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 Becan-McBride
Garza
TENTH EDITION

PHLEBOTOMY

PHLEBOTOMY HANDBOOK
HANDBOOK
B LO O D S P E C I M E N C O L L E C T I O N F R O M B A S I C T O A DVA N C E D

Diana Garza
Kathleen Becan-McBride

FROM BASIC TO ADVANCED

BLOOD SPECIMEN COLLECTION

www.pearson.com

ISBN-13: 978-0-13-470932-1
ISBN-10: 0-13-470932-2
9 0 0 0 0

9 780134 709321

Garza_mech.indd 1 3/9/18 2:19 PM

 Contents vii

Other Factors Affecting the Patient 295 Procedure 10–3 Basics of Patient Identification 325
Complications Associated with Test Requests and Special Considerations 326
Identification 296 Identity Errors are Preventable 328
Identification Discrepancies 296 Equipment Selection and Preparation 329
Time of Collection 296 Supplies for Venipuncture 329
Requisitions 296 Venipuncture Site Selection 330
Complications Associated with the Specimen Collection Tools to Make Difficult Veins More Prominent 336
Procedure 296 Procedure 10–4 Use of a Tourniquet and Vein Palpation 337
Tourniquet Pressure and Fist Pumping 296 Procedure 10–5 Cleansing the Puncture Site 339
Failure to Draw Blood 297 Tourniquet Application 340
Backflow of Anticoagulant 298 Decontamination of the Puncture Site 340
Fainting (Syncope) 298 Venipuncture Methods 340
Hematomas 300 Evacuated Tube System and Winged Infusion System, or
Petechiae 300 Butterfly Method 340
Excessive Bleeding 300 Procedure 10–6 Performing a Venipuncture Using the
Nerve Complications 300 Evacuated Tube Method 341
Seizure during Blood Collection 300 Procedure 10–7 Hand Vein Venipuncture Using a
Hemoconcentration 300 Winged Infusion/Butterfly Set 347
Intravenous Therapy 301 Syringe Method 350
Hemolysis 301 Procedure 10–8 Syringe Method 351
Collapsed Veins 302 Failure to Collect Blood after a Puncture 353
Improper Collection Tube 302 Order of Draw for Blood Collection Tubes 354
Self Study Manufacturers of Blood Collection Tubes 357
Study Questions 304 Specimen Identification and Labeling 357
Case Study 305 Caring for the Puncture Site 358
Action in Practice 1 305 Disposal of Used Supplies and Equipment 359
Action in Practice 2 305 Patient Assessment at the End of the Venipuncture
Competency Assessment 306 Procedure 359
References 306 Other Issues Affecting Venipuncture Practices 360
Resources 307 Self Study
Study Questions 365
CHAPTER 10 Venipuncture Case Study 1 366
Procedures 308 Case Study 2 366
Action in Practice 366
Chapter Learning Objectives 308 Competency Assessment 367
Key Terms 308 References 369
NAACLS Entry-Level Phlebotomist Competencies 309 Resources 370
Blood Collection 310
Health Care Worker Preparation 310 CHAPTER 11 C
 apillary or Dermal Blood
Procedure 10–1 Preparing for the Patient Encounter 312
Specimens 371
Procedure 10–2 Hand Hygiene and Gloving
Technique 315 Chapter Learning Objectives 371
Precautions 317 Key Terms 371
Needlestick Prevention Strategies 317 NAACLS Entry-Level Phlebotomist Competencies 372
Approaching, Assessing, and Identifying the Patient 318 Indications for Skin Puncture 372
Initial Introduction and Patient Approach 318 Composition of Capillary Blood 373
Physical Disposition of the Patient 320 Basic Technique for Collecting Diagnostic Capillary
Positioning of the Patient and the Health Care Worker 322 Blood Specimens 374
Test Requisitions 324 Preparation for Skin Puncture 376
Patient Identification Process 324 Supplies for Skin Puncture 376
viii Contents

Skin Puncture Sites 378 Self Study

Improving Site Selection 379 Study Questions 419
Cleansing the Skin Puncture Site 380 Case Study 1 420
Skin Puncture Procedure 380 Case Study 2 420
Procedure 11–1 Acquiring a Capillary Case Study 3 420
Blood Specimen (Dermal or Skin Puncture) Action in Practice 420
Using a Retractable Safety Device 381 Competency Assessment 421
Order of Collection 385 References 422
Blood Films/Slides for Microscopic Analyses 386
Resources 422
Procedure 11–2 Blood Smears/Films/Slides for
Microscopic Analysis 387
PART IV P
 oint-of-Care Testing and
Other Considerations for Capillary Blood Samples 390
Test Results Notations Due to Differences in Type of
Special Procedures
Specimen 390
Microhematocrit and Other Hematology Specimens 390 CHAPTER 13 P
 ediatric and Geriatric
Blood pH and Blood Gas Determinations 390 Procedures 423
Completing the Interaction 390 Chapter Learning Objectives 423
Disposal 390 Key Terms 423
Labeling 390 NAACLS Entry-Level Phlebotomist Competencies 424
Completing the Patient Interaction 391 Pediatric Patients 424
Future Trends 391 Age-Specific Care Considerations 425
Self Study Preparing Child and Parent 425
Study Questions 392 Psychological Response to Needles and Pain 428
Case Study 1 393
Distraction Techniques 428
Case Study 2 393
Room Location 428
Case Study 3 393
Equipment Preparation for a Friendlier Environment 428
Action in Practice 1 393
Positions for Restraining a Child 429
Action in Practice 2 393
Combative Patients 430
References 395
Decreasing the Needlestick Pain 430
Resources 395
Oral Sucrose 431
Precautions to Protect the Child 431
CHAPTER 12 Specimen Handling,
Latex Allergy Alert 431
Transportation, and
Pediatric Phlebotomy Procedures 431
Processing 396 Microcapillary Skin Puncture 431
Chapter Learning Objectives 396 Skin Puncture Sites 432
Key Terms 396 Procedure 13–1 Heel Stick Procedure 433
NAACLS Entry-Level Phlebotomist Competencies 397 Capillary Blood Gases 436
Specimen Handling After the Venipuncture 397 Procedure 13–2 Collection for Capillary Blood Gas
Specimen Delivery Methods 404 Testing 437
Hand Delivery 405 Neonatal Screening 439
Pneumatic Tube Systems 405 Procedure 13–3 Collection of Capillary Blood for
Transportation by Automated Carrier 406 Neonatal Screening 440
Transportation by Drone 406 Fingerstick on Children 442
Processing the Specimen on Arrival at the Clinical Venipuncture on Children 442
Laboratory 406 Collecting Blood from IV Lines 446
Shipping Biohazardous Specimens 413 Procedure 13–4 Procedure for Heparin or Saline Lock
Reporting Laboratory Results 417 Blood Collection 447
Written Reports 417 Procedure 13–5 Procedure for Central Venous
Verbal Reports 417 Catheter Blood Collection 448
Computerized Reports 418 Geriatric Patients 450
 Contents ix

