Venipuncture- is the process of collecting of • Room number and bed (if patient)

blood or drawing blood from a vein. Most • Test(s) that are to be performed
common way to collect a blood in the ✓ Collection site, if appropriate
laboratory. There are two ways of collection of ✓ Date test is to be performed (
blood the open system (e.g. syringe) and the and time if applicable)
closed system (e.g. evacuated tube system and ✓ Test status (e.g., timed, fasting,
capillary). priority)
✓ Other relevant information and
Pre-analytical procedures
instructions (e.g., special
1. Patient registration- registration is a precautions like latex
routine process during which data are sensitivity)
collected that creates a patient record ✓ Billing information and ICD-10
for the specimen individual who is being codes (if outpatient)
admitted to the facility, or has arrived
Barcoding of specimen- barcode systems allow
for testing at the specimen collection
for fast, accurate processing, and their use has
center. The patient’s identity includes
been shown to decrease laboratory errors
full name, address, date of birth, proof
associated with clerical mistakes.
id, and sex.
The process typically involves Venipuncture
assignment of a patient-specific
identifier which will appear on all test The most important venipuncture step is patient
requests and specimen labels for that identification:
patient. Step 1: receive, review, and accession test
2. Requesting for testing- typically, a request
physician or other qualified healthcare
professional request laboratory testing; • Receipt of the test requested
the exceptions are certain rapid test • Reviewing the requisition
that can be purchased and performed at • Check to see that all required
home by consumers and blood information is present and complete.
specimen requested by law ✓ Make a certain that the request
enforcement officials that are used for matches the label generated.
evidence. Test request may be manul, ✓ Resolved any problems or
computerized or barcoded. discrepancies by contacting the
provider.
Required requisition information: ✓ Identify diet restrictions or
• Ordering healthcare provider or another other special circumstances
authorized person’s name that must be met prior to
• Patient’s full name (first, last and middle collection
name or initial if applicable or available) ✓ Determine test status and
• Patient-specific identifier (e.g., inpatient collection priority.
medical record number) • Accessioning the test request (process
• Patient’s sex of accepting the request form).
• Patient’s date of birth or age (per facility
policy)
Step 2: Approach, greet, and identify the patient ➢ Patient identification- it is the process of
verifying a patient’s identity; it is the
➢ Approaching the patient- observe the
most crucial step in specimen collection.
surrounding area for important
It should not be rushed, or any part
conditions or details pertain to your
skipped to save time.
encounter with the patient. A sign with
“law and ethics: never takes shortcuts
the letters DNR (do not resuscitate) or
wit the ID process. In addition to being
DNAR ( do not attempt resuscitation)
unethical, misidentifying a patient’s
means that there is an order (also called
specimen or obtaining a specimen from
a no code order) stating that the patient
the wrong patient can have serious,
should nor be revived if he or she stops
even fatal, consequences, especially
breathing.
specimens for type and cross-match
➢ Bedside manner- the behavior of a
prior to blood transfusion.
healthcare provider toward or as
Consequently, misidentifying a patient
perceived by a patient is called bedside
or specimen can be grounds for
manner.
dismissal and can even lead to a
✓ Knock on the door gently before
malpractice lawsuit if the patient is
entering the room.
injured as a result”.
✓ Make a good impression by
2 positive identification
greeting the patient warmly
✓ you must ask the patient to
✓ Stay organized and have all the
state his or her full name and
supplies available and approach
date of birth (DOB) and spell
the patient in a professional
the first and last name.
manner that goes well with
Reminder: when identifying a
having a neat appearance
patient, never say, for example
✓ Maintain a calm expression as
“are you Mrs. smith? A person
most patients are afraid of
who is very ill, hard of hearing
blood collection
or sedated may say “yes” to
✓ Introduce your self and explain
anything.
the procedure. Obtain the
✓ Check the ID band/wrist band
verbal or expressed consent of
Reminder : the ID band must be
the patient before proceeding
attached to the patient, and the
with the test.
information on the ID band
✓ Remain compassionate and
must match the required
professional during the
information on the requisition
procedure
and all specimen labels exactly.
