SH CP 83

Phlebotomy Protocol
Version: 4

Summary: To enable Southern Health Staff to be confident and competent, undertaking

phlebotomy when it is judged clinically safe and appropriate to do so.

Keywords: Phlebotomy, venepuncture, consent, competency, blood tests, Vacutainer,

butterfly, blood cultures, disposable tourniquet, restraint, order of draw

Target Audience: Health Care Professionals according to agreed roles and responsibilities within
their job description

Next Review Date: October 2021

Approved & Patient Safety Group Date of meeting:

Ratified by: 20th September 2018

Date issued: October 2018

Author: Clinical Education Team

Accountable Director of Nursing and Allied Health Professionals

Executive Lead:

1
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
Version Control
Change Record

Date Author Version Page Reason for Change

Aug Jane Byrnell 2 all Replace ANTT terminology with ‘Aseptic Technique’
2014
Nov Wendy Eastman 3 Review date extended from Nov 15 to Feb 16 to allow for policy review
2015
15.12.15 Wendy Eastman 3 Policy review
4 Definition of aseptic technique changed as per IPC Policy
6 Included wording Safety devices in line with Trust policy
7 Included wording Blood cultures should only be collected by members
of staff who have been trained ….
10/11 Add the wording Do not re-palpate the skin after cleaning
13 Add the wording Also check the blood culture bottles to ensure it is in
date
14 Add Do not re-palpate the skin after cleaning
15 After blood cultures are taken clearly document in medical records
17 Updated reference NMC The Code 2015
Review date extended for further 2 years
4.5.16 Wendy Eastman 2 4 2.2 additional wording regarding phlebotomy on the under 18s
20/10/17 2 Review date extended for 6 months (February to August 2018)
June Clinical 4 Policy review - Multiple changes throughout to clarify protocol, including
2018 Education Team rearranging sections. Included best practice and updated to be in line
with current national guidance and SHFT policy.
4&8 Use of non-sterile not sterile gloves for blood cultures according to
aseptic policy and IPC team advice
4 Definitions clarified and checked against other updated policies
4 Blood cultures definition changed as per IPC and Aseptic technique
policy from sterile gloves to non-sterile gloves
5 Restraint definition changed to be in line with restraint policy on advice
of supporting safer services
7 Phlebotomy under restraint section written by lead supporting safer
8 services team
9 Update skin cleansing with regard to iodine allergy
Clarifying four points of identification in alignment with IV, Medicines
10 and Blood transfusion policy
12 Section on problems in practice added to
13 Clarified training and competency requirements
18-25 References updated
Procedures removed from main text, updated and added as
appendices. Review date set for 3 years.

Reviewers/contributors

Name Position Version Reviewed & Date

Simon Johnson Resuscitation Officer Version 1 2012

Marie Corner Medical Device Advisor Version 1 2012
Wendy Eastman GP Development Lead V 3 Nov-Feb 2016
Sue Gasparro Clinical trainer V 3 Nov-Feb 2016
Mandy Lyons Clinical educator V 3 Nov-Feb 2016 & Jan 2018
Sharon Guy Lead Clinical educator V 3 Nov-Feb 2016 & V4April 2018
Theresa Lewis Lead Nurse IPC V3 Feb 2018
Steve Coopey Head of clinical development Bands 5 and above V 4 Feb 2016
Claire Hollywell Clinical educator V 4 June 2018
Virginia Roberts Clinical educator V 4 June 2018
Claire Rawasa Clinical educator V 4 June 2018
Jacky Hunt Lead Nurse Infection Control V3 June 2018
Lucy Abraham Supporting safer services Team V 4 June 2018
Sam Boyes Supporting safer services Team V 4 June 2018
Lee Spencer Supporting safer services Team V 4 June 2018
Tracy Hammond Medical Devices Adviser (MDSO V4 October 2018

2
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 Contents

Section Title Page

1. Introduction 4

2. Scope 4

3. Definitions 4

4. Duties and responsibilities 6

5. Assessment and preparation for phlebotomy 8

6. Management of problems in practice 10

7. Training requirements 11

8. Associated Documents 12

9. Supporting references 12

Appendices
A1 Training needs analysis 14

A2 Evidence of clinical practice 15

A3 Evidence based guidelines of clinical practice – Phlebotomy procedures 18

A4 Level of competency rating scale 26

3
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 Phlebotomy Protocol

1. Introduction

1.1 This protocol details the correct technique for obtaining a specimen of blood for the purposes of
phlebotomy, and reduces the risk associated with phlebotomy for both patients and staff. The
risks include haematoma, pain, localised infection and sepsis, inappropriate blood sampling,
errors in collection and occupational sharps injury for staff. Adherence to the protocol will
substantially reduce the risk to both patients and staff.

1.2 Phlebotomy is the drawing of blood from a vein by the insertion of a needle to collect samples for
analysis. Poor collection technique can lead to inaccurate and misleading blood results. The
three major errors in collection are haemolysis, contamination and inaccurate labelling (WHO
2010).

