Blood Specimen Collection 3

Elaine M. Keohane*

OUTLINE OBJECTIVES
Safety After completion of this chapter, the reader will be able to:
Responsibility of
the Phlebotomist 1. Describe the application of standard precautions to 7. Describe the steps recommended by the Clinical and
in Infection Control the collection of blood specimens. Laboratory Standards Institute for skin puncture, in-
Physiologic Factors 2. List collection equipment used for venipuncture and cluding collection sites for infants, children, and
Affecting Test Results skin puncture. adults, and the order of draw for tubes with additives.
Venipuncture 3. Correlate tube stopper color with additive, if any, and 8. Describe components of quality assurance in speci-
Equipment for Venipuncture explain the purpose of the additive and use of that men collection.
Selection of a Vein for Routine tube type for laboratory tests. 9. List reasons for specimen rejection.
Venipuncture 4. Explain reasons for selection of certain veins for 10. Given a description of a specimen and its collection,
Venipuncture Procedure venipuncture and name the veins of choice in the determine specimen acceptability.
Venipuncture in Children
antecubital fossa in order of preference. 11. Recognize deviations from the recommended veni-
Complications Encountered
5. Describe the steps recommended by the Clinical puncture practice in a written scenario and describe
in Venipuncture
Venipuncture in Special and Laboratory Standards Institute for venipuncture, corrective procedures.
Situations including the recommended order of draw for tubes 12. State the most important step in the phlebotomy
Inability to Obtain a Blood with additives. procedure.
Specimen 6. Describe complications encountered in blood 13. List reasons for inability to obtain a blood specimen.
Skin Puncture collection and the proper response of the phle- 14. Summarize legal issues that need to be considered
Collection Sites botomist. in blood specimen collection and handling.
Precautions with Skin
Puncture
Equipment for Skin Puncture CASE STUDIES
Skin Puncture Procedure After studying the material in this chapter, the reader should be able to respond to the
Quality Assurance in following case studies:
Specimen Collection
Technical Competence Case 1
Collection Procedures A phlebotomist asks an outpatient, “Are you Susan Jones?” After the patient answers yes, the phle-
Anticoagulants and Other botomist proceeds by labeling the tubes and drawing the blood. What is wrong with this scenario?
Additives
Requirements for a Quality Case 2
Specimen A patient must have blood drawn for a complete blood count (CBC), potassium level, pro-
Collection of Blood for Blood
thrombin time (PT), and type and screen. The phlebotomist draws blood into the following
Culture
tubes in this order:
Quality Control and
Preventive Maintenance 1. Serum separation tube
on Specimen Processing 2. Light blue stopper tube for PT
and Storage Equipment 3. Lavender stopper tube for CBC
Reasons for Specimen 4. Green stopper tube for the potassium
Rejection Which of the results will be affected by the incorrect order of draw? Explain.
Specimen Handling
Legal Issues in Phlebotomy

*The author extends appreciation to Carole A. Mullins, whose work in prior editions provided the foundation for this chapter.

19
20 PART I Introduction to Hematology

Contaminated sharps and infectious wastes should be

SAFETY
placed in designated puncture-resistant containers. The red
Standard precautions must be followed in the collection of or red-orange biohazard sign (Figure 2-2) indicates that a
blood, and all specimens must be treated as potentially infec- container holds potentially infectious materials. Biohazard
tious for bloodborne pathogens. Regulations of the Occupa- containers should be easily accessible and should not be
tional Safety and Health Administration (OSHA) that took overfilled.
effect on March 6, 1992, outlined in detail what must be done
to protect health care workers from exposure to bloodborne
RESPONSIBILITY OF THE PHLEBOTOMIST
pathogens, such as the pathogens that cause hepatitis C, hepa-
IN INFECTION CONTROL
titis B, hepatitis D, syphilis, malaria, and human immunode-
ficiency virus (HIV) infection.1 Because phlebotomists interact with patients and staff through-
Bloodborne pathogens may enter the body through an out the day, they potentially can infect numerous people. Phle-
accidental injury by a sharp object, such as a contaminated botomists should become familiar with and observe infection
needle, a scalpel, broken glass, or any other object that can control and isolation policies. Violations of policies should be
pierce the skin. Cuts, skin areas with dermatitis or abrasions, reported. A phlebotomist must maintain good personal health
and mucous membranes of the mouth, eyes, and nose may and hygiene, making sure to have clean clothes, clean hair, and
also provide a portal of entry. Indirect transmission can occur clean, short fingernails. Standard precautions must be followed
when a person touches a contaminated surface or object and at all times, with special attention to the use of gloves and
then touches the mouth, eyes, nose, or nonintact skin without hand washing.
washing the hands. Hepatitis B virus can survive on inanimate
or dried surfaces for at least 1 week.2
PHYSIOLOGIC FACTORS AFFECTING TEST
Hand washing is the most important practice to prevent the
RESULTS
spread of infectious diseases. The phlebotomist should wash his
or her hands with soap and running water between patients and Certain physiologic variables under the control of the
every time gloves are removed. An alcohol-based hand rub may patient or the phlebotomist may introduce preanalytical
be used if hands are not visibly contaminated.3 Antimicrobial variation in laboratory test results. Examples of these factors
wipes or towelettes are less effective for hand sanitation.3 Gloves include posture (supine or erect), diurnal rhythms, exercise,
are essential personal protective equipment and must be worn stress, diet (fasting or not), and smoking (Box 3-1).4-8
during blood collection procedures. When gloves are removed, The phlebotomist must adhere to the specific schedule for
no blood from the soiled gloves should come in contact with timed specimen collections and accurately record the time
the hands. Glove removal is covered in detail in Chapter 2. of collection.

BOX 3-1 Some Physiologic Factors That Can Contribute to Preanalytical Variation in Test Results

Ms
Posture denease Stress
Changing from a supine (lying) to a sitting or standing position results Anxiety and excessive crying in children can cause a temporary
in a shift of body water from inside the blood vessels to the interstitial
spaces. Larger molecules, such as protein, cholesterol, and iron cannot
I /
increase in the white blood cell count.4

filter into the tissues, and their concentration increases in the blood.4,5 Diet
! means no food or beverages except water for 8 to 12 hours
Fasting -

Diurnal Rhythm before a blood draw. If a patient has eaten recently (less than
Diurnal rhythm refers to daily body fluid fluctuations that occur with 2 hours earlier), there will be a temporary increase in glucose and
some constituents of the blood. For example, levels of cortisol, thyroid- lipid content in the blood. In addition, the increased lipids may
stimulating hormone, and iron are higher in the morning and decrease cause turbidity (lipemia) in the serum or plasma, affecting some
C
in the afternoon.4,5 Other test values, such as the eosinophil count, are tests that require photometric measurement, such as the hemo-
-

lower in the morning and increase in the afternoon.4,5 globin concentration and coagulation tests performed on optical
-/
/ -
detection instruments.
Exercise -
↑ WBC count
atinine,
u
m
total
/
Exercise can increase various constituents in the blood such as cre-
protein, creatine kinase, myoglobin, aspartate amino-
Smoking
-