Considerations in Home Care Blood Collections 453 Procedure 15–3 Safety Butterfly Assembly Blood
Self Study Culture Collection 479
Study Questions 454 Procedure 15–4 Evacuated Tube System for Blood
Case Study 455 Culture Collection 481
Action in Practice 455 Procedure 15–5 After Blood Culture Collection by the
Previous Methods 482
Competency Assessment 455
Possible Interfering Factors 482
References 456
Glucose Tolerance Test (GTT) and HbA1c 483
Resources 457
Postprandial Glucose Test 487
Modified Oral Glucose Tolerance Test 487
CHAPTER 14 Point-of-Care Collections 458 Lactose Tolerance Test 487
Chapter Learning Objectives 458 Arterial Blood Gases 488
Key Terms 458 Radial Artery Puncture Site 488
NAACLS Entry-Level Phlebotomist Competencies 459 Brachial and Femoral Artery Puncture Sites 489
Types of POCT 460 Procedure 15–6 Radial ABG Procedure 491
Glucose Monitoring 460 Therapeutic Drug Monitoring (TDM) 494
Procedure 14–1 Obtaining Blood Specimen for Glucose Collection for Trace Metals (Elements) 495
Testing (Skin Puncture) 462 Genetic Molecular Tests 495
Point-of-Care Testing for HbA1c 464 Intravenous Line Collections 496
Quality in Point-of-Care Testing and Disinfecting POCT Collecting Blood through a Central Venous
Analyzers 464 Catheter 497
Blood Gas and Electrolyte Analysis 466 Procedure 15–7 Collecting Blood through a CVC 497
Point-of-Care Testing for Acute Heart Damage 467 Cannulas and Fistulas 499
White Blood Cell Count System 467 Donor Room Collections 499
Blood Coagulation Monitoring 467 Donor Interview and Selection 500
Hematocrit, Hemoglobin, and Other Hematology Collection of Donor’s Blood 501
Parameters 468 Autologous Transfusion 501
Cholesterol Screening 469 Therapeutic Phlebotomy 502
Other POCT Tests and Future Trends 469 Self Study
Self Study Study Questions 503
Study Questions 470 Case Study 1 504
Case Study 471 Case Study 2 504
Action in Practice 1 471 Action in Practice 504
Action in Practice 2 471 Competency Assessment 505
Competency Assessment 472 References 505
References 472 Resources 506
Resources 472

CHAPTER 16 U
 rinalysis, Body Fluids, and
CHAPTER 15 B
 lood Cultures, Arterial, Other Specimens 507
Intravenous (IV), and Special
Chapter Learning Objectives 507
Collection Procedures 473 Key Terms 507
Chapter Learning Objectives 473 NAACLS Entry-Level Phlebotomist Competencies 508
Key Terms 473 Urine Collection 509
NAACLS Entry-Level Phlebotomist Competencies 474 Single-Specimen Collection 511
Blood Cultures 474 Procedure 16–1 Clean-Catch Midstream Urine
Procedure 15–1 Site Preparation for Blood Culture Collection Instructions for Women 512
Collection 475 Procedure 16–2 Clean-Catch Midstream Urine
Procedure 15–2 Safety Syringe Blood Culture Collection Instructions for Men 513
Collection 477 Timed Urine Collections 514
x Contents

Procedure 16–3 Collecting a 24-Hour Urine Blood Alcohol and Breath Testing 549
Specimen 514 Future Trends 552
Cerebrospinal Fluid 516 Self Study
Fecal Specimens 517 Study Questions 553
Seminal Fluid 518 Case Study 1 554
Amniotic Fluid 518 Case Study 2 554
Synovial Fluid 519 Case Study 3 554
Other Body Fluids 519 Competency Assessment 555
Culture Specimens 519 References 555
Buccal Swabs 519 Resources 556
Sputum Collection 520
Nasopharyngeal Culture Collections 520 Appendix
Throat Swab Collections 520
Appendix 1  AACLS Entry-Level Phlebotomist
N
Procedure 16–4 Collecting a Sputum Specimen 521 Competencies and Chapter
Procedure 16–5 Collecting a Throat Swab for Coverage 558
Culture 522 Appendix 2 Competency Assessment Tracking
Skin Tests 524 Checklist 561
Gastric Analysis 524 Appendix 3 Finding a Job 569
Breath Analysis for Peptic Ulcers 525 Appendix 4 International Organizations 574
Sweat Chloride by Iontophoresis 525 Appendix 5 The Basics of Vital Signs 575
Self Study Procedure A5–1 Taking Oral Temperature 576
Study Questions 526 Procedure A5–2 Taking Aural Temperature 577
Case Study 526 Procedure A5–3 Taking Axillary Temperature 578
Action in Practice 1 527 Procedure A5–4 Assessing Peripheral Pulse
Rate 579
Action in Practice 2 527
Procedure A5–5 Taking Blood Pressure 581
Competency Assessment 527
Procedure A5–6 Assessing Respiration Rate 585
References 528 Appendix 6 Hand Hygiene in Health Care Settings:
Resources 528 Stay Up-to-Date with the Centers
for Disease Control and Prevention
(CDC) and the Food and Drug
CHAPTER 17 D
 rug Use, Forensic Toxicology, Administration (FDA) 586
Workplace Testing, Sports Appendix 7 Common Laboratory Assays,
Medicine, and Related Reference Intervals, and Critical
Limits 588
Areas 529
Appendix 8 Blood Collection and Allowable
Chapter Learning Objectives 529 Volumes from Pediatric and Neonatal
Key Terms 529 Patients 596
NAACLS Entry-Level Phlebotomist Competencies 530 Appendix 9 Cautious Use of Abbreviations,
Acronyms, and Symbols 598
Overview and Prevalence of Drug Use 530
Appendix 10 Formulas, Calculations, and Metric
Drug Analysis: Rationale, Methods, and Conversion 600
Interferences 535
Appendix 11 Military Time (24-Hour Clock) 603
Drug Testing in Neonates or Pregnant Women 538 Appendix 12 Basic Spanish for Specimen Collection
Forensic Toxicology Specimens 539 Procedures 605
Chain of Custody 541 Appendix 13 Answers to Study Questions,
Workplace Drug Testing 541 Case Studies, and Competency
Tampering with Specimens 547 Checklists 608
Drug Testing in the Private Sector 548
Drug Use in Sports 548 Glossary 626
Blood Doping and the Use of Erythropoietin
(EPO) 549 Index 638
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. Dr. Garza 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). Dr. Garza’s 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 Medicine. While
in Houston, Drs. Garza and Becan-McBride were involved in numerous national and
international courses for technologists, nurses, and physicians to teach phlebotomy tech-
niques. Together, they developed curriculum materials, and in 1984 published one of the
first comprehensive textbooks focused solely on phlebotomy practices. Their successful
coauthoring partnership has endured for over three decades. In 1990, Dr. Garza joined the
faculty of Texas Woman’s University–Houston Center, where she taught online quality
improvement courses, was tenured, and became editor of several journals and contin-
uing education publications. She has taught extensively; been a reviewer/inspector in
many regulatory processes; participated in accreditation procedures; and continues to
author, edit, and publish numerous manuscripts in the field of phlebotomy. Dr. Garza
has served on numerous health care advisory boards, as a board member for many non-
profit health care organizations, and on nationwide committees in the field of laboratory
medicine, including those for certification examinations, accrediting committees, and 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 recently retired from the Directorship 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 the University of Houston with completion of her medical laboratory sci-
ence 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’s collaborative Masters in Allied Health Education
and Administration Program. This inspired Dr. Becan-McBride to continue her stud-
ies, and she completed her Doctorate in Higher Education 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 pro-
gram at ­Houston Community College. She then became a faculty member and Chair of
the Clinical Laboratory Science Department at 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.
xi
xii About the Authors