✓ Thank the patient for his/her
cooperation before leaving How to identify patients (in special
➢ Greet the patient in a cheerful friendly circumstances):
manner and identify yourself by stating
❖ Sleeping patient-gently try to approach.
your name, your title, and why you are
Do not turn on light immediately until
there (e.g., “good morning. I am joseph
woken up.
smith, form the lab. I’m here to collect a
❖ Unconscious patients- ask a relative or
blood specimen if it is alright with you").
the patient’s nurse or other designated
healthcare provider to identify the notify the appropriate personnel that
patient and record the name of that the specimen was not obtained
person. because of patient refusal.
❖ Unidentified ER patients-assign a
Step 4: verify collection requirements, and
temporary wrist band/number
identify sensitives and potential problems
❖ Young, mentally incompetent, or non-
english-speaking patients- ask the Step 5: sanitize hands and put gloves
patient’s healthcare provider, attendant,
relative, or friend to identify the patient Caution: gloves must remain intact throughout
by name, address, and identification the procedure (e.g., do not removes the
number or birth date. fingertips)
❖ Neonates and other infants- ID bands Wearing gloves during blood collection is
placed on lower legs, card on the required by OSHA to protect the phlebotomist
neonatal crib; the infant may be from potential exposure to bloodborne
identified by a nurse, relative, or pathogens.
guardian (record the informant).
Step 6: position patient, apply tourniquet, and
Step 3: Explain the procedure and obtain ask the patient to make a fist
consent
➢ Recumbent patients- if the bed is
• The patient must be told that you are adjustable, raise or lower the head of
going to collect a blood specimen. the bed if needed to help enable arm
Explain what will happen in simple extension;
terms. Special procedures may require ➢ Use a pillow or rolled towel to support
additional information. and position the arm so that at least the
• Obtain informed consent before hand is lower than the elbow.
starting- always explain why you are
there; this is not only courteous but Tourniquet application and fist-clenching
also legally required. • A tourniquet is applied to 3-4 inches
• Never attempt to explain the purpose above (i.e., proximal to) the intended
of a test to a patient. Because a test can venipuncture site to restrict venous
ordered to rule out different problems, blood flow and make the veins more
any attempt to explain its purpose prominent.
could mislead or unduly alarm the • The tourniquet should feel snug or
patient. slightly tight to the patient, but not
Key point: don not attempt to badger uncomfortable.
the patient into cooperating or to
restrain a conscious, mentally alert When the tourniquet is in place, ask the patient
adult patient to obtain a specimen. to clench or make a fist. First-clenching is not
Remember, a patient has the right to mandatory, but when a patient makes a fist, the
refuse testing. veins in that arm become more prominent,
If the patients truly objects and refuses making them easier to locate and enter with a
to let you collect the specimen, write needle. Do not allow the patient to pump the fist
on the requisition that the patients has (repeatedly make and release a fit).
refused to have blood drawn, and
Key point: fist-pumping most notably effects before the venipuncture is attempted, it should
levels of potassium and ionized calcium. be released and reapplied after two minutes.

Step 7: select a vein, release the tourniquet, and Step 8: clean and dry the site
ask the patient to open the fist
➢ Clean the site with a gauze pad soaked
Caution: according to CLSI standard, an attempt with 70% isopropyl alcohol or a
must made to locate the veins in the median commercially prepared alcohol prep
aspect ( center of the arm) on both arms before pad.
considering an alternative vein. Because of the ➢ Use back-and-forth friction to clean an
possibility of nerve injury and damage to the area 2 to 3 in a diameter around the
brachial artery, the basilic vein or other veins in selected site of needle entry. If the site
the medial aspect (inside of the arm) should not is especially dirty. Clean it again using
be chosen unless it appears that no other vein new alcohol-soaked gauze or alcohol
in either arm can be safely or successfully prep pad.
accessed.
Air-drying the site
A patient vien is turgid (distended from being
Allow the cleaned area to dry naturally for
filled with blood), giving it bounce or resilience,
30 seconds to one minute.
and has a tube-like feel.
