of a few
seconds that even the stranger was evidently bent on accosting him.
Determined not to have his meditations interrupted he turned short
round, and began to retrace his way towards his own abode.
But not so was he to secure isolation. The rapid pitpat of steps
behind him quickly proved that the stranger was as desirous of a
meeting as he was wishful to avoid it; and scarcely had the Spanish
nobleman had time to entertain thoughts of mingled wonder and
annoyance, when he shrank angrily from a tap on his arm, and faced
round to see what manner of individual it might be who had dared
such a familiarity with one of the grandees of Aragon. The
explanation was sudden and complete.
A low, mocking laugh greeted the involuntary widening of his eyes.
Don Diego stood face to face with the man he had seen but once
before; but that was on an occasion never to be forgotten, for it was
the evening of his marriage, and the man before him was the one
who had dared try to deprive him of his bride. For that he bore him
no love, nor for the hinted threats then uttered; but now his blood
curdled with instinctive horror as he gazed at the sinister, cruel face
mocking his with an expression on it of such cool insolence.
Don Diego's most eager impulse was to dash his companion to the
ground and leave him; but for the first time in his life fear had gained
possession of him. Fear, not for himself, but for those whom he held
more precious.
"Why do you stay me? What would you with me?" he questioned at
last, in tones that vainly strove for their customary accent of
haughtiness. The cynical triumph of the Italian grew more visible.
"Meseems, my Señor," he replied with a sneer; "meseems from your
countenance, and your new-found humility of voice, that your heart
must have prophesied to you that matter anent which I have stayed
you, that counsel that I would, for our mutual advantage, hold with
you. It is of Don Philip and his daughter Rachel that I wish to speak
with you."
Montoro de Diego inclined his head in silent token of attention, and
the foreigner continued in slow, smooth speech:
"Doubtless, my Señor, you remember that in your presence, some
few weeks ago, I made proposals of marriage for the fair, rich
daughter of Don Philip. The night of the day on which I made these
proposals the birds flew from me, and from my little hints in case of
contumacy, out of Saragossa. That was a foolish step to take, my
Señor, was it not?"
He paused for an answer, and the dry lips of Don Diego replied
stiffly: "Don Philip asked me not for counsel in his actions, neither did
I give it."
"Ah!" resumed the Italian with a second sneer, "that may perchance
be a true statement, Don Diego; but I shall be better inclined to
accept it worthily, when you shall now reverse your professed
behaviour, and accept the post of adviser to the obstinate heretic."
"I cannot," was the hasty exclamation. "Don Philip is no heretic, but a
faithful son of the Church, and I have no clue to his retreat."
"Then I can give you one," was the low-spoken answer. "Don Philip
has been tracked, and brought back. But his daughter is not with
him. He refuses to confess her hiding-place, although he is now in
the dungeons of the Holy Inquisition, and can purchase freedom by
the information."
"Cruel, black-hearted villain!" exclaimed Don Diego, shocked and
infuriated at length beyond all prudence; "know this, that Rachel,
daughter of Don Philip, is now my bride. And know this yet further,
that the nobles of Aragon are not yet so ground beneath the feet of a
new dominion that they cannot protect their wives, and those
belonging to them, from the perjured baseness of dastards who
would destroy them."
Once more the young nobleman turned to quit his abhorred
companion, but once more that hated touch fell upon his arm, and
the Italian again confronted him with a face literally livid with malice
as he hissed out:
"The nobles of Aragon are doubtless all-powerful, my Señor, and yet
for your news of your bride I will give you news of her father. Ere this
hour to-morrow the burnt ashes of his body will have been scattered
to the four winds of heaven. Take that news back to your bride to win
her welcome with."
Don Diego was alone. Whether he had been leaning against the
walls of that heavy portico five seconds, five minutes, or five hours,
he could scarcely tell when he became conscious of his own painful
reiteration of the words, "Ere this hour to-morrow—ere this hour to-
morrow."
"What is the matter, Montoro? rouse yourself. What about this hour
to-morrow?" asked the voice of Don Alonso at his elbow. And
Montoro shudderingly raised himself from the wall, looked with
dazed eyes at his friend, and repeated:
"Ere this hour to-morrow. Will she know?"