Patients who smoke before blood collection may have increased white
-
- -
transferase, white blood cell count, and HDL-cholesterol.6 The extent blood cell counts and cortisol levels.7,8 Long-term smoking can lead to Leg
-
- =RBU
and duration of the increase depend on the intensity, duration, decreased pulmonary function and result in Iincreased hemoglobin 5
-

and frequency of the exercise and the time the blood specimen was levels./

cheese
-
*
collected postexercise.
-x
5
ma
t
 CHAPTER 3 Blood Specimen Collection 21

be necessary if testing for the glucose level is delayed. The most

VENIPUNCTURE
commonly used antiglycolytic agent is sodium fluoride.4.5
This chapter only covers an overview of blood specimen collec- Tubes containing sodium fluoride alone yield serum. Tubes
tion; sources that provide detailed information are listed in the containing sodium fluoride and an anticoagulant (such
reference section. as EDTA or oxalate) yield plasma. Anticoagulated blood can
be centrifuged immediately to obtain plasma for testing, thus
Equipment for Venipuncture decreasing the specimen preparation time.
Tourniquet
A tourniquet is used to provide a barrier against venous blood Separator Gel. Separator gel is an inert material that
flow to help locate a vein. A tourniquet can be a disposable undergoes a temporary change in viscosity during the centrifu-
elastic strap, a heavier Velcro strap, or a blood pressure cuff. gation process; this enables it to serve as a separation barrier
The tourniquet should be applied 3 to 4 inches above the between the liquid (serum or plasma) and cells. Because this
venipuncture site and left on for no longer than 1 minute gel may interfere with some testing, serum or plasma from
before the venipuncture is performed.9 Latex-free tourniquets these tubes cannot be used with certain instruments or for
are available for individuals with a latex allergy. blood bank procedures.

Collection Tubes Needles

The most common means of collecting blood specimens Venipuncture needles are sterile and are available in a variety of
is through the use of an evacuated tube system. The system lengths and gauges (bore or opening size). Needles used with
includes an evacuated tube, which can be either plastic or glass; evacuated tube systems screw into a plastic needle holder and
a needle; and an adapter that is used to secure the needle and are double pointed. The end of the needle that is inserted into
the tube. When the needle is inserted into a vein and a tube is the vein is longer and has a point with a slanted side or bevel. A
inserted into the holder, the back of the needle pierces the plastic cap covers this end of the needle and is removed prior to
stopper, allowing the vacuum pressure in the tube to auto- insertion. The end of the needle that pierces the stopper of the
matically draw blood into the tube. For safety, OSHA recom- evacuated tube is shorter and is covered by a rubber sleeve in
mends the use of plastic tubes whenever possible. Most glass multiple-sample needles. The rubber sleeve prevents blood from
tubes are coated with silicone to help decrease the possibility dripping into the holder when changing tubes (Figure 3-2).
of hemolysis and to prevent blood from adhering to the sides Needles used with syringes are discussed below.
of the tube. Evacuated tubes are available in various sizes and The gauge number of a needle is inversely related to the
may contain a variety of premeasured additives. bore size: the smaller the gauge number, the larger the bore.
Manufacturers of evacuated tubes in the United States Needles for drawing blood range from 19 to 23 gauge.9 The
follow a universal color code in which the stopper color indi- most common needle size for adult venipuncture is 21 gauge
cates the type of additive contained in the tube. Figure 3-1 pro- with a length of 1 inch. The advantage of using a 1-inch needle
vides a summary of various types of evacuated collection tubes. is that it provides better control during venipuncture.

Additives in Collection Tubes Needle Holders

Clot activators. Blood specimens for serum testing must Needles and holders are designed to comply with OSHA’s
first be allowed to clot for 30 to 60 minutes prior to centrifugation revised Occupational Exposure to Bloodborne Pathogens
and removal of the serum.10 A clot activator accelerates the clotting Standard (effective April 18, 2001) and its requirement for
process and decreases the specimen preparation time. Examples of implementation of safer medical devices.11 Needles and hold-
clot activators include glass or silica particles (activates factor XII in ers have safety features to prevent accidental needle sticks.
the coagulation pathway) and thrombin (an activated coagulation Needle holders are made to fit a specific manufacturer’s
factor that converts fibrinogen to fibrin) (Chapter 37). needles and tubes and should not be interchanged. The hold-
ers are disposable and must be discarded after a single use with
Anticoagulants. An anticoagulant prevents blood from the needle still attached as required by OSHA.12
clotting. Ethylenediaminetetraacetic acid (EDTA), citrate, and The following are some examples of safety needles and
oxalate remove calcium needed for clotting by forming insolu- holders:
ble calcium salts. Heparin prevents clotting by binding to anti- 1. The Vacutainer® Eclipse™ Blood Collection System (BD
thrombin in the plasma and inhibiting thrombin and activated Medical, Franklin Lakes, NJ) allows single-handed activa-
coagulation factor X (Chapter 37). Tubes with anticoagulant tion after the venipuncture is performed by pushing the
must be gently inverted immediately after collection according safety shield forward with the thumb until it is over the
to the manufacturer’s directions to ensure proper mixing. needle and an audible click is heard. The BD Eclipse needle
Tubes with anticoagulant are either tested as whole blood or is used with a single-use needle holder. After the safety
are centrifuged to yield plasma. shield is activated, the entire assembly is discarded intact
into a sharps container.
Antiglycolytic Agent. An antiglycolytic agent inhibits 2. The Jelco multisample blood collection needle used with
the metabolism of glucose by blood cells. Such inhibition may the Venipuncture Needle-Pro® Device (Smiths Medical ASD,
22 PART I Introduction to Hematology

BD Vacutainer® Venous Blood Collection

Tube Guide
For the full array of BD Vacutainer® Blood Collection Tubes, visit www.bd.com/vacutainer.
Many are available in a variety of sizes and draw volumes (for pediatric applications). Refer to our website for full descriptions.
BD Vacutainer® Tubes BD Vacutainer® Tubes Inversions
with with at Blood Your Lab’s
BD Hemogard™ Closure Conventional Stopper Additive Collection* Laboratory Use Draw Volume/Remarks
• Clot activator and gel 5 For serum determinations in chemistry.
for serum separation May be used for routine blood donor
Gold
Red/ screening and diagnostic testing of serum
Gray for infectious disease.** Tube inversions
ensure mixing of clot activator with blood.
Blood clotting time: 30 minutes.
• Lithium heparin 8 For plasma determinations in chemistry.
Light Green/ and gel for plasma Tube inversions ensure mixing of anticoagulant
Green Gray separation (heparin) with blood to prevent clotting.

• Silicone coated (glass) 0 For serum determinations in chemistry.

• Clot activator, Silicone 5 May be used for routine blood donor
Red Red coated (plastic) screening and diagnostic testing of serum
for infectious disease.** Tube inversions
ensure mixing of clot activator with blood.
Blood clotting time: 60 minutes.
• Thrombin-based clot 5 to 6 For stat serum determinations in chemistry.
activator with gel for Tube inversions ensure mixing of clot activator
Orange with blood. Blood clotting time: 5 minutes.
serum separation

• Thrombin-based clot 8 For stat serum determinations in chemistry.

activator Tube inversions ensure mixing of clot activator
Orange with blood. Blood clotting time: 5 minutes.