To prevent contamination of the site:
• An artery has a pulse and must be
avoided. • Do not dry the alcohol with gauze.
• Do not select a vein that feel hard and • Do not fan the site with your hand
cord-like or lacks resilience, as it is or blow on it to hasten drying time.
probably sclerosed or thrombosed. • Do not touch the site after cleaning
• Tendons are also hard and lack it.
resilience.
• If a suitable vein still cannot be found, Step 9: prepare collection equipment and put
massage the arm from wrist to elbow to on gloves.
force blood into the area or wrap a Steps in equipment preparation for different
warm, wet towel around the arm or venipuncture procedures:
hand for a few minutes.
• After you have selected a suitable vein, A. Syringe system
mentally visualize its location if it is not 1. Select the appropriate syringe and
obvious. needle.
2. Test the plunger before opening the
If a tourniquet was applied during vein sterile.
selection, releasing it and ask the patient to 3. Open the package aseptically.
open the fist. This allows the vein to return to 4. Securely attach the needle to the
normal and minimizes the effects of stasis syringe.
(slowing or stopping normal flow) on specimen B. Evacuated tube system
composition. 1. Select the tube appropriate tube for
ETS and tap to lodge any additives
Key point: according to CLSI, when a tourniquet
in stopper.
has been in place for longer than one minute
2. Select and inspect the needle for Step 10: reapply the tourniquet, uncap, and
defects inspect the needle
3. Twist needle to expose the back of
Needle should not come in contact with
the needle
anything prior to venipuncture. If this happens,
4. Screw this end to the threaded hub
remove and replace it with anew one.
of the tube holder
5. Place the first tube in the holder Step 11: ask the patient to remake a fist, anchor
6. Position the tube in the holder to vein, and insert needle.
Steps in Equipment preparation for different Hold the collection device or butterfly needle
venipuncture procedures with your dominant hand, position the needle
above the insertion site with the bevel facing
A. Syringe Systems
up, then insert it using a smooth forward
1. Select the appropriate syringe and
motion in a 30 degree.
needle.
2. Test the plunger before opening the Step 12: Establish the blood flow, release the
sterile package. tourniquet, and ask the patient to open fist
3. Open the package aseptically.
4. Securely attach the needle to the Step 13:fill, remove, and mix the tubes inorder
syringe. of draw or fill the syringe
B. Evacuated tube system Invert the tube several times gently to mix the
1. Select the tube appropriate tube for content; the tourniquet must be released before
ETS and tap to dislodge any removing the needle to avoid hematoma.
additives in the stopper.
2. Select and inspect the needle for Step 14: place the gauze, remove the needle,
defects active the safety feature and apply pressure
3. Twist needle to expose the back of Step 15: discard the collection unit, syringe
the needle needle or transfer device
4. Screw this end to the threaded hub
of the tube holder Step 16: label the tubes
5. Place the first tube in the holder
✓ Patient’s complete name (first
6. Position the tube in the holder
and last)
Steps in equipment preparation for different ✓ Date of birth
venipuncture procedures ✓ ID number (if applicable)
✓ Date and time of collection
c. winged infusion set (butterfly) ✓ Initials of the phlebotomist
1. use a 23-gauge butterfly gauge with a safety ✓ Additional information such as
feature. fasting.

2. inspect the package before aseptically Step 16: observe special handling instruction
opening and removing the butterfly. Step 17: checks patient’s arm and apply
3. attach the butterfly to an ETS or syringe bandage

4. select the appropriate small-valume tube for Step 18: dispose of contaminated materials
the test. Step 19: thank the patient
Step 20: transport the specimen to the lab. 4. Heparin or saline lock/ hep lock-for
medicine administration or blood
Pre-Analytical considerations in phlebotomy
sampling
❖ Pre analytical testing phase 5. IV sites- phlebos should collect below IV
• Includes procedures such as lines
laboratory handling and 6. Central vascular access devices (CVADS)
identification, which take place indwelling lines- it could be a central
before any laboratory testing venous catheter lines, implanted port,
• Strict and proper control peripherally inserted central catheter
measures should be observed Handling patient complications associated with
to avoid further issues blood collection
• It starts when the doctor’s
order is given and ends when 1. Allergies to equipment and supplies
the laboratory testing has ✓ Adhesives allergy-apply guaze
officially commenced for 15 minutes
✓ Antiseptic allergy-use a
Problem areas to avoid and troubleshooting in different antiseptic technique
the site selection ✓ Latex allergy-use non-latex
Phlebotomist should be aware of the ff problem gloves, tourniquet, bandages.