"Will who know?" again questioned Don Alonso, as he passed his
arm through his friend's and drew him on, for the street was no
longer empty. Doors were opening on all sides, and the people
pouring forth to the various entertainments of the evening. Some
curious glances had already been cast at Don Diego, as he leant
there stupefied with horror and anguish for his wife's threatened
misery.
In the early part of the evening the Italian tool of the Inquisition had
sought Don Diego. When evening had given way to night, Don Diego
sought the Italian, and as a suppliant.
"It ill suits an Aragonese to sue to the villain of a foreigner," said the
wretch, with malicious sarcasm. "It makes me marvel, my Señor, that
you should deign thus to condescend."
"I marvel also," murmured the Spaniard, rather to himself than to his
unworthy companion. "When the sword of the Moor was at my throat
I disdained to sue for mercy; when I lay spurned by the pirate's foot I
felt no fear; but now—ay now, if you will—I will give you the power to
boast that one of the greatest of the nobles of Aragon has knelt at
your feet to sue for a favour at your hands."
"And you will not deny the humiliating fact if I should publish it?"
demanded the Italian, with a half air of yielding, and Montoro Diego,
with a light of hope springing into his face, exclaimed:
"No, no. I will myself declare the deed, if for its performance you will
obtain me the life and freedom of Don Philip."
Like a drowning man stretching forth to a straw, Montoro had
snatched at a false hope. With that low, mocking laugh that issued
freely enough from his thin, cruel lips, the Italian said slowly:
"Ah! your wish is very great, my Señor, I see that—truly very great to
save a heart-ache to your bride. But—see you—you have hindered
Jerome Tivoli of his desire, and now it is his turn, the turn of the
'base, black-hearted villain,' Jerome. And he takes your desire into
his ears, he tastes it on his palate, it is sweet to him, sweetened with
the thought of revenge, and then—he spurns it—spits it forth from
him—thus!"
The Aragonese tore his rapier from its sheath, and darted forward,
his fierce southern blood aflame with fury at the insult. But his
companion stood there coolly with folded arms, content to hiss
between his teeth:
"We are not unwatched, my Señor. I have plenty to avenge me if you
think Doña Rachel will be gratified to lose husband now as well as
father."
The mention of his wife was opportune. It restored Don Diego to his
self-control. With a mighty effort mastering his pride, he collected his
thoughts for one final attempt on behalf of the good old man doomed
so tyrannically to an awful death.
Before seeking this second interview with the foreigner Montoro de
Diego had schooled himself to bear everything for the sake of his
one great object, and although for a moment he had allowed self to
rise uppermost, he now once more crushed it down, and returned to
the attitude of the humble suppliant.
He did not indeed repeat the offer, so insultingly rejected, to kneel to
the informer, but he appealed earnestly to more sordid instincts. The
man had alluded to Don Philip's daughter as rich as well as beautiful,
and he now offered him the heiress's wealth as compensation for the
loss of the heiress herself.
As he spoke a sudden gleam of satisfaction shot into the Italian's
eyes, and a second time a hope, far greater than the first, rose in the
petitioner's heart; but yet again it was dashed to the ground. Just as
he was prepared to hear that his terms were agreed upon, his
companion's countenance underwent a sudden change. A shadow
had just fallen across the floor, and with a heavy scowl replacing the
expression of greed he bent forward with the hasty mutter:
"Fool of a Spaniard, has that idiot tongue of thine but one tone, that
thou must needs screech thy offers, like a parrot from the Indies, into
all ears that choose to listen?" Then aloud, as though in continuation
of a widely-different theme: "And so, as I tell thee, thy offers go for
nought, for the wealth will of right flow into the coffers of the Sacred
Office when the accursed Jew shall have suffered in the flesh to
save his soul. And now," insolently, "I have no more time to listen to
thy prating, and so go."
Whether he went of his free will, or was turned out, Montoro de
Diego never clearly remembered, but on finding himself beneath the
starry sky, he dashed off to the palace of the dread Arbues himself.
Well-nigh frantic with despair, as he thought of the torments that the
aged prisoner was even then all too probably undergoing, he forced
admittance, late though the hour was, to the presence of the stern
ecclesiastic, who was prudently surrounded by guards even in the
privacy of his own supper-room. Nothing short of the great influence
of Don Diego's high rank would have enabled him to penetrate so
far, but even that did not protect him from the Inquisitor's rebuke, nor
gain him a favourable hearing for his cause.