Dr. Becan-McBride has published 24 books and more than 57 articles, and has been
on numerous national and international health care advisory boards and several editorial
boards for health care journals. She is continuing to serve on national and international
committees and commissions. She has had research projects related to the medical lab-
oratory sciences and also the community (i.e., UV/TB Prevention Research Project in
­Homeless Shelters in Houston). Most recently, she had received a National Institute
of Health (NIH) grant in research on new point-of-care (POC) technology as defined
through blood collection techniques. Dr. Becan-McBride 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 in 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;
the ASCP Board of Certification Distinguished Service Award in 2012; and the ASCP
Mentorship Award in 2016. Dr. Becan-McBride continues her Texas Higher Education
Consultants’ activities in writing, presenting, and editing, mainly in the expanding area
of blood collection.
During her years at UTHealth, Dr. Becan-McBride 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 authors developed one of the first comprehensive textbooks devoted
strictly to phlebotomy and its importance in the clinical laboratory and in health care
settings. After several editions, it went on to become an award-winning, top-selling
international textbook that has been considered to be a “gold standard” in the field of
phlebotomy. Drs. Becan-McBride and Garza have been collaborators for over 33 years on
numerous phlebotomy textbooks (including e-books), videos, online teaching products
for instructors, and other curricular materials. They have also been invited presenters at
many national and international conferences. Their efforts, work, and passion in phle-
botomy have inspired many valuable improvements to the field.
Preface

Phlebotomy Handbook: Blood Specimen Collection from Basic to Advanced,

Tenth ­Edition, is designed for health care students and practitioners who are responsible
for blood and specimen collections (i.e., nurses, phlebotomists, medical laboratory tech-
nicians, medical laboratory scientists, respiratory therapists, and others). The primary
goals of this book are:

■■ to link the phlebotomist (blood collector) to the latest safety information, techniques,
skills, and equipment for the provision of safe and effective collection procedures,
■■ to improve diagnostic and therapeutic laboratory testing,
■■ to enhance customer satisfaction, and
■■ to promote better health outcomes for all patients.

This renowned and updated textbook provides the most up-to-date, comprehensive
compilation of information about phlebotomy available in the world.
This edition has reconfigured student learning objectives to be a more advanced
extension of the National Accrediting Committee for Clinical Laboratory Sciences’
(NAACLS) “entry-level” competencies. Both NAACLS and Student Learning Objectives
are listed at the beginning of each chapter. The chapter-specific Student Learning Objec-
tives cover a range of basic to more advanced techniques and concepts for phlebotomists.
The key features include:

■■ Communication, clinical, technical, and safety skills that any health care worker will
use in the practice of phlebotomy and other specimen collection procedures.
■■ A renewed focus highlights professionalism and ethical behavior in serving every
individual patient.
■■ The chapter featuring new equipment (Chapter 8) emphasizes the most updated and
comprehensive safety features of phlebotomy supplies and equipment, with new
images from key manufacturers in the industry.
■■ The latest information about current industry standards from the Clinical and
­Laboratory Standards Institute (CLSI), World Health Organization (WHO), the
Centers for Disease Control and Prevention (CDC), risk and error reduction, patient
and worker safety, needlestick prevention, and The Joint Commission National
Patient Safety Goals.
■■ Content stresses the importance of patient communication through topics such as
generational traits, age-specific considerations, cultural factors, patients with special
needs, and current health care issues related to gender identity. More advanced content
provides the latest techniques in vascular access for difficult blood collections from
pediatric and/or adult patients; and the latest information on diabetic testing using
procedures overlapping between the glucose testing and Hemoglobin A1c protocols.
■■ Provides extensive information and insights about quality issues to improve tech-
nical skills and patient outcomes and highlights the professional role that phleboto-
mists play as essential members of the health care team.
■■ An advanced focus on medical terminology, roles of other health care providers,
special considerations for specific and/or vulnerable groups of patients, and health
literacy.
xiii
xiv Preface

■■ Expanded content areas include drug testing, paternity testing, drug-resistant bac-
teria, viral infections, importance of timed tests, and special high risk situations in
patient identification.

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 every patient, treat
their families with respect, handle any special needs, and establish effective collabora-
tions with other members of the health care teams. These roles and responsibilities have
global applications.
As with previous editions, and based on input from various reviewers, 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 understanding 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 specimen 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, which can be used by instructors as a supplement for evaluation and by
students to self-monitor their skills and knowledge. And the Glossary has been updated
and expanded to include key words and other terms important to phlebotomists. The
appendices provide useful procedures (such as taking vital signs) and important terms,
phrases, and symbols. Updates include the lastest blood pressure categories from the
American College of Cardiology.
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
industry and presents information about quality, communication skills, legal issues,
safety, first aid, and infection control in the workplace. Special attention is focused
on compassionate communication with vulnerable patients.
■■ PART II: Anatomy and Physiology of the Human Body—provides the detailed
anatomy and physiology of body systems, with a more advanced emphasis on the
circulatory system. Relevant medical terminology is also covered thoroughly.
■■ PART III: Phlebotomy Equipment and Procedures—provides comprehensive,
advanced coverage on the latest equipment and supplies, and the most updated
information and comprehensive description of the actual techniques and proce-
dures used in phlebotomy. This section also includes updated documentation and
transportation procedures needed for safe handling of biohazardous specimens, and
sending specimens both nationally and internationally. Special emphasis is given to
minimizing adverse risks and preventing clinical and technical complications that
may occur during the preanalytical processes.
■■ PART IV: Point-of-Care Testing and Special Procedures—provides information
about pediatric phlebotomy procedures, the latest developments in vascular access
procedures, blood culture collections, arterial and IV collections, and special consid-
erations for the elderly, homebound, and long-term care patients. In addition, topics
such as testing for prediabetes and diabetes, neonatal testing, paternity testing, and
drug, alcohol, and forensic laboratory testing practices are reviewed.
 Preface xv