areas when selecting the venipuncture site: 2. Excessive bleeding- pressure should be
applied until bleeding stops
1. Burns, scar and tattoos 3. Fainting- lie down during procedure
2. Damaged veins-could be sclerosed, 4. Nausea and vomiting- discontinue
hardened, thrombosed or clotted procedure until patient feels better
3. Edema/oedema- accumulation of fluids 5. Pain-if pt complains extreme numbness
in the tissues or pain, remove needle and apply ice to
4. Hematoma-leakage of blood from the site because this may indicate nerve
vessels during venipuncture involvement
5. Mastectomy-tourniquet could not be 6. Petechiae- small red or purple spot that
applied in this arm because it can cause looks like rashes when tourniquet is
injury applied.
6. Obesity- deep and difficult to locate; use 7. Seizures or convulsion- discontinue
a longer tourniquet, palpate the asap; check mouth for any obstruction,
cephalic or cubital vein and patient is protected from any self-
Vascular access sites and devices VADS- are injury. Notify first aid personnel.
needed for blooding sampling, infusing Avoiding and handling procedural error risks
medication, central venous pressure readings, and failure to draw blood
and blood transfusion of a patient.
❖ Hematoma formation
1. Arterial line • Hold pressure over the site
2. Arteriovenous shunt or fistula immediately after discontinuing
3. Blood-sampling device the draw
• Cold compress or ice pack may 1. Hemoconcentration- decrease in fluid
be offered to help address the content or plasma volume caused by
swelling tourniquet that stagnate the flow of
• The following are the conditions blood
that trigger hematoma: 2. Hemolysis- rupture of the RBCs, the
✓ There is excessive or HGB is then released to the surrounding
blind probing fluid.
✓ There is inadvertent 3. Partially-filled tube or short draw-
arterial puncture phlebo pulls a tube before the required
✓ The size of the vein is volume; this leads to incorrect blood-to-
too small additive ratio.
✓ The needle penetration 4. Specimen contamination
has gone all through 5. Wrong or expired collection tube
the vein
Troubleshooting failed venipuncture
✓ Needle is not
completely inserted ❖ The needle position is critical to the
✓ Tourniquet is still on success of the venipuncture. The
when the needle was phlebotomist should ensure that the
removed following do not happen:
✓ The pressure is not ✓ Needle not inserted far enough
adequate ✓ Bevel partially out of skin
➢ Iatrogenic anemia- blood loss due to ✓ Bevel partially into the vein
blood draw. Phlebo should ensure that ✓ Bavel partially through the vein
only the required volume should be ✓ Bevel complete through vien
extracted from the patient because a ✓ Bevel against vein wall
10% loss blood could face a threat to ✓ Needle beside vein
the patient. ✓ Undetermined position
➢ Inadvertent arterial puncture- observed
Collapsed vein- this happens when there is a
when the filling of the tube happens
strong pressure in the vacuum of the tube or
rapidly and there is rapid formation of
plunger; the tourniquet is too close to the site
hematoma on the site
or is too tight; or the tourniquet has been
➢ Infection- sterile conditions, vein site
removed during the draw
should be kept closed for 15 mins.
➢ Nerve injury- improper site selection, Tube vacuum- phlebotomist should make sure
rapid needle insertion, excessive that the bevel is not partially out of skin and the
redirection of the needle, and blind tube itself is not damaged.
probing; phlebo should swim slowly or
stop vein and look for alternatives sites
➢ Reflux of anticoagulant- downward
position should be observed and tube
should be below the vein site
➢ Vein damage- follow proper techniques
and avoid blind probing

Specimen quality