• Clot activator 8 For trace-element, toxicology, and

(plastic serum) nutritional-chemistry determinations.
• K2EDTA (plastic) 8 Special stopper formulation provides
Royal
Blue
low levels of trace elements
(see package insert). Tube inversions ensure
mixing of either clot activator or anticoagulant
(EDTA) with blood.
• Sodium heparin 8 For plasma determinations in chemistry.
• Lithium heparin 8 Tube inversions ensure mixing of anticoagulant
Green Green (heparin) with blood to prevent clotting.

• Potassium oxalate/ 8 For glucose determinations. Oxalate and

sodium fluoride EDTA anticoagulants will give plasma
Gray Gray • Sodium fluoride/Na2 EDTA 8 samples. Sodium fluoride is the
• Sodium fluoride 8 antiglycolytic agent. Tube inversions
(serum tube) ensure proper mixing of additive with blood.

• K2EDTA (plastic) 8 For lead determinations. This tube is certified

to contain less than .01 !g/mL(ppm) lead.
Tan Tube inversions prevent clotting.

• Sodium 8 SPS for blood culture specimen collections

polyanethol sulfonate (SPS) in microbiology.
• Acid citrate dextrose
additives (ACD): ACD for use in blood bank studies, HLA
Solution A - 8 phenotyping, and DNA and paternity testing.
Yellow 22.0 g/L trisodium citrate,
8.0 g/L citric acid, 24.5 g/L Tube inversions ensure mixing of anticoagulant
dextrose with blood to prevent clotting.
Solution B - 8
13.2 g/L trisodium citrate,
4.8 g/L citric acid, 14.7 g/L
dextrose
• Liquid K3EDTA (glass) 8 K2EDTA and K3EDTA for whole blood
• Spray-coated K2EDTA 8 hematology determinations. K2EDTA may be
Lavender Lavender (plastic) used for routine immunohematology testing,
and blood donor screening.***
Tube inversions ensure mixing of anticoagulant
(EDTA) with blood to prevent clotting.
• K2EDTA and gel for 8 For use in molecular diagnostic test methods
plasma separation (such as, but not limited to, polymerase chain
White
reaction [PCR] and/or branched DNA [bDNA]
amplification techniques.) Tube inversions
ensure mixing of anticoagulant (EDTA) with
blood to prevent clotting.
• Spray-coated K2EDTA 8 For whole blood hematology determinations.
(plastic) May be used for routine immunohematology
Pink Pink
testing and blood donor screening.***
Designed with special cross-match label for
patient information required by the AABB.
Tube inversions prevent clotting.
• Buffered sodium citrate 3-4 For coagulation determinations. CTAD for
0.105 M (!3.2%) glass selected platelet function assays and routine
Light Light
0.109 M (3.2%) plastic coagulation determination. Tube inversions
Blue Blue
• Citrate, theophylline, 3-4 ensure mixing of anticoagulant (citrate) to
adenosine, dipyridamole prevent clotting.
(CTAD)
Clear

• None (plastic) 0 For use as a discard tube or secondary

New specimen tube.
Clear
Red/
Light Gray

Note: BD Vacutainer® Tubes for pediatric and partial draw applications can be found on our website.
BD Diagnostics BD Global Technical Services: 1.800.631.0174 * Invert gently, do not shake
** The performance characteristics of these tubes have not been established for infectious disease testing in general; therefore, users must
Preanalytical Systems BD Customer Service: 1.888.237.2762 validate the use of these tubes for their specific assay-instrument/reagent system combinations and specimen storage conditions.
1 Becton Drive www.bd.com/vacutainer *** The performance characteristics of these tubes have not been established for immunohematology testing in general; therefore, users must
Franklin Lakes, NJ 07417 USA validate the use of these tubes for their specific assay-instrument/reagent system combinations and specimen storage conditions.

BD, BD Logo and all other trademarks are property of Becton, Dickinson and Company. © 2010 BD Printed in USA 07/10 VS5229-13

Figure 3-1 Vacutainer® tube guide. (Courtesy and © Becton, Dickinson and Company.)
 CHAPTER 3 Blood Specimen Collection 23

Figure 3-2 Multisample needle. The rubber sleeve prevents blood from
dripping into the holder when tubes are changed. (Courtesy and © Becton,
Dickinson and Company.)

Figure 3-4 QUICKSHIELD Complete PLUS with flash window. Blood in the
flash window indicates successful venipuncture. (Courtesy Greiner Bio-One,
Monroe, NC.)

1 2 3

B
Figure 3-3 A, Jelco Needle-Pro®. B, Use of Jelco Needle-Pro®. (1) Attach
needle. (2) Remove cap and draw blood from patient. (3) After collection
press sheath on flat surface. (Courtesy Smiths Medical ASD, Norwell MA.)

Norwell, MA) allows the Needle-Pro® sheath to be snapped

over the needle by pushing it against a flat, firm surface
Figure 3-5 Jelco Saf-T Wing® Blood Collection set. (Courtesy Smiths
after the venipuncture is completed. The entire device is Medical ASD, Norwell, MA.)
discarded into the sharps container (Figure 3-3).
3. The Greiner Bio-One (Monroe, NC) VACUETTE® QUICK-
SHIELD has a sheath that locks into place over the needle devices to minimize the risk of needle stick injury. Examples
after use. The QUICKSHIELD Complete PLUS is a system include MONOJECTTM ANGEL WINGTM Blood Collection
that incorporates a holder with an attached VACUETTE® Set (Covidien, Mansfield, MA), Vacutainer® Safety-Lok™ and
Visio PLUS multisample needle. The flash window in the Vacutainer® Push Button Blood Collection Set (BD Medical,
needle hub indicates when a successful venipuncture has Franklin Lakes, NJ), VACUETTE® Safety Blood Collection Set
been achieved (Figure 3-4). (Greiner Bio-One, Monroe, NC), and Jelco Saf-T Wing® Blood
Collection set (Smiths Medical ASD, Norwell, MA).
Winged Blood Collection Set (Butterfly)
A winged blood collection set or butterfly consists of a short Syringes
needle with plastic wings connected to thin tubing (Figure 3-5). A syringe consists of a barrel, graduated in milliliters, and a
The other end of the tubing can be connected to a needle holder plunger. Syringe needles have a point at one end and an open
for an evacuated tube, a syringe, or a blood culture bottle with hub at the other end that attaches to the barrel of the syringe.
the use of special adapters. Winged blood collection sets are use- Syringes are available with different types of needle attach-
ful in collecting specimens from children or other patients from ments and in different sizes. It is important to attach the needle
whom it is difficult to draw blood. They also have sheathing securely to the syringe to prevent air from entering the system.
24 PART I Introduction to Hematology