Key Features of the Tenth Edition

■■ Student Learning Objectives at the beginning of each chapter list the important
concepts discussed in the chapter. These objectives go beyond minimal or “entry-
level” expectations for phlebotomists.
■■ NAACLS Competencies for Entry-Level Phlebotomists provides selected N ­ AACLS
competencies covered in each chapter and indicates the level of coverage in that
chapter as “beginning or basic (B), intermediate (I), or advanced (A).” Naturally,
the earlier chapters are more basic, and some competencies are repeated later in the
textbook as they are covered at a more detailed, intermediate, or advanced level.
■■ Key Terms list the vocabulary introduced and clearly 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 and safe practices 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 proce-
dure, thereby avoiding adverse outcomes for the patient, phlebotomist, or the health
care organization.
■■ Procedures throughout the text provide illustrated, step-by-step instructions with
an “on-the-job” perspective.
■■ New colorful photographs and figures illustrate important concepts and show pro-
cedural steps and equipment. Updated artwork provides visual reinforcement of
key concepts.
■■ 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
critical 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/or 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 covered in
specific chapters, essentials for finding a job, basic procedures for taking vital signs,
a hand hygiene update, laboratory tests with blood requirements, reference inter-
vals, and critical limits, cautious use of abbreviations and symbols, formulas and
calculations used in laboratories, use of military time, Spanish phrases for health
care personnel, current information about allowable volumes of blood withdrawn
from pediatric and neonatal patients, and more.
xvi Preface

Video Program
A video library is available for viewing on The Phlebotomy Handbook’s Student Resources
Page (www.pearsonhighered.com/healthprofessionsresources). The video series con-
tains segments demonstrating a wide array of blood specimen collection procedures and
patient interactions (including pediatrics and adults in both clinic and hospital settings).
The videos emphasize safety, infection control, effective communication, quality assess-
ment, and avoiding errors. The footage correlates with many of the procedures shown in
Phlebotomy ­Handbook, 10th 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 provides an additional teaching tool to support National Association
for Accreditation of Clinical Laboratory Sciences competencies for accredited programs
in Phlebotomy.

Additional Resources for Educators

This tenth edition has online/electronic companion resources that are cross-­referenced
to the text. The Instructor’s Resource Manual contains a wealth of material to help fac-
ulty 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,
8th 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, with 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 can use as a central authority on blood
collection practices. Instructors can also use this as the central text for teaching specimen
collection skills.
Acknowledgments

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 mate-
rials were nonexistent. As licensing, credentialing, manufacturing of new products, pro-
cedures, 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 tenth edition with the participation
of so many talented people. Thus, we thank many phlebotomists, medical technicians
and technologists, artists, photographers, reviewers, 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 Matt Ostroff 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 photographer 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.
Diana Garza
Kathleen Becan-McBride

xvii
Reviewers
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
Jimmy Boyd, MLS (ASCP)
Program Director
Arkansas State University-Beebe
Beebe, Arkansas
Jennifer M. Elenbaas, MBA-HM
Instructor
Davenport University
Grand Rapids, Michigan
xviii
Penny Ewing, BS, CMA (AAMA)
Instructor
Gaston College
Dallas, North Carolina
Vickie Kirk, MBA, MT(ASCP),
PBT(ASCP)CM
Phlebotomy Director, Instructor of
Health Sciences
Edison State Community College
Piqua, Ohio
Michelle Mantooth, MSc, MLS
(ASCP)CM, CG(ASCP) CM
Instructor
Trident Technical College
North Charleston, South Carolina
Kimberly Meshell
Program Director, Instructor
Angelina College
Lufkin, Texas
Angela Norwood, BS, PBT(ASCP)
Phlebotomy Professor, Department
Chairperson
College of Lake County
Grayslake, Illinois
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
Chapter 1

Phlebotomy Practice and

Quality Assessment
KEY TERMS

Chapter Learning Objectives acute care

aliquot
Upon completion of Chapter 1, the learner is responsible for doing the ambulatory care
following: anatomic pathology
Centers for Medicare & Medicaid
1. Define phlebotomy and identify health professionals who perform phlebotomy
Services (CMS)
procedures.
clinical decisions
2. Identify the importance of phlebotomy procedures to the overall care of the patient. Clinical Laboratory Improvement
3. List professional competencies for phlebotomists, the role in delivering, collecting, Amendments
and/or transporting specimens to and from the laboratory, and key elements of a clinical pathology
performance assessment. competency statement
4. List members of a health care team who interact with phlebotomists. continuing education (CE)
continuous quality improvement (CQI)
5. Describe the roles and qualifications of clinical laboratory personnel and common
examination (analytical phase)
laboratory departments/sections.
Food and Drug Administration (FDA)
6. Describe the health care delivery system and settings in which phlebotomy services are inpatients
routinely performed.
International Organization for
7. Describe the clinical laboratory workflow pathway, or testing cycle, from beginning Standardization (ISO)
laboratory requests to reporting laboratory test results. long-term care
8. Explain components of professionalism and desired character traits for phlebotomists. nanotechnology
nosocomial infections
9. Describe coping skills that are used to reduce stress in the workplace.
personal protective equipment (PPE)
10. List the basic tools used in quality improvement activities and give examples of how a phlebotomist
phlebotomist can participate in quality improvement activities. phlebotomy
11. Define the difference between quality improvement and quality control procedures. point-of-care (POC)
postexamination (postanalytical
phase)
preexamination (preanalytical phase)
professionalism
quality
quality control (QC)
quality improvement
Six Sigma
stakeholders
standards of practice
2 Chapter 1 Phlebotomy Practice and Quality Assessment

NAACLS Entry-Level Phlebotomist Competencies

Addressed in This Chapter
(From NAACLS Revised 11-2017, accessed 1/18/2018. Copyright by National Association for
Accreditation of Clinical Laboratory Sciences (NAACLS).)
(Depth and Level of Coverage: B = basic/beginning; I = intermediate; A = advanced)
Please note that topics covered in one chapter may also be discussed in more detail in other chapters.
1.00 Demonstrate knowledge of the health care delivery system and medical terminology.
1.1 Identify the health care providers in hospitals and clinics and the phlebotomist’s role as
a member of this health care team. (B, I)
1.2 Describe the various hospital departments and their major functions in which the
­phlebotomist may interact in his/her role. (B)
1.3 Describe the organizational structure of the clinical laboratory department. (B)
1.4 Discuss the roles of the clinical laboratory personnel and their qualifications for these
professional positions. (B)
1.5 List the types of laboratory procedures performed in the various disciplines of the clinical
laboratory department. (B)
4.00 Demonstrate understanding of the importance of specimen collection and specimen
integrity in the delivery of patient care.
4.2 Describe the types of patient specimens that are analyzed in the clinical laboratory. (B)
4.3 Define the phlebotomist’s role in collecting and/or transporting these specimens to the
laboratory. (B)
7.00 Demonstrate understanding of requisitioning, specimen transport, and specimen processing.
7.1 Describe the process by which a request for a laboratory test is generated. (B)
7.5 Identify and report potential preanalytical errors that may occur during specimen
­collection, labeling, transporting, and processing. (I)
8.00 Demonstrate understanding of quality assurance and quality control in phlebotomy.
8.1 Describe quality assurance in the collection of blood specimens. (B, I)
8.2 Identify policies and procedures used in the clinical laboratory to assure quality in the
obtaining of blood specimens (B, I)
8.2.1 Perform quality control procedures. (B)
8.2.2 Record quality control results. (B)
8.2.3 Identify and report control results that do not meet predetermined criteria. (B)
9.00 Communicate (verbally and nonverbally) effectively and appropriately in the workplace.
9.3 Interact appropriately and professionally. (I)
9.6 Model professional appearance and appropriate behavior. (I)
9.7 Follow written and verbal instructions. (I)
9.9 List the causes of stress in the work environment and discuss the coping skills used to
deal with stress in the work environment. (I)