"It is our blessed office," said the bigoted supporter of Rome's worst
errors, "to purge the Church, to—"
"If Don Philip die, others will die with him," sharply interrupted the
young Spaniard, with fierce significance, and he left the Inquisitor's
palace as abruptly as he had entered it, half determined, in that bitter
hour, to throw in his lot with the conspirators. If there were none to
listen to reason, none to obey the dictates of justice or mercy, why
should he maintain alone his integrity?
So passion and despair tried to argue against his conscience, as he
retraced his steps to his own home and the waiting Rachel. But the
events of that night were not yet over.
 CHAPTER IV.
THINKING OF EXILE.
As Montoro de Diego entered the deep portico of his palace
entrance, he stumbled against some obstruction in the way. He
stooped, and found there was a man dead, or in a deep swoon, lying
at his feet.
Before he could ascertain more, or summon his servants, a third
person stepped out of the obscurity and muttered rapidly:
"Remember, the gold is to be mine. It is not my fault that he has thus
suffered before release."
Then the whisperer of those significant words was gone, and the
young man was alone with the prostrate form of his father-in-law.
Relinquishing his intention to call for aid, he lifted the inanimate body
in his own strong arms, and bore his burden into a small inner
apartment, reserved for his own devotion to such learned studies as
were then flourishing in Aragon under the fostering care of royal
encouragement. Something of medicine and surgery he had also
acquired, but he soon discovered with bitter sorrow that in the
present case his skill was useless. The old man was dying. Every
limb had been dislocated on the rack.
"They tortured me to try to extort the secret of my child's hiding-
place," murmured the old man quietly. "But thanks be to the Lord, He
gave me strength. This day I shall be with Him. They have but
hastened my coming home, my children."
And so, with forgiveness and love in his heart, and the light of
coming glory on his face, this rescued victim of the Inquisition died in
his daughter's arms, just as the sun's first golden rays were
brightening the streets of Saragossa. Those rays that were glowing
on the walls of the dungeons, within which slept, for the last time on
earth, those innocent ones who were that day to be burnt in one of
the awful Autos da Fé; those rays that were glowing on the walls and
windows of the palace where Arbues the Inquisitor still slumbered.
"For so He maketh His sun to shine on the evil and the good."
The morning was still young when Don Diego received two visitors.
The first, Jerome Tivoli, was quickly dismissed with the curt but
satisfying speech:
"A noble of Aragon ever keeps his word. The miserable treasure you
crave is yours."
His interview with Don Alonso was far longer.
"Surely now you must join us," urged that fiery spirit with impatient
indignation. "You cannot refuse to aid in avenging the wrongs of your
father-in-law."
"His mode," murmured the other, "of avenging his own wrongs, was
to pray for light for his murderers."
But Don Alonso was marching with hasty strides up and down the
apartment, and did not hear the words. His own conscience was ill at
ease, as the head of conspirators having assassination for their
object, and he had an unacknowledged feeling that he would be
more comfortable in his mind if the upright Montoro would throw in
his lot with them. But Don Diego was firm in his refusal. That recent
death-bed scene had given him back his faith in the wisdom and love
of God, in spite of the darkness now around him, and he ended the
discussion at last, by saying:
"No, Alonso, I will keep my honour whatever else I may be forced to
lose. But, although I will not join you, I will tell you whom I would join,
were my Rachel a man, or, being a woman, had she but been inured
to hardships as a mountain peasant. I would suffer exile thankfully,
so embittered to me has my native land become."
"Embittered indeed to us all," almost groaned the other, adding, "But
whom then is it you would join in your exile? Any of our friends, or
one I know not?"
"One you know not, nor I either, personally," was the reply; "but one
whom we both know well by reputation. That Christopher Colon, the
Genoese, who, for the past six months almost, has been wearying
our Queen Isabella of Castile to provide him means to find some
strange new world; some vision of wonder that has risen in his
imagination, brilliant with lands of gold and pearl, and perfumed with
sweeter spices than the Indies."
Don Alonso uttered a short laugh of contempt.
"Ah, ha! And you mean to tell me that you would be willing to throw
in your lot with that beggarly, visionary adventurer! Our King
Ferdinand knows better than to waste his maravedis on such moon-
struck projects, or to let his consort do so either."
"And yet," said Montoro, somewhat doubtfully, "and yet, although of
course new worlds are foolishness to dream of, some islands might
perchance fall to our share, if we adventured somewhat to find them,
as such good and profitable prizes have been falling, during the past
fifty years, pretty plentifully, to our clever neighbours, the
Portuguese."