Syringes may be useful in drawing blood from pediatric, geri- compounds, or another isopropyl alcohol prep.9 Some health
atric, or other patients with tiny, fragile, or “rolling” veins that care facilities use a one-step application of chlorhexidine
would not be able to withstand the vacuum pressure from gluconate/isopropyl alcohol or povidone-70% ethyl alcohol.9
evacuated tubes. With a syringe, the amount of pressure exerted Whatever method is used, the antiseptic agent should be in
is controlled by the phlebotomist by slowly pulling back the contact with the skin for at least 30 seconds to minimize the
plunger. Syringes may also be used with winged infusion sets. risk of accidental contamination of the blood culture.
If only one tube of blood is needed, the phlebotomist fills
the syringe barrel with blood, removes the needle from the Selection of a Vein for Routine Venipuncture
arm, activates the needle safety device, removes and discards The superficial veins of the antecubital fossa (bend in the
the needle in a sharps container, and attaches the hub of the elbow) are the most common sites for venipuncture. There are
syringe to a transfer device to transfer the blood into an evacu- two anatomical patterns of veins in the antecubital fossa4,9
ated tube. An example is the BD Vacutainer® Blood Transfer (Figure 3-7). In the “H” pattern, the three veins that are used,
Device with Luer adapter. If multiple tubes are needed, the in the order of preference, are (1) the median cubital vein,
phlebotomist can use a closed blood collection system such as
the Jelco Saf-T Holder® with male Luer adapter with Saf-T
Wing® butterfly needle (Smiths Medical ASD) (Figure 3-6). Cephalic Antecubital fossa
With this system, the butterfly needle tubing branches into a vein
Y shape and attaches to the syringe on one side and an evacu-
ated tube in a holder on the other side. Clamps in the tubing
control the flow of blood from the arm to the syringe and then
from the syringe to the evacuated tube. To prevent hemolysis
Median Basilic
when using transfer devices, only the tube’s vacuum (and not cubital vein
the plunger) should be used to transfer the blood from the vein
syringe into the evacuated tube. A

Solutions for Skin Antisepsis Accessory

cephalic vein Antecubital fossa
The most common skin antiseptic is 70% isopropyl alcohol in
a commercially prepared pad. The phlebotomist cleans the
phlebotomy site in a circular motion, beginning in the center
and working outward. The area is allowed to air-dry before the
venipuncture is performed so that the patient does not experi-
ence a burning sensation after needle insertion and to prevent Median Basilic
contamination of the specimen with alcohol. The phlebotomist vein vein
must use a non-alcohol-based antiseptic to collect blood for a
legal blood alcohol level.9 When a sterile site is prepared B
for collection of specimens for blood culture, a two-step proce- Figure 3-7 Superficial veins of the anterior right arm in the antecubital
dure with a 30- to 60-second scrub is used in which cleansing fossa (two views). A, “H” pattern of veins. B, “M” pattern of veins. The preferred
with 70% isopropyl alcohol is followed by cleansing with 1% vein for venipuncture is the median cubital vein in the H pattern and the median
to 10% povidone-iodine pads, tincture of iodine, chlorhexidine vein in the M pattern. (Adapted from McCall RE, Tankersley CM. Phlebotomy
Essentials, ed. 5, Philadelphia, 2012, Lippincott, Williams & Wilkins.)

Saf-T Holder

Sample
Side clamp syringe
directs blood flow Luer

A B
Figure 3-6 A, Jelco closed blood collection system. (Courtesy Smiths Medical ASD, Norwell, MA.) B, Device for transferring blood from syringe to vacuum
tube. (1) Draw blood with syringe. (2) Close clamp. (3) Insert tube to transfer blood from syringe to tube. To fill additional tubes, open clamp, draw blood with
syringe again, close clamp, and transfer. (Courtesy Smiths Medical ASD, Norwell, MA.)
 CHAPTER 3 Blood Specimen Collection 25

which connects the basilic and cephalic veins in the antecubi- bevel up, with an angle less than 30 degrees between the
tal fossa; (2) the cephalic vein, located on the outside (lateral) needle and the skin. Collect tubes using the correct order
aspect of the antecubital fossa on the thumb side of the hand; of draw, and invert each tube containing any additive im-
and (3) the basilic vein, located on the inside (medial) aspect mediately after collection. CLSI recommends a particular
of the antecubital fossa. In the “M” pattern, the order of prefer- order of draw when collecting blood in multiple tubes
ence is the (1) median vein, (2) accessory cephalic vein, and from a single venipuncture.9 Its purpose is to avoid possi-
(3) the basilic vein. The cephalic and basilic veins should only ble test result error because of cross-contamination
be used if the median cubital or median veins are not promi- from tube additives. The recommended order of draw is as
nent after checking both arms. The basilic vein is the last choice follows: (Box-3-2)
due to the increased risk of injury to the median nerve and/or a. Blood culture tube (yellow stopper)
accidental puncture of the brachial artery, both located in close b. Coagulation tube (light blue stopper)
proximity to the basilic vein.9 c. Serum tube with or without clot activator or gel (red,
If necessary, the phlebotomist should have the patient make gold, red-gray marbled, orange, or yellow-gray stopper)
a fist after application of the tourniquet; the veins should be- d. Heparin tube (green or light green stopper)
come prominent. The patient should not pump the fist because e. EDTA tube (lavender or pink stopper)
it may affect some of the test values. The phlebotomist should f. Sodium fluoride tube with or without EDTA or oxalate
palpate (examine by touching) the vein with his or her index (gray stopper)
finger to determine vein depth, direction, and diameter. If a 13. Release and remove the tourniquet as soon as blood flow
vein cannot be located in either arm, it may be necessary to is established or after no longer than 1 minute.
examine the veins on the dorsal surface of the hand. 14. Ensure that the patient’s hand is open.
The veins in the feet should not be used without physician 15. Place gauze lightly over the puncture site without pressing
permission. The policy in some institutions is to request that a down.
second phlebotomist attempt to locate a vein in the arm or the 16. After the last tube has been released from the back of the
hand before a vein in the foot is used. The veins in the inner multisample needle, remove the needle and activate the
wrist should never be used due to the high risk of injury to safety device according to the manufacturer’s directions.
tendons and nerves in that area.9 17. Apply direct pressure to the puncture site using a clean
gauze pad.
Venipuncture Procedure 18. Bandage the venipuncture site after checking to ensure that
The phlebotomist uses standard precautions, which include bleeding has stopped.
washing hands and applying gloves at the beginning of the 19. If a syringe has been used, fill the evacuated tubes using a
procedure and removing gloves and washing hands at the end syringe transfer device.
of the procedure. The Clinical and Laboratory Standards Insti- 20. Dispose of the puncture equipment and other biohazard-
tute (CLSI) recommends the following steps:9 ous waste.
1. Prepare the accession (test request) order. 21. Label the tubes with the correct information. The minimal
2. Greet the patient and identify the patient by having the amount of information that must be on each tube is as
patient verbally state his or her full name and confirm with follows:
the patient’s unique identification number, address, and/ a. Patient’s full name
or birth date. Ensure the same information is on the re- b. Patient’s unique identification number
quest form. c. Date of collection
3. Sanitize hands. d. Time of collection (military time)
4. Verify that any dietary restrictions have been met (e.g., fast- e. Collector’s initials or code number
ing, if appropriate) and check for latex sensitivity. NOTE: Compare the labeled tube with the patient’s identi-
5. Assemble supplies and appropriate tubes for the requested fication bracelet or have the patient verify that the informa-
tests. Verify paperwork and tube selection. tion on the labeled tube is correct whenever possible.
6. Reassure and position the patient.
7. If necessary to help locate a vein, request that the patient
clench his or her fist.
BOX 3-2 Order of Draw for Venipuncture9
8. Apply the tourniquet and select an appropriate venipuncture
site, giving priority to the median cubital or median vein.
1. Blood culture tube (yellow stopper)
Ensure the tourniquet is on for no longer that 1 minute.
2. Coagulation tube (light blue stopper)
9. Put on gloves.
3. Serum tube with or without activator (red, gold, red-gray marbled,
10. Cleanse the venipuncture site with 70% isopropyl alcohol
orange, or yellow-gray stopper)
using concentric circles from the inside to outside. Allow
4. Heparin tube (green or light green stopper)
skin to air-dry.
5. EDTA tube (lavender or pink stopper)
11. Inspect the equipment and needle tip for burrs and bends.
6. Sodium fluoride with or without EDTA or oxalate (gray stopper)
12. Perform the venipuncture by anchoring the vein with the
thumb 1 to 2 inches below the site and inserting the needle, EDTA, ethylenediaminetetraacetic acid
26 PART I Introduction to Hematology