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 symptoms.
Therefore, before physicians can make clinical decisions, they need laboratory test results
for the patient. The development of modern diagnostic techniques, clinical laboratory
automation/robotics, nanotechnology, computer technology, standardization, globaliza-
tion, 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 play such an important role in the clinical 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
 Chapter 1 Phlebotomy Practice and Quality Assessment 3

(certified or registered, CMA or RMA), clinical assistants, home health personnel, and
others. Regardless of specific job backgrounds, common elements about the practice of
phlebotomy should be known by all who are responsible for blood specimen collections.
The term phlebotomy is derived from the Greek words, phlebo, which relates to
veins, and tomy, which relates to cutting. In ancient times, phlebotomy was practiced
to withdraw blood using various means, including knives, crude lancets, leeches, blood
cups or bowls, pumps, and glass syringes. In some cultures, phlebotomy was thought
to cleanse or purify the body and/or get rid of unwanted spirits. However, today, mod-
ern phlebotomy equipment and practices are very advanced. The current definition of
­phlebotomy can be summarized as the incision of a vein for collecting a blood sample
(a portion of blood that is small enough so as not to cause harm) for laboratory testing or
other therapeutic purposes (e.g., transfusion of blood components); synonymous words
are venesection or venisection. The phlebotomist, or blood collector, is the individual
who performs phlebotomy. The term phlebotomist will be used throughout this text even
though it is interchangeable with blood collector. Phlebotomists often assist in the collec-
tion and transportation of specimens other than venous blood (e.g., arterial blood, urine,
tissues, sputum) and may perform clinical, technical, or clerical functions. However, the
primary function of the phlebotomist is to assist the health care team in the accurate, safe,
and reliable collection and transportation of specimens for laboratory analyses.
In this text, numerous phlebotomy procedures and practices are covered, ranging
from the most basic to more advanced procedures. However, there are two commonly
used phlebotomy techniques that 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 (cov-
ered in Chapters 8 and 10).
■■ Skin (dermal) or capillary puncture—Using a superficial skin puncture (typically
a finger) with a specially designed safety lancet to withdraw a smaller amount of
capillary blood (covered in Chapters 8, 11, and 13).
■■ 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.1 Laboratory
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 abnormal-
ities) or for screening to detect irregularities that require
follow-up testing. Specific laboratory procedures are cov-
ered in later chapters.
■■ 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 disease 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 FIGURE 1–1
range, depending on the setting. They may have duties related Clinical Laboratory Procedures are Used to Monitor Astronauts’ Health
to all phases of laboratory analysis or may be assigned to only on the International Space Station (ISS)
specimen collection duties in one area of a hospital. Technol- Many venipuncture procedures during space flight are performed to
ogy has enabled laboratory testing to be performed closer to acquire blood samples for research after they are returned to earth.
the point-of-care (POC); for example, at the patient’s bedside, at Here, Astronaut Aki Hashide holds his blood samples and prepares the
ancillary or mobile clinic sites, at a pharmacy clinic, in the home, tubes in a centrifuge in the ISS’s Columbus module. Note that one end
in an ambulance, or in more remote places such as a war zone, a of the tourniquet is floating near his face.
field clinic, or even the International Space Station (FIGURE 1–1 NASA
4 Chapter 1 Phlebotomy Practice and Quality Assessment

BOX 1–1

Potential Job Sites for Phlebotomists

and Clinical and Medical Assistants
Hospital (Inpatient) Settings
Acute-care hospitals (urban or rural)
Specialty hospitals (cancer, psychiatric,
­long-term care, pediatric)
Ambulatory Care (Outpatient) Settings
Health department clinics
Community health centers (CHCs)
Rural health clinics
Community-based mental health centers
School-based clinics
Prison health clinics
Dialysis centers
Screening centers
Home health agencies
Home hospice agencies
Durable medical equipment suppliers
Emergency care centers
Hospital-based clinics
Hospital-based emergency centers
Health maintenance organizations (HMOs)
Insurance companies
Physician group practices
Individual or solo medical practices
Specialty practices
Rehabilitation centers
Mobile vans for blood donations
Mobile vans for primary care delivery
Mobile mammography units
Free-standing surgical centers
Reference laboratory collection sites
Drug screening sites
Field hospitals and clinics
Fertility clinics
Pharmacy clinics

and BOX 1–1). Phlebotomists’ duties have become more coordinated with other health
care processes. In some cases, health professionals—such as nurses, respiratory therapists,
patient care technicians, clinical assistants, medical assistants, and others—have been cross-
trained to assume phlebotomy duties; in other cases, traditional laboratory-based phle-
botomists have been cross-trained to assume expanded clerical tasks such as procedural
coding for billing purposes, or patient care duties such as performing electrocardiograms
and low-risk laboratory procedures. Whatever the case, phlebot-
omists work closely and professionally in a variety of settings and
with varied patients and health care professionals (BOX 1–2 and
FIGURE 1–2).

HEALTH CARE SETTINGS AND HEALTH CARE

TEAMS
Health care organizations in the United States vary widely but
most fit into two categories: inpatient or hospital care (Box 1–2)
and outpatient or ambulatory care. Traditional hospitals are
typically organized into departments according to medical/
surgical specialties and/or around organ systems, as shown in
TABLE 1–1. Sometimes, departments are organized by therapy
FIGURE 1–2 services or procedures offered to the patient. Phlebotomists
Phlebotomists are Members of the Health Care Team should become knowledgeable about these areas of the hospi-
Wavebreakmedia/Shutterstock tal and the personnel who work there because patients spend
 Chapter 1 Phlebotomy Practice and Quality Assessment 5

BOX 1–2

Hospitals in the United States

According to the American Hospital Association, there are over 5,500 registered hospitals in the
United States. They vary according to the following factors2:

■■ Mission (patient care, education, research)

■■ Total number of staffed beds (over 897,000 beds in the United States)2
■■ Total annual admissions (over 35 million per year)2
■■ Total annual expenses for all registered hospitals (over $936 billion)
■■ Ownership (public or nonprofit, governmental [federal, state, local, prison system, college
infirmaries, etc.], 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, cancer center, psychiatric, long-term care, pediatric,
rehabilitation, etc.)
■■ Location (urban or rural)
■■ Relationship to other health facilities (e.g., hospital system-managed by a central organi-
zation 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 approx-
imately 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, phy-
sician 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.