2. Scope

2.1 This protocol is for all healthcare professionals working within Southern Health who are
performing adult phlebotomy within Southern Health as part of their job description in all hospital
and community settings.

2.2 When required for services that provide phlebotomy to patients under the age of 18, this must be
agreed with their clinical manager who must ensure that staff are competent to undertake this
task and it is within their job description.

3. Definitions/ Glossary of terms

3.1 Adult - A person aged 18 years or more.

3.2 Aerobic Bacteria – Bacteria that can only replicate in the presence of oxygen.

3.3 Anaerobic Bacteria – Bacteria that can only replicate in the absence of oxygen.

3.4 Aseptic technique – Aseptic Technique is defined as a means of preventing or minimising the
risk of introducing harmful micro-organisms onto key parts or key sites of the body when
undertaking clinical procedures.

3.5 Bacteraemia – The presence of bacteria in the blood stream.

3.6 Blood Cultures – Blood Cultures are a test used to detect the presence of pathogenic micro-
organisms, such as bacteria, in the blood. Blood culture samples must be drawn before any
other samples and the procedure must adhere to an aseptic technique as these samples are
subject to contamination with normal skin flora. Always obtain using non-sterile gloves and a
disposable apron.

3.7 Blood Test - Obtaining a representative blood sample for analysis.

3.8 Butterfly Collection System - A system for blood collection to be used when a patient has
fragile skin and /or thin veins

3.9 Central Line Sampling - Taking blood samples from central lines requires specific competencies
and is therefore outside the scope of this policy. Refer to SHFT Policy SH CP 137 Intravenous
therapy and peripheral cannulation policy

4
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
3.10 Collection System - A disposable singe use device such as Vacutainer or BD used to withdraw
blood into pre-vacuumed blood bottles

3.11 Competency - Can perform an activity with understanding of theory and practice principles
without assistance and/or direct supervision

3.12 Consent - “Consent is based upon giving accurate information which is confirmed as having
been understood, either verbally, by gesture or in writing.”

3.13 Contaminant –
a) A micro-organism inadvertently introduced into the sample from the environment, skin of the
operator or patient which leads to a false positive result.
b) A tube additive, which may be carried over to subsequently drawn samples producing
incorrect results.

3.14 Culture and Sensitivity (C&S) - A microbiology investigation to assist in the management of the
septic patient, identification of the causative organism and antibiotic therapy.

3.15 Disposable Single Use Tourniquet - A disposable single use device that promotes venous
distension for insertion of a needle. It should remain taut for a maximum of 60 seconds.

3.16 Haemoconcentration - Applying a tourniquet for over 60 seconds causes stasis trapping blood
cells and larger molecules whilst water and small solutes are able to pass through. This results in
cells and large molecules becoming more concentrated in the sample leading to erroneous
results.

3.17 Haemolysis - Damage to red blood cells which releases potassium into the serum invalidating a
number of biochemical parameters.

3.18 Health Care Professional - Health Care Professionals, staff who are registered with their
appropriate governing body (e.g. GMC , NMC, HCPC GDC). A registered practitioner or non-
registered practitioners specially trained to perform phlebotomy e.g. bands 2, 3, 4 and
phlebotomists.

3.19 Order of Draw - The sequence of obtaining blood samples to prevent contamination of tube
additives. It is in accordance with local pathology department procedures.

3.20 Personal Protective Equipment (PPE) - Single use disposable equipment designed to protect
the patient and member of staff, these include disposable gloves and aprons.

3.21 Phlebotomy - Phlebotomy is the drawing of blood from a vein by the insertion of a needle to
collect samples for analysis.

3.22 Restraint - Restrictive interventions are defined as deliberate acts on the part of another person
(persons) that restrict a service users movement, liberty and/or freedom to act independently.
Refer to Restrictive interventions policy SH NCP 23

3.23 Sepsis - A systemic and life-threatening response to infection that can lead to tissue damage,
organ failure and death

3.24 Sharps Box - A container approved and tested to the appropriate standard for the safe disposal
of items that may present a sharps injury risk

3.25 Skin Preparation - All inpatients or those requiring blood cultures require skin to be cleaned
using a Clinell 2% chlorhexidine in 70% isopropyl alcohol sterile wipe or a suitable alternative.

5
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 Care should be taken with the use of products containing chlorhexidine as evidence suggests,
although rare, it is known to induce hypersensitivity, including generalised allergic reactions and
anaphylaxis in some individuals. In this case a suitable alternative i.e.: povidone-iodine in 70%
alcohol should be used.

3.26 Povidone-iodine in 70% alcohol – a solution to be used to cleanse the skin or equipment if a
patient is allergic to chlorhexidine gluconate. Checks must be made against manufacturers
guidelines of compatibility with the equipment in use.