22. Carry out any special handling requirements (e.g., chilling Complications Encountered in Venipuncture
or protecting from light). Ecchymosis (Bruise)
23. Cancel any phlebotomy-related dietary restrictions and Bruising is the most common complication encountered
thank the patient. in obtaining a blood specimen. It is caused by leakage of a
24. Send the properly labeled specimens to the laboratory. small amount of blood in the tissue around the puncture site.
The most crucial step in the process is patient identification. The phlebotomist can prevent bruising by applying direct
The patient must verbally state his or her full name, or some- pressure to the venipuncture site with a gauze pad. Bending
one must identify the patient for the phlebotomist. In addi- the patient’s arm at the elbow to hold the gauze pad in place
tion, at least one additional identifier needs to be checked such is not effective in stopping the bleeding and may lead to
as the address, birth date, or the unique number on the bruising.
patient’s identification bracelet (for hospitalized patients). The
phlebotomist must match the patient’s full name and unique Hematoma
identifier with the information on the test requisition. Any A hematoma results when leakage of a large amount of blood
discrepancies must be resolved before the venipuncture can around the puncture site causes the area to rapidly swell. If
continue. Failure to confirm proper identification can result in swelling begins, the phlebotomist should remove the needle
a life-threatening situation for the patient and possible legal immediately and apply pressure to the site with a gauze pad for
ramifications for the facility. The phlebotomist must also label at least 2 minutes. Hematomas may result in bruising of the
all tubes immediately after the blood specimen has been patient’s skin around the puncture site. Hematomas can also
drawn, with the label attached to the tube, before leaving the cause pain and possible nerve compression and permanent
patient’s side. damage to the patient’s arm. Hematomas most commonly oc-
cur when the needle goes through the vein or when the bevel
Coagulation Testing of the needle is only partially in the vein (Figure 3-8, B and C)
If only a light blue stopper coagulation tube is to be drawn and when the phlebotomist fails to remove the tourniquet
for determination of the prothrombin time or activated par- before removing the needle or does not apply enough pressure
tial thromboplastin time, the first tube drawn may be used for to the site after venipuncture. Hematomas can also form after
testing. It is no longer necessary to draw a 3-mL discard non- inadvertent puncture of an artery.
additive tube before collecting for routine coagulation test-
ing. The phlebotomist must fill tubes for coagulation testing Fainting (Syncope)
to full volume (or to the minimum volume specified by the Fainting is also a common complication encountered. Before
manufacturer) to maintain a 9:1 ratio of blood to anticoagu- drawing blood, the phlebotomist should always ask the patient
lant. Underfilling coagulation tubes results in prolonged test whether he or she has had any prior episodes of fainting dur-
values. When a winged blood collection set is used to draw a ing or after blood collection. The CLSI does not recommend
single light blue stopper tube, the phlebotomist must first the use of ammonia inhalants to revive the patients because
partially fill a nonadditive tube or another light blue stopper they may trigger an adverse response that could lead to patient
tube to clear the dead air space in the tubing before collecting injury.9 The phlebotomist should follow the protocol at his or
the tube to be used for coagulation testing. For special coagu- her facility.
lation testing, however, a second-drawn light blue stopper If the patient begins to faint, the phlebotomist should
tube may be required.9 Chapter 42 covers specimen collection
for hemostasis testing in more detail.
X
remove and discard the needle immediately, apply pressure to
I
the site with a gauze pad, lower the patient’s head, and loosen
any constrictive clothing. The phlebotomist should also --notify
Venipuncture in Children the
- designated first-aid providers at the facility. The incident
Pediatric phlebotomy requires experience, special skills, and a should be documented.
tender touch. Excellent interpersonal skills are needed to deal
with distraught parents and with crying, screaming, or fright- Hemoconcentration
ened children. Ideally, only experienced phlebotomists should Hemoconcentration is an increased concentration of cells,
draw blood from children; however, the only way to gain expe- larger molecules, and analytes in the blood as a result of a shift
rience is through practice. Through experience, one learns what in water balance. Hemoconcentration can be caused by leaving
works in different situations. Smaller gauge (22- to 23-gauge) the tourniquet on the patient’s arm for too long. The tourni-
needles are employed.9 Use of a syringe or winged blood quet should not remain on the arm for longer than 1 minute.
collection set may be advantageous for accessing small veins in If it is left on for a longer time because of difficulty in finding
young children. The child’s arm should be immobilized as a vein, it should be removed for 2 minutes and reapplied
much as possible so that the needle can be inserted successfully before the venipuncture is performed.9
into the vein and can be kept there if the child tries to move.
Use of special stickers or character bandages as rewards may Hemolysis
serve as an incentive for cooperation; however, the protocol The rupture of red blood cells with the consequent escape of
of the institution with regard to their distribution must be hemoglobin—a process termed hemolysis—can cause the
followed. plasma or serum to appear pink or red. Hemolysis can occur if
 CHAPTER 3 Blood Specimen Collection 27

Skin Vein Skin Vein Hematoma Skin Hematoma Vein

A Correct needle position B Needle inserted through vein C Partial needle insertion

Vein Skin Skin Veins Skin Vein

D Bevel resting on vein wall E Needle too near vein valve F Collapsed vein
Figure 3-8 Proper and improper needle insertion for venipuncture.