Department Functions Personnel

Allergy Diagnosis and treatment of persons who have allergies or “reactions” to irritating Physicians, nurses, medical assistants
agents.
Anesthesiology Pain management before, during, and after surgery. Anesthesiologist, nurse anesthetist
Cardiology Medical diagnosis and treatment of conditions relating to the heart and Cardiologist (MD)
circulatory system.
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 Uses ionizing radiation for treating disease, fluoroscopic and radiographic x-ray Radiologist, radiologic technician/technologist
Radiology instrumentation and imaging methods for diagnosis, and radioisotopes for both
diagnosing and treating disease. Sometimes patients are injected with dye that
might interfere with some laboratory tests. The phlebotomist should document
the circumstances as appropriate. In addition, the phlebotomist should be
aware of applicable safety requirements.
Electrocardiography Uses the electrocardiograph (ECG or EKG) to record the electric currents Cardiologist, nurse, medical assistant, EKG
produced by contractions of the heart. This assists in the diagnosis of heart technician
disease.
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 Care of general medical problems of all family members. Family practice or primary care physician (MD)
Practice
Gastroenterology Diagnosis and treatment of conditions relating to the esophagus, stomach, and Gastroenterologist
intestines.
(continued)
6 Chapter 1 Phlebotomy Practice and Quality Assessment

TABLE 1–1

Medical, Surgical, and Ancillary Service Departments in Large Health Care Facilities (continued)
Department Functions Personnel

Geriatrics/Gerontology Diagnosis and treatment of the older adult 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 or more Internist (MD) or doctor of osteopathic medicine
internal organs. (DO), nurse, physician assistant (PA)
Laboratory Medicine/ Uses sophisticated instrumentation to analyze blood, body fluids, and tissues for Pathologist, pathology assistant, laboratory
Pathology pathological conditions. Laboratory results are used in diagnosis, treatment, and personnel (Table 1–2, Box 1–4)
monitoring of patients’ health status.
Neonatal/Perinatal Study, support, and treatment of newborn and prematurely born babies and Neonatologist
their mothers.
Nephrology Diagnosis and treatment of conditions relating to the 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 Nutritionist, dietician
for 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 Oncologist (MD)
(i.e., cancer).
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 the ears, nose, and Otolaryngologist, speech pathologist, audiologist
throat (ENT).
Pathology See Laboratory Medicine/Pathology
Pediatrics General diagnosis and therapy for children. Pediatrician (MD)
Pharmacy Dispenses medications ordered by physicians. Pharmacists also collaborate Doctor of Pharmacy (Pharm. D), pharmacist
with the health care team on drug therapies. Phlebotomists may collect blood
specimens at 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 Plastic surgeon (MD)
skin.
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 Psychiatrist/Neurologist (MD)
nervous 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 Radiotherapist (MD), nuclear medicine technician
of disease, particularly cancer. Safety precautions are important to avoid
unnecessary irradiation.
Rheumatology Diagnosis and treatment of joint and tissue diseases, including arthritis. Rheumatologist (MD)
Social Work/Patient Case management, patient navigators, and assist in discharge planning and Social workers (MSW, LCSW, DSW)
Advocacy emotional, financial, and social needs.
Surgery Diagnosis and treatment in which the physician physically alters a part of the General surgeon, specialty surgeon (orthopedic,
patient’s body. 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.
Another random document with
no related content on Scribd:
 new Russian year is changed from the first of
September to the first of January.

THE EIGHTEENTH CENTURY

1703 Peter begins the building of St. Petersburg.

1706 The Cossacks of the Don revolt.
1707 The secret marriage of Peter with Catherine takes
place.
1709 Mazeppa, hetman of the Little-Russian Cossacks,
revolts. Battle of Pultowa.
1710 Turkey declares war against Russia.
1711 The old supreme council of boyars (douma) is replaced
by the senate, into which merit and service might obtain
admission independently of noble origin. By the terms of
the Treaty of the Pruth Peter surrenders to the Turks his
artillery, gives back Azov, and undertakes to rase
Taganrog.
1714 The Russians gain over the Swedes the important
naval victory of Åland or Hankül. Peter becomes master
of Finland.
1717 Peter makes a second tour through Europe. A general
police, modelled on that of France, is instituted.
1718 Peter’s eldest son, Alexis, is executed. The old prikaz
is replaced by colleges for foreign affairs, finance,
justice, and commerce.
1719 The Russians ravage Sweden almost up to the gates
of Stockholm.
1720 The Russians renew their devastation of Sweden,
notwithstanding the presence of an English fleet.
1721 Treaty of Nystad with Sweden: Peter is left master of
Livonia, Esthonia, Ingria, and the districts of Viborg and
 Kexholm in Finland. Peter promulgates an ukase
(afterwards abrogated by Paul) that the sovereign has
the right of naming his successor. The Patriarchate is
abolished and its income united to the public revenue. In
its place the holy synod is established for the supreme
direction of church affairs.
1722 The tchin is established: whoever enters the service of
that state becomes a gentleman. The exporting of
merchandise through Archangel is prohibited in favor of
St. Petersburg.
1722-24 War with Persia. The provinces of Ghilan,
Mazandaran, and Astrabad (Astarabath) are annexed to
Russia.
1725 Death of Peter. He is succeeded by his second wife,
Catherine.
1726-27 The St. Petersburg Academy of Science founded.