"Ay, and even they won't listen to this Genoese, you may recollect.
Besides, the Pope has given everything in the seas and on it, I have
heard, to those lucky neighbours of ours, so of what use for
Spaniards to jeopardize lives and treasure to benefit the
Portuguese?"
"Nay," answered Don Diego, "the Pope's grant to them is only for the
countries from Cape Horn to India. Why should not we obtain a grant
for lands in the other hemisphere?"
And so the poor young nobleman tried to stifle grief and
apprehension in dreams of other lands, of whose discovery he would
not live to hear, although his son would one day help others to found
new homes on their far-off soil.
 CHAPTER V.
DEATH FOR ARBUES DE EPILA.
The days went by; the days of that year, 1485: and still the hideous
spectacles of the Auto da Fé continued to be witnessed with shame
and anguish by the inhabitants of Saragossa. Still the cry of the
tortured victims ascended up to heaven, and still Arbues de Epila
lived in his case of mail.
Those were busy, agitating days for Spain. The war with Granada
was still in progress. King Ferdinand was much exercised in mind
with various jealousies connected with French affairs, and, more
than all important for future ages, the Queen's confessor, Ferdinand
di Talavera, together with a council of self-sufficient pedants and
philosophers, was taking into consideration that request of the
Genoese, Christopher Colon, or, as we call him, Columbus, to be
provided with such an equipment of ships, men, and necessary
stores, as should enable him to find and found countries hitherto
unheard of, and only thought of, most people declared, by crack-
brained dreamers.
"Besides," finally decided Talavera and his sage council, with
pompous absurdity; "besides, if there were nothing else against this
scheme, such as the convex figure of the globe, for instance, which,
of course, would prevent vessels ever getting back again, up the
side of the world, once they got down, there was the impudence of
the suggestion. It was presumptuous in any person to pretend that
he alone possessed knowledge superior to all the rest of the world
united."
And such impertinent presumption was certainly not to be
encouraged in an "obscure Genoese pilot." And so, for that while,
after weary waiting, and the weary hope deferred that maketh the
heart sick, Columbus and his splendid plans were dismissed. But
this result was not arrived at until four years after the months with
which we are, for the minute, more immediately concerned; and so
to return to the thread of our narrative, and to add yet further—and
still the men of Saragossa gathered into secret bands, discussing
rather by tokens, than by words, the unspeakable cruelties that were
being committed in their midst, and the proposed destruction of their
arch-instigator, Arbues de Epila.
All was ripe at length for the fulfilment of the fatal plot; fatal, alas, not
only to the Inquisitor, but to his murderers also, and to many and
many another wholly innocent of the crime.
All day long Don Alonso, Don Miguel, Don James of Navarre, with
the rest of the conspirators, many of them with the noblest blood of
Aragon flowing in their veins, watched with a fierce, hungry
eagerness for the moment in which to strike the blow. The hours
wore on, the evening came. In low-breathed murmurs one and
another rekindled their own fury, or revived the flagging courage of a
companion, by recalling the generosity of character, the blameless
life, of some friend or relative snatched out of life by this barbarous
persecution.
Night fell over the city of Saragossa, and gradually the conspirators
stealthily, silently drew round about the walls of the cathedral. It was
approaching midnight. The fierce persecutor of his fellow-men was
on his knees before the great altar of the cathedral, on his knees
before Him who has said, "I will have mercy, and not sacrifice."
Arbues knelt there in the flood of brightness from the lighted altar,
and his enemies gathered up around him in the gloomy shadows of
the surrounding darkness. Suddenly there was a muffled shout—a
cry. He raised his head;—too late,—escape was impossible. Already
the arm and hand were streaming with blood that had signed so
many warrants for the torture and death of others. Then came the
fatal blow.
 Arbues knelt there in a flood of brightness from the lighted altar.
Suddenly there was a muffled shout—a cry. He raised his head;—too
late,—escape was impossible.

A dagger shone, gleaming red with life-blood, in the light, from the
back of the victim's neck, in the flesh of which its point was firmly
embedded.
Who gave that final thrust none knew but the giver. Only Don Miguel,
who stood by in the fierce crush and melée, heard the words hissed
out as the deadly weapon was darted forth:
"So dies the fiend, Arbues de Epila!"