the phlebotomist used too small a needle during a difficult Seizures

draw; drew the blood through an existing hematoma; pulled Patients occasionally experience seizures because of a preexist-
back too quickly on the plunger of a syringe; forced blood into ing condition or as a response to the needle stick. If a seizure
a tube from a syringe by pushing the plunger; mixed a tube too occurs, the phlebotomist should immediately remove and dis-
vigorously; or contaminated the specimen with alcohol or wa- card the needle, apply pressure with a gauze pad, and notify
ter at the venipuncture site or in the tubes. Hemolysis also can the nurse or designated first-aid providers at the facility.
occur physiologically as a result of hemolytic anemias. Hemo- The phlebotomist should also ensure the patient’s safety by
lyzed specimens can alter test results, such as levels of potas- preventing injury from nearby objects.
sium, lactate dehydrogenase, and aspartate aminotransferase,
which can result in patient treatment errors.10 Vomiting
If the patient begins vomiting, the phlebotomist should pro-
Petechiae vide the patient an appropriate container and tissues, notify
Petechiae are small red spots indicating that small amounts of the nurse or designated first-aid providers at the facility, and
blood have escaped into the skin. Petechiae indicate a possible ensure the patient’s head is positioned so that he or she does
hemostasis abnormality and should alert the phlebotomist to not aspirate vomit.
be aware of possible prolonged bleeding.
Venipuncture in Special Situations
Allergies Edema
Some patients may be allergic to skin antiseptic substances and Swelling caused by an abnormal accumulation of fluid in
adhesive bandages and tape. The phlebotomist should use the intercellular spaces of the tissues is termed edema. The most
hypoallergenic tape or apply pressure manually until the common cause is infiltration of the tissues by the solution
bleeding has stopped completely. The phlebotomist should running through an incorrectly positioned intravenous cathe-
also determine if the patient has a latex sensitivity before the ter. Edematous sites should be avoided for venipuncture
phlebotomy procedure. because the veins are hard to find and the specimens may
become contaminated with tissue fluid.
Nerve Damage
The phlebotomist must select the appropriate veins for Obesity
venipuncture and should not blindly probe the arm with the In obese patients, veins may be neither readily visible nor
needle or try to laterally relocate the needle. If a nerve has easy to palpate. Sometimes the use of a blood pressure cuff
been affected, the patient may complain about shooting or can aid in locating a vein. The cuff should not be inflated any
sharp pain, tingling, or numbness in the arm. The phleboto- higher than 40 mm Hg and should not be left on the arm
mist should immediately remove and discard the needle, for longer than 1 minute.9 The phlebotomist should not
apply pressure with a gauze pad, and collect the blood from probe blindly in the patient’s arm because nerve damage
the other arm. may result.
28 PART I Introduction to Hematology

Burned, Damaged, Scarred, and Occluded Veins be drawn, the phlebotomist should alert the nurse, who will
Burned, damaged, scarred, and occluded veins should be either talk to the patient or notify the physician. The phleboto-
avoided because they do not allow the blood to flow freely and mist must not force an uncooperative patient to have blood
may make it difficult to obtain an acceptable specimen. drawn; it can be unsafe for the phlebotomist and for the
patient. In addition, forcing a patient of legal age and sound
Intravenous Therapy mind to have blood drawn against his or her wishes can result
Drawing blood from an arm with an intravenous (IV) infusion in charges of assault and battery or unlawful restraint.
should be avoided if possible; the phlebotomist should draw If the patient is a child and the parents offer to help hold
the blood from the opposite arm without the IV. If there is the child, it is usually acceptable to proceed. Any refusals or
no alternative, blood should be drawn below the IV with the problems should be documented for legal reasons.
tourniquet also placed below the IV site. Prior to venipuncture,
the phlebotomist should ask an authorized caregiver to stop Missing Patient
the infusion for 2 minutes before the specimen is drawn. The For hospitalized patients, if the patient is not in his or her
phlebotomist should note on the requisition and the tube room, the absence should be reported to the nursing unit so
that the specimen was obtained from an arm into which an that the nurses are aware that the specimen was not obtained.
IV solution was running, indicating the arm and the location
of the draw relative to the IV.4,9 The phlebotomist should
SKIN PUNCTURE
always follow the protocol established at his or her facility.
Skin puncture is the technique of choice to obtain a blood
Mastectomy Patients specimen from newborns and pediatric patients. In adults skin
The CLSI requires physician consultation before blood is puncture may be used in patients who are severely burned and
drawn from the same side as a prior mastectomy (removal of whose veins are being reserved for therapeutic purposes; in
the breast), even in the case of bilateral mastectomies.9 The patients who are extremely obese; and in elderly patients with
pressure on the arm that is on the same side as the mastectomy fragile veins.
from a tourniquet or blood pressure cuff can lead to pain or Blood obtained from skin puncture is a mixture of blood
lymphostasis from accumulating lymph fluid. The other arm from venules, arterioles, capillaries, and interstitial and intra-
on the side without a mastectomy should be used. cellular fluids.9 After the puncture site is warmed, the specimen
more closely resembles arterial blood. The phlebotomist
Inability to Obtain a Blood Specimen should note that the specimen was obtained by skin puncture
Failure to Draw Blood because those specimens may generate slightly different test
One reason for failure to draw blood is that the vein is missed, results.13 For example, higher glucose values are found in
often because of improper needle positioning. The needle specimens obtained by skin puncture compared with those
should be inserted completely into the vein with the bevel obtained by venipuncture, and this difference can be clinically
up and at an angle of less than 30 degrees.9 Figure 3-8 shows significant.13 It is especially important to note the specimen
reasons for unsatisfactory flow of blood. It is sometimes type when a glucose tolerance test is performed or when
possible to reposition the needle in the vein by slightly with- glucometer results are compared with findings from venous
drawing or advancing the needle, but only an experienced specimens.
phlebotomist should attempt this. The phlebotomist should
never attempt to relocate the needle in a lateral direction be- Collection Sites
cause such manipulation can cause pain and risk a disabling The site of choice for skin puncture in infants under 1 year of
nerve injury to the patient. age is the lateral (outside) or medial (inside) plantar (bottom)
Occasionally an evacuated tube has insufficient vacuum, surface of the heel (Figure 3-9, A). In children older than 1 year
and insertion of another tube yields blood. Keeping extra of age and in adults, the palmar surface of the distal portion of
tubes within reach during blood collection can avoid a recol- the third (middle) or fourth (ring) finger on the nondominant
lection when the problem is a technical issue associated with hand may be used.13 The puncture on the finger should be
the tube. made perpendicular to the fingerprint lines (Figure 3-9, B).
Each institution should have a policy covering the proper Fingers of infants should not be punctured because of the risk
procedure when a blood specimen cannot be collected. If two of serious bone injury.
unsuccessful attempts at collection have been made, the CLSI Warming the site can increase the blood flow sevenfold.13
recommends that the phlebotomist seek the assistance of The phlebotomist should warm the site with a commercial
another practitioner with blood collection expertise.9 Another heel warmer or a warm washcloth to a temperature no greater
individual can make two attempts to obtain a specimen. If a than 42° C and for no longer than 3 to 5 minutes.13 The phle-
second person is unsuccessful, the physician should be notified. botomist should clean the skin puncture site with 70% isopro-
pyl alcohol and allow it to air-dry. Povidone-iodine should
Patient Refusal not be used because of possible specimen contamination,
The patient has the right to refuse to give a blood specimen. If which could falsely elevate levels of potassium, phosphorus,
gentle urging does not persuade the patient to allow blood to or uric acid.13
 CHAPTER 3 Blood Specimen Collection 29

Puncture across first drop of blood should be wiped away with a clean gauze pad
fingerprints to prevent contamination of the specimen with tissue fluid and to
facilitate the free flow of blood.13