1727 Death of Catherine. She is succeeded by Peter II, son
of Alexis. Menshikov, who was the real ruler of Russia
under Catherine, is banished to Siberia.
1730 Death of Peter II. Anna, daughter of Ivan, the brother
of Peter the Great, is chosen his successor after
submitting to the terms dictated by the great nobles—
terms intended to convert the government into an
oligarchy.
1733-35 War of the Polish Succession: Russia intervenes on
behalf of the elector of Saxony, Augustine III, and
defeats the French attempt to replace Stanislaus
Leszczynski on the throne of Poland.
1735 Russia surrenders her Persian possessions in return
for extensive trading privileges to Russian merchants.
1735-39 War with Turkey, in conjunction with Austria. The
Russians conquer Otchakov at the mouth of the Dnieper
and the important fortress of Khotin on the same river.
 But at the peace of Belgrade, hastily concluded by the
Austrians, they retain only Azov.
1740 Death of Anna. Ivan VI, her grand-nephew, succeeds
her, with Biron, duke of Courland, as regent during his
minority.
1741 A coup d’état, led by Field-marshal Münich deposed
Biron and raises Princess Anna, mother of Ivan, to the
regency. But Münich is the real ruler. A palace revolution
deposes Ivan, sends Münich to Siberia, and raises to
the throne Elizabeth, a daughter of Peter the Great by
Catherine. Sweden, urged on by France, declares war.
The Swedes are defeated at Vilmanstrand.
1742 Seventeen thousand Swedes surrender at Helsingfors.
The Armenian churches in both capitals are suppressed
by order of the holy synod.
1743 Treaty of Åbo with Sweden; Russia acquires the
southern part of Finland as far as the river Kymmene.
1753 The custom-houses of the interior, as well as many toll
duties, are suppressed.
1755 The first Russian university is founded at Moscow.
1756 The first Russian public theatre is established at St.
Petersburg. Three years later another theatre is
established at Moscow.
1757 The Russians under Apraxin defeat at Jägerndorf the
Prussians under Lewald.
1758 The Russians under Fermor are defeated by Frederick
the Great at Zorndorf. The Academy of Fine Arts is
established at St. Petersburg.
1759 Saltikov defeats Frederick at Kunersdorf.
1760 The Russians plunder Berlin.
1762 Death of Elizabeth. She is succeeded by her nephew,
Peter III, son of her sister Anna. He makes peace with
 Frederick, restores to him east Prussia, which was
entirely in the hands of the Russians, and orders his
army to aid Frederick against the Austrians. Peter
issues an ukase freeing the nobility from the obligation
of entering upon some state employment; is
assassinated and is succeeded by his wife, Catherine.
Catherine recalls the Russian armies from Prussia.
1764 Assassination of Prince Ivan. Resumption of the
ecclesiastical lands with their one million serfs by the
state.
1766-68 A great sobor is convened, first at Moscow and then
at St. Petersburg, for the compilation of a new code. It
fails of its object.
1767 An ukaze forbids serfs to bring complaints against their
masters, who were authorised to send them at will to
Siberia or to force them into the army.
1767-74 War with Turkey.
1768 Massacre of Jews at Uman, in the Government of Kiev,
under the leadership of the Cossack Gonta.
1769 The Russians under Galitzin take Khotin.
1770 Rumiantzev is victorious over the Tatars on the banks
of the Larga and over the grand vizir at Kagul. Three
hundred thousand Kalmucks, with their wives and
children, their cattle and their tents, flee from Russia to
China.
1771 Conquest of the Crimea by Dolgoruki. Annihilation of
the Turkish fleet at Tchesme.
1772 The Congress of Fokshani fails to bring about peace
and the war is renewed. First division of Poland. Russia
acquires White Russia, including Polotsk, Vitebsk,
Orsha, Mohilev, Mstislavl, Gomel.
1773-74 Pugatchev’s revolt.
1774 Peace of Kutchuk-Kainardji: the sultan acknowledges
the independence of the Tatars of the Crimea, the Bug
and the Kuban, and cedes to Russia Azov on the Don,
Kinburn at the mouth of the Dnieper, and all the fortified
places of the Crimea.
1775 The Zaparog military republic of the Cossacks is
dissolved. The empire is reorganized. Instead of fifteen
provinces there are created fifty governments
subdivided into districts.
1783 Formal annexation of the Crimea and the country of
the Kuban.
1787-92 Second war with Turkey in conjunction with Austria.
1788-89 War with Sweden. The Peace of Varela restores the
status quo ante bellum.
1788 The storming of Otchakov by Potemkin, accompanied
by an indiscriminate massacre.
1789 Suvarov wins the battles of Fokshani and Rimnik.
Potemkin takes Bender.
1790 Suvarov takes Ismail. The Austrians sign the Peace of
Sistova, but the Russians continue the war. Repnin
defeats the grand vizir at Matchin.
1792 Treaty of Jassy. The Russians retain only Otchakov
and the seaboard between the Bug and the Dniester.
1793 Second division of Poland. Russia obtains an
enormous extension of territory in Lithuania and absorbs
the rest of Volhinia, Podolia, and Ukraine.
1794 Kosciuszko is defeated by Fersen at Maciejowice and
Suvarov storms Praga, a suburb of Warsaw.
1795 Third division of Poland. Russia obtains the rest of
Lithuania, besides other territories which at one time
had been Russian, while Poland proper is divided
between Austria and Prussia. The former power also
 obtains Galicia or Red Russia. Courland is annexed by
Russia. Its last duke, Peter Biron, voluntarily renounces
it in return for a yearly revenue.
1796 Death of Catherine. Accession of her son Paul.
1798 Paul promulgates the line of succession according to
primogeniture, with precedence in the male line. Russia
joins the second coalition against France, with England,
Austria, Naples and Turkey.
1799 Suvarov defeats Moreau on the Adda, Macdonald on
the Trebbia, and Joubert at Novi. Korsakov is defeated
by Massena at Zurich, and Suvarov is forced to make
his memorable retreat across the Alps.
1800 Reconciliation with France, chiefly owing to the English
occupation of Malta.