Equipment for Skin Puncture

Devices for skin puncture contain sterile lancets that puncture
or sterile blades that make a small incision in the skin. The
lancet or blade is spring-loaded in the device, and when acti-
vated by the phlebotomist, pierces the skin. Devices are single-
use, disposable, and have retractable blades in compliance
with OHSA safety standards.11 Devices are available for new-
borns, children, and adults that produce punctures or incisions
Medial of varying depths in the skin.
side Containers for collecting blood from skin puncture include
Lateral of heel
side of capillary tubes and microcollection tubes.13 Capillary tubes of
heel various sizes are available with or without heparin. OSHA rec-
ommends the use of plastic tubes or Mylar-coated glass tubes to
A B
avoid injury by broken glass and exposure to bloodborne
Figure 3-9 Areas for skin puncture: A, Heel of infant less than 1 year old. pathogens. Microcollection tubes are preferred and are available
Puncture is made on the lateral or medial plantar surface of the heel, in the with or without additives. The cap colors on microcollection
shaded area demarcated by lines from the middle of the big toe to the heel, tubes correspond with the color coding system for evacuated
and from between the fourth and fifth toe to the heel.12,13 B, Finger. Puncture tubes. The order of draw, however, is different for microcollec-
is made on the palmar surface of the distal portion of the third or fourth
tion tubes (Box 3-3). The EDTA microcollection tube should be
finger, perpendicular to the fingerprint lines.
filled first to ensure adequate volume and accurate hematology
results, especially for platelets, which tend to aggregate at the
site of puncture.13 Skin puncture specimens should be labeled
Precautions with Skin Puncture with the same information as required for evacuated tubes. Ex-
The finger or heel must be securely immobilized. Heel punc- amples of skin puncture equipment are shown in Figure 3-10.
tures in infants should not be made more than 2 mm
deep because of the risk of bone injury and possible infection Skin Puncture Procedure
(osteomyelitis).13 In premature infants, a puncture device that The phlebotomist uses standard precautions that include wash-
makes an incision with even less depth is preferred. ing hands and applying gloves at the beginning of the proce-
The phlebotomist should not puncture an area that is dure and removing gloves and washing hands at the end of the
swollen, bruised, infected, or already has been punctured. In addi- procedure. CLSI recommends the following steps:13
tion phlebotomists should not perform skin puncture in patients 1. Prepare the accession (test request) order.
with edema, dehydration, or poor peripheral circulation because 2. Greet the patient (and parents); identify the patient by
specimen integrity and test accuracy may be compromised. The having the patient (or parent in the case of a child) verbally

A B
Figure 3-10 Examples of equipment used for skin puncture. A, Various puncture devices. B, Various microcollection tubes. (A, B Courtesy Dennis J. Ernst,
MT[ASCP], Director, Center for Phlebotomy Education, Inc.)
30 PART I Introduction to Hematology

state his or her full name and confirm with patient’s 18. Remove gloves and wash hands.
identification number, address, and/or birth date. Ensure 19. Deliver the properly labeled specimens to the laboratory.
that the same information is on the requisition form.
3. Position the patient and the parents (or individual desig- Preparation of Peripheral Blood Films
nated to hold an infant or small child) as necessary. Peripheral blood films can be made directly from skin punc-
4. Verify that any dietary restrictions have been met (e.g., fast- ture blood or from a tube of EDTA-anticoagulated venous
ing), and check for latex sensitivity. blood. With a skin puncture, the phlebotomist must remember
5. Wash hands and put on gloves. to wipe away the first drop of blood and use the second drop
6. Assemble supplies and appropriate tubes for the requested to make the blood film. Chapter 16 covers preparation of
tests. Check paperwork and tube selection. blood films in detail.
7. Select the puncture site.
8. Warm the puncture site.
QUALITY ASSURANCE IN SPECIMEN
9. Cleanse the puncture site with 70% isopropyl alcohol us-
COLLECTION
ing concentric circles, working from the inside to outside.
Allow skin to air-dry. To ensure accurate patient test results, it is essential that the blood
10. Open and inspect the sterile disposable puncture device, collection process, which includes specimen handling, be moni-
and perform the puncture while firmly holding the heel tored. Patient diagnosis and medical care are based on the out-
or finger. Discard the device in the appropriate sharps comes of these tests. The following areas should be monitored.
container.
11. Wipe away the first drop of blood with a clean, dry gauze pad. Technical Competence
This removes any residual alcohol and any tissue fluid /The individual performing phlebotomy should be trained
contamination. properly in all phases of blood collection.-
Certification by an
12. Make blood films if requested. appropriate agency is recommended. / Continuing education is
13. Collect blood in the appropriate collection tubes and mix required to keep current on all the changes in the field./
Com-
as needed. If an insufficient specimen has been obtained petency should be assessed and documented on an annual
because the blood flow has stopped, repeat the puncture at basis for each employee performing phlebotomy.
a different site with all new equipment. CLSI recommends
the following order of draw:13 (Box 3-3) Collection Procedures
a. Tube for blood gas analysis
/Periodic review of collection procedures is essential to main-
b. Slides, unless made from a specimen in the EDTA mi- taining the quality of specimens. This includes a review of
-

crocollection tube policies on the allowable number of blood collection attempts

c. EDTA microcollection tube for unsuccessful blood draws, procedures for what to do

-
d. Other microcollection tubes with anticoagulants when the patient is unavailable for a blood draw, or when the
e. Serum microcollection tubes patient refuses a draw. Proper patient preparation and correct
14. Apply pressure and elevate the puncture site until bleeding patient identification are crucial. The correct tube or specimen
has stopped. container must be used.
15. Label each specimen with the required information and
indicate skin puncture collection. Anticoagulants and Other Additives
NOTE: Compare the labeled tubes with the identification The/phlebotomist must follow the manufacturer’s instructions
bracelet for inpatients; have outpatients verify that the with regard to mixing all tubes with additives to ensure proper
information on the labeled tubes is correct, whenever specimen integrity and prevent formation of microclots in the
possible. anticoagulated tubes. / All tubes should be checked for cracks,
16. Handle the specimens appropriately. expiration dates, and discoloration or cloudiness, which could
17. Discard all puncture equipment and biohazardous materi- indicate contamination./ New lot numbers of tubes must
als appropriately. /
be checked to verify draw and fill accuracy. When blood is
collected in the light blue stopper tube for coagulation, a
9:1 ratio of blood to anticoagulant must be maintained to
ensure accurate results./Specimens must be stored and handled
BOX 3-3 Order of Draw for Skin Puncture13
properly before testing.
1. Tube for blood gas analysis
2. Slides, unless made from specimen in the EDTA microcollection Requirements for a Quality Specimen
tube Requirements for a quality specimen are as follows:
3. EDTA microcollection tube 1. Patient properly identified
4. Other microcollection tubes with anticoagulants 2. Patient properly prepared for draw
5. Serum microcollection tubes 3. Specimens collected in the correct order and labeled correctly
4. Correct anticoagulants and other additives used
EDTA, ethylenediaminetetraacetic acid 5. Specimens properly mixed by inversion, if required
 CHAPTER 3 Blood Specimen Collection 31

6. Specimens not hemolyzed results depend on what happens to the specimen during that
7. Specimens requiring patient fasting collected in a timely time. This pretesting period is called the preanalytical phase of
manner the total testing process (Chapter 5).
8. Timed specimens drawn at the correct time Blood collected into additive tubes must be inverted to mix
the additive and blood according to manufacturer’s instruc-
Collection of Blood for Blood Culture tions. Shaking can result in hemolysis of the specimen and
Each facility should monitor its blood culture contamination lead to specimen rejection or inaccurate test results. Specimens
rate and keep that rate lower than 3% as recommended by the should be transported in an upright position to ensure com-
CLSI and the American Society for Microbiology.14,15 Higher plete clot formation and reduce agitation, which can also result
blood culture contamination rates should prompt an investi- in hemolysis.
gation of the causes and implementation of the appropriate Exposure of the blood specimen to light can cause falsely
corrective action. False-positive blood culture results lead to decreased values for bilirubin, beta-carotene, vitamin A, and
unnecessary testing and treatment for patients and increased porphyrins.9 For certain tests, the specimens need to be chilled,
costs for the institution.14,15 A 2012 CDC-funded Laboratory not frozen, and should be placed in an ice-water bath to slow
Medicine Best Practices systematic review and meta-analysis down cellular metabolism. Examples of these tests include am-
concluded that the use of well-trained phlebotomy teams and monia, lactic acid, parathyroid hormone, and gastrin.9 Other
proper venipuncture technique was an effective way to reduce tests, such as the cold agglutinin titer, require that specimens
blood culture contamination rates.15 be kept warm to ensure accurate results. If the specimen is
refrigerated before the serum is removed, the antibody in the
Quality Control and Preventive Maintenance serum will bind to the red blood cells, thus falsely decreasing
for Specimen Processing and Storage the serum cold agglutinin titer. To ensure accurate results, cells
Equipment and serum must be separated within 2 hours of collection for
Thermometers used in refrigerators and freezers in which tests such as those measuring glucose, potassium, and lactate
specimens are stored should be calibrated annually, or only dehydrogenase.10 The CLSI provides recommendations to
thermometers certified by the National Bureau of Standards laboratories for the maximum time uncentrifuged specimens
should be used. Centrifuges should be maintained according are stable at room temperature for various tests based on
to the manufacturer’s instructions for cleaning and timing studies in the literature.10
verification.

LEGAL ISSUES IN PHLEBOTOMY

Reasons for Specimen Rejection
A laboratory result is only as good as the integrity of the speci- There are many daily practices in health care that, if per-
men provided. Specimens are rejected for conditions that may formed without reasonable care and skill, can result in a
result in identification errors or inaccurate results. Box 3-4 lists lawsuit. Facilities have been and will continue to be held
some reasons for specimen rejection. legally accountable for the actions of those who collect blood
for diagnostic testing. Two areas of particular concern to phle-
botomists are breach of patient confidentiality and patient
SPECIMEN HANDLING
misidentification. Unless there is a clinical need to know or a
Proper handling of specimens begins with the initiation of the patient has given written permission, no one has a right to
test request and ends when the specimen is tested. Accurate test patient information. A patient will not be misidentified if
correct procedures for specimen collection are followed. Phle-
botomists often are called to testify in court in cases involving
blood alcohol levels. The phlebotomist is asked about patient
BOX 3-4 Reasons for Specimen Rejection identification procedures and skin antisepsis. Only alcohol-
free antiseptics should be used for skin antisepsis in such
• Test order requisition and the tube identification do not match. cases. Soap and water may be used if no other cleaners are
• Tube is unlabeled, or the labeling, including patient identification available.
number, is incorrect. To minimize the risk of legal action, the phlebotomist
• Specimen is hemolyzed. should do the following:
• Specimen was collected at the wrong time. 1. Follow up on all incident reports.
• Specimen was collected in the wrong tube. 2. Participate in continuing education.
• Specimen was clotted, and the test requires whole blood or 3. Become certified in the profession.
plasma. 4. Acknowledge the extent of liability coverage.
• Specimen was contaminated with intravenous fluid. 5. Follow established procedures.
• Specimen is lipemic.* 6. Always exhibit professional, courteous behavior.
*Lipemic specimens cannot be used for certain tests; however, the phlebotomist 7. Always obtain proper consent.
has no control over this aspect. Collection of a specimen after patient fasting may 8. Respect and honor the Patients’ Bill of Rights.
be requested to try to reduce the potential for lipemia. 9. Maintain proper documentation.
32 PART I Introduction to Hematology

SU M M A RY
• Laboratory test results are only as good as the integrity of the • CLSI guidelines should be followed for venipuncture and skin
specimen tested. puncture.
• Standard precautions must be followed in the collection of blood • Sites for skin puncture include the lateral or medial plantar
to prevent exposure to bloodborne pathogens. surface of the heel (infants), or the palmar surface of the distal
• Some physiologic factors affecting test results include posture, portion of the third or fourth finger on the nondominant hand
diurnal rhythm, exercise, stress, diet, and smoking. (children and adults). Heel punctures are used for infants less than
• U.S. manufacturers of evacuated tubes follow a universal color 1 year old; the puncture must be less than 2 mm deep
coding system in which the stopper color indicates the type of to avoid injury to the bone.
additive contained in the tube. • Common complications of blood collection include bruising,
• The gauge numbers of needles relate inversely to bore size: hematoma, and fainting.
the smaller the gauge number, the larger the bore. Needle • Each institution should establish a policy covering proper proce-
safety devices are required for venipuncture equipment. dure when a blood specimen cannot be obtained.
• For venipuncture in the antecubital fossa, the median cubital • Following established procedures and documenting all incidents
vein (H-shaped vein pattern) or median vein (M-shaped vein minimize the risk of liability when performing phlebotomy.
pattern) is preferred to avoid accidental arterial puncture and
nerve damage. If those veins are not available after checking Now that you have completed this chapter, go back and
both arms, the cephalic, then the basilic veins are the second and read again the case studies at the beginning and respond
third choices. to the questions presented.

RE V I E W Q U ES T I ONS
Answers can be found in the Appendix. 4. The vein of choice for performing a venipuncture is the:
a. Basilic, because it is the most prominent vein in the
1. Which step in the CLSI procedure for venipuncture is part antecubital fossa
of standard precautions? b. Cephalic or accessory cephalic, because it is the least
a. Wearing gloves painful site
b. Positively identifying the patient c. Median or median cubital, because it has the lowest risk
c. Cleansing the site for the venipuncture of damaging nerves in the arm
d. Bandaging the venipuncture site d. One of the hand veins, because they are most superficial
and easily accessed
2. Select the needle most commonly used in standard veni-
puncture in an adult: 5. The most important step in phlebotomy is:
a. One inch, 18 gauge a. Cleansing the site
b. One inch, 21 gauge b. Identifying the patient
c. One-half inch, 23 gauge c. Selecting the proper needle length
d. One-half inch, 25 gauge d. Using the correct evacuated tube

3. For a complete blood count (hematology) and measure- 6. The venipuncture needle should be inserted into the arm
ment of prothrombin time (coagulation), the phlebotomist with the bevel facing:
collected blood into lavender stopper and green stopper a. Down and an angle of insertion between 15 and 30 degrees
tubes. Are these specimens acceptable? b. Up and an angle of insertion less than 30 degrees
a. Yes, EDTA is used for hematologic testing and heparin is c. Down and an angle of insertion greater than 45 degrees
used for coagulation testing. d. Up and an angle of insertion between 30 and 45 degrees
b. No, although EDTA is used for hematologic testing,
citrate, not heparin, is used for coagulation testing.
c. No, although heparin is used for hematologic testing,
citrate, not EDTA, is used for coagulation testing.
d. No, hematologic testing requires citrate and coagulation
testing requires a clot, so neither tube is acceptable.