THE NINETEENTH CENTURY

1801 Assassination of Paul. His son Alexander succeeds

him. The new emperor concludes treaties of peace with
England, France, and Spain. Georgia, or Grusia, is
formally annexed, and a war with Persia follows in
consequence.
1802 Eight ministries are established in place of the colleges
founded by Peter the Great.
1804 The Persians are defeated at Etchmiadzin.
1805 Alexander joins the third coalition with Austria and
England. Battle of Austerlitz.
1806 Conquest of the Persian province of Shirvan, and the
taking of Derbent.
1806 War with Turkey. Alexander joins fourth coalition, of
which Prussia is also a member. Battles of Pultusk and
Golymin.
1807 Battles of Eylau and Friedland. Peace of Tilsit. Russia
acquires Bielostok, a part of Prussian Poland.
1808 War with Sweden. Finland is overrun by a Russian
army.
1809 By the Treaty of Fredrikshamn Sweden surrenders
Finland. The Finns are allowed complete autonomy, the
czar being its grand duke. War with Turkey. The
Russians are defeated at Silistria.
1810 The Russians are victorious over the Turks at Batyen
on the Danube.
1811 The Russians are victorious at Rustchuk. Twenty
thousand Turks surrender at Giurgevo.
1812 By the Treaty of Bukharest Russia acquires Bessarabia
and a large part of Moldavia, with the fortresses of
Khotin and Bender. The Pruth becomes its boundary.
The district of Viborg, which was acquired from Sweden
in 1744, is added to Finland. Count Speranski, leader of
the liberal party, is dismissed. Later he was exiled to
Peru. Invasion of Russia by Napoleon. Battles of
Smolensk and Borodino. Firing of Moscow. Napoleon
orders a retreat (October 18). Battle of Malojaroslavetz
compels Napoleon to retreat by his old route. The
Beresina crossed (November 26th-29th).
1813 By the Treaty of Kalish Alexander engages not to lay
down his arms until Prussia had recovered all its lost
territories. The Russians and Prussians are defeated at
Lützen and Bautzen. The allies are repulsed before
Dresden. Battle of Leipsic. Peace of Gulistan with
Persia. Russia obtains Baku and the western shore of
the Caspian.
1814 The Russians invade France together with the allies. At
the congress of Vienna Alexander insists on the creation
of a kingdom of Poland under his rule.
1815 By the Treaty of Vienna Alexander obtains all of
Poland, except Galicia, Cracow, and Posen. Conclusion
of the Holy Alliance.
1816 Abolition of serfdom in Esthonia.
1817 Abolition of serfdom in Courland.
1818 Abolition of serfdom in Livonia. In all Baltic provinces
the emancipated peasants receive no portion of the
land, which remains in possession of the nobles. A
constitution and separate administration are granted to
the Polish kingdom.
1819 Establishment of military colonies in the border
provinces of the north, west and south.
1825 Death of Alexander. His brother Nicholas I succeeds
him. Revolt of the Dekabrists.
1826 War with Persia.
1827 War with Turkey. The Turkish fleet is destroyed at
Navarino by the combined fleets of England, France,
and Russia.
1828 Peace of Turkmanchai. Persia cedes the provinces of
Erivan and Nakhitchevan, pays a war indemnity, and
grants important trading privileges. The Russians invade
the Danubian principalities and take Varna. Paskievitch
takes Kars.
1829 Diebitsch defeats the Turks at Kluvetchi, takes Silistria,
crosses the Balkans, and takes Adrianople. Peace of
Adrianople. Russia gets control of the mouths of the
Danube, of a portion of Armenia including Erzerum, and
receives a war indemnity.
1830 The new code, a complete collection of the laws of the
Russian Empire, is promulgated. Polish insurrection.
The Russians are compelled to evacuate the country.
1831 Paskievitch takes Warsaw. The building of new Roman
Catholic churches in Poland is prohibited.
1832 Poland is incorporated with Russia. The constitution
granted by Alexander is annulled, and Poland is divided
into five governments.
1833 By the Treaty of Unkiar-Skelessi Russia obtains
additional rights to meddle in the internal affairs of
Turkey.
1839 A Russian expedition to the khanate of Khiva is
compelled to return.
1849 A Russian army is sent into Hungary. Capitulation of
Görgei at Villagos.
1853 The Crimean War. The Russians occupy the Danubian
principalities. Destruction of the Turkish fleet at Sinope.
1854 France and England join Turkey. Battle of the Alma.
Siege of Sebastopol. Fall of Bomarsund.
1855 Sardinia joins the allies. Battles of Balaklava,
Inkerman, and Tchernaia. Fall of Sebastopol.
Bombardment of Sveaborg. The Russians take Kars.
Nicholas I dies. His son Alexander II succeeds him.
1856 Treaty of Paris. Russia relinquishes the mouths of the
Danube and a portion of Bessarabia, restores Kars,
gives up the protectorate over the Oriental Christians
and the Danubian principalities, and agrees to have no
war vessels in the Black Sea.
1858 General Muraviev signs the treaty of Aigun with the
Chinese, by which Russia acquires the entire left bank
of the Amur.
1859 Capture of Schamyl.
1861 Emancipation of the serfs.
1863 Polish insurrection.
1864 Final pacification of the Caucasus. Reforms in judicial
administration. Institution of representative assemblies
(zemstvos) for governments and districts. By ukase,
Polish peasants are given in fee-simple the lands which
they had cultivated as tenants-at-will.
1865 Tashkend taken from the emir of Bokhara; organisation
of the province of Turkestan.
1866 Karakozov fires at the emperor at St. Petersburg.
1867 Governor-generalship of Turkestan created. Sale of
Alaska to the United States. A Slavophil congress is
held at Moscow. The prince of Mingrelia relinquishes his
sovereign rights for one million rubles. Russian is
substituted for German as the official language of
Livonia, Esthonia, and Courland. Peasants are given the
ownership of the lands which they occupied as tenants.
1868 Samarkand taken from Bokhara.
1870 Khiva is stormed by General Kauffman.
1871 The Pontus Conference, held at London, abolishes
paragraph 11 of the Paris treaty delimiting Russian
fortifications and naval forces on the Black Sea.
1873 The right bank of the Amu Daria (Jaxartes) is annexed
and the rest of Khiva becomes a vassal state.
1874 Universal compulsory military service is introduced.
The vice-royalty of Poland is abolished, and its
administrative fusion with Russia becomes complete.
1875 Russia cedes to Japan the Kurile islands. Japan gives
up its claims to the southern part of Sakhalin.
1876 The khanate of Khokand is absorbed and transformed
into the province of Ferghana.
1877 War with Turkey. The Russian advance is beaten back
in Europe and in Asia. The Shipka pass alone remains
in Russian hands. Three defeats before Plevna, which is
 besieged and forced to capitulate with 40,000 men. Kars
is taken.
1878 The Russians cross the Balkans. The Shipka army is
captured, Adrianople taken, the last Turkish army is
almost annihilated, and the Russians reach the Sea of
Marmora. Treaty of San Stefano: Treaty of Berlin.
Assassination of General Trepov at St. Petersburg, and
acquittal of Vera Zassulitch. Assassination of General
Mezentsev, chief of gendarmerie.
1879 Soloviov fires six shots at the emperor. An attempt is
made to wreck the train by which the czar was travelling
from Moscow to St. Petersburg.
1880 An attempt is made to blow up the Winter Palace.
Loris-Melikov is placed at the head of a commission with
dictatorial powers.
1881 Assassination of the emperor. The Tekke-Turkomans
are subjected by Skobelev. Anti-Jewish riots in southern
Russia.
1882 The “May laws” of Ignatiev issued against the Jews.
Agrarian disturbances in the Baltic provinces give the
government a welcome pretext for additional measures
of russification.
1883 Alexander III is crowned at Moscow.
1884 The Turkomans of the Merv oasis make submission to
Russia. The emperors of Russia, Germany and Austria
meet at Skierniewice, where they form the Three
Emperors’ League for the term of three years.
1885 The Afghans are defeated by General Komarov at
Penjdeh. The Trans-Caspian railway is begun.
1886 Contrary to Article 59 of the Treaty of Berlin, Batum is
transformed into a fortified naval port.
1887 A convention between England and Russia is signed
for the delimitation of the Russo-Afghan frontier. The
 Russian advance in the direction of Herat is stopped.
1888 An army officer named Timoviev makes an attempt on
the czar’s life. The Trans-Caspian railway is completed.
Samarkand is linked with the Caspian. The imperial train
is derailed at Borki. The czar and his family escape
injury.
1890 Three commissions are appointed to prepare plans for
assimilating the Finnish postal, monetary, and fiscal
systems with those of the empire.
1891 A French squadron under Admiral Gervais visits
Kronstadt. A succession of famines begins. An ukase is
issued directing the construction of a railway line which
should connect the European system with the Pacific
coast. Work is commenced on seven sections
simultaneously.
1893 A Russian squadron under Admiral Avelan visits
Toulon.
1894 A military convention, arranged by the military
authorities of Russia and France, is ratified. Death of
Alexander III and accession of Nicholas II.
1895 An Anglo-Russian convention is signed settling the
disputes as to the Pamirs. Russia, in conjunction with
Germany and France, forces Japan to revise the terms
of the Treaty of Shimonoseki by giving up the Liao-tung
peninsula. Russia obtains the right to carry the Siberian
railway across Chinese territory from Stretensk to
Vladivostok, thus avoiding a long detour, besides getting
control of North Manchuria.
1896 Coronation of the czar at Moscow. Catastrophe on the
Khodinski plain. The emperor visits Germany, Austria,
England, and France.
1897 President Faure makes an official visit to St.
Petersburg, and the term “alliance” is for the first time
 used in the complimentary speeches. Specie payment is
established.
1898 Russia leases Port Arthur and Talienwan, and obtains
leave to carry a branch of the Trans-Siberian line
through Manchuria to the sea. An imperial decree
declares that the powers of the Finnish diet are to be
limited to matters of strictly local, not imperial, concern.
General Bobrikov is appointed Governor-general of
Finland.
1899 During the Boxer uprising the Chinese authorities in
Manchuria declare war against Russia. The Russian
authorities retaliate with the massacre of
Blagovestchensk. Russia assumes the civil and military
administration of Manchuria. Peace Conference held at
the Hague.
1900 The Bank of Persian Loans is founded by the Russian
government.

THE TWENTIETH CENTURY

1901 The state monopoly in the manufacture and sale of

spirits is extended to the whole empire.
1903 Vice-Admiral Alexiev appointed as first Russian viceroy
of the Far East.
1904 Outbreak of the Russo-Japanese war.
 THE RUSSIAN EMPIRE

showing the Accessions since Peter the

Great
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