3.27 Vacuum System - A specifically designed vacuum system which comprises of:
a) Pre vacuumed blood sample tube
b) A double ended needle and plastic needle holder or a
c) A ‘winged’ needle (Butterfly) and associated tubing, Luer adaptor and plastic
Holder

It must include safety devices in line with Trust policy to minimise the risk of needle-stick injuries.

4. Duties / Responsibilities

4.1 Ward/Department Managers need to ensure adequate stock of appropriate sampling equipment
is held and that all staff members who are required to perform phlebotomy are appropriately
trained and have their practical competency formally assessed, successfully achieved and
documented. Staff performing this task must also have completed an aseptic technique
competency assessment (on line eLearning followed by practical assessment in the workplace, at
least once in their employment with Southern Health, a copy of which should be retained by
employer and manager – see Aseptic and Clean Technique SHCP13.

4.2 Professional Accountability and Legal Issues

Health Care Professionals should uphold their professional standards e.g. “The Code” (NMC
2015). When delegating to a non registered practitioner the trained nurse must ensure the health
care support worker or phlebotomist has completed phlebotomy training and has successfully
passed the practical competency assessment..

Competency can be signed off by a healthcare professional who is competent at a level 4 or

above according to the SHFT competency rating scale. Competencies must be signed off within
six months of completing training. The healthcare professional must successfully undertake ten
withdrawals of blood using a vacutainer needle in the antecubital fossa before their competency
is completed.

Any Health Care Professional has the right to refuse undertaking phlebotomy if they have
concerns about the patient’s veins or the patient’s condition; if they do not feel confident to
undertake the procedure or if no blood sample request form has been completed.

All healthcare professionals should identify the patient prior to phlebotomy using a minimum of
four forms of identification that includes the forename and surname and NHS number or hospital
number and Date of Birth and address. NHS numbers must be stated on all relevant
documentation and on Community Hospital patient identification bracelets. Information should be
obtained using open questions.

It is a legal and ethical principle that practitioners obtain valid informed consent prior to this
procedure. Consent is based upon giving accurate information which is confirmed as having been
understood, either verbally, by gesture or in writing.

Practitioners need to adhere to the principles and practices of the Mental Capacity Act 2005.

6
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 All record keeping must adhere to standards set out by the Southern Health Clinical Record
Keeping Policy SH CP 221. Additionally, only the person who takes the sample can label the
blood bottle.

Blood cultures should only be collected by members of medical or nursing staff that have been
trained in the collection procedure and whose competence in blood culture collection and aseptic
technique has been assessed and maintained.

Blood sampling prior to blood transfusion including cross match and group and save can be taken
by any member of staff who is competent in phlebotomy. Refer to Blood Transfusion Policy SH
CP 42

4.3 Restraint
Patients requiring phlebotomy, who are detained under the Mental Health Act (2005), may require
restraint to obtain the blood sample. When considering using restraint there must be objective
reasons to justify that restraint is necessary. It must be a multidisciplinary decision making
process, and will require assessment for mental capacity to consent to phlebotomy. Staff should
be able to identify that the person being cared for is likely to suffer harm should the blood test not
be performed. Proportionate restraint should be used. A carer or professional must not use
restraint just so that they can do something more easily.

The recording of the decision making process and the rationale must be documented in the
patients notes including care plan and risk assessment. This decision making should be
individualised and include the rationale regarding device and site to be used. Staff undertaking
restraint should have attended and be in date with training in Supporting Safer Services (sSs)
and are confident and competent in undertaking restraint. The staff undertaking the phlebotomy
should be competent and experienced in phlebotomy.

If restraint is necessary to prevent harm to the person who lacks capacity, it must be the
minimum amount of force for the shortest amount of time It is recommended that the team
practice holds and positioning prior to engaging with the patient. Further advice and support can
be sought from the SSS team . If considering taking blood under restraint staff should first refer to
SH NCP 23 Restrictive Interventions Policy and Restrictive Practices Policy SH NCP 83.

4.4 Infection Control

All phlebotomy procedures require the use of an aseptic technique, with observation of the
standard precautions and product sterility. The practitioner should ensure a thorough hand
hygiene technique with alcohol sanitising foam or soap and water if hands are visibly soiled,
ensuring arms are bare below the elbow, no nail varnish or false nails; any cuts and abrasions to
be covered with secure waterproof plaster. Infection Prevention and Control policies should be
followed at all times.

Skin cleansing - Outpatient clinics and patients in their own homes only require skin cleansing –
with soap and water and 2% chlorhexidine in 70% isopropyl alcohol – if the skin is visibly soiled
or if the patient is immunocompromised.

Inpatients should have skin cleansed with 2% chlorhexidine in 70% isopropyl alcohol. Wipe the
area for 30 seconds then allow at least 30 seconds for skin to air dry

In the event of patient allergy to chlorhexidine, use povidone iodine as an alternative cleanser if
compatible with equipment (see manufacturers guidelines).

Aseptic Technique - A closed sterile system should be used at all times. (E.g. Vacutainer
system components and appropriate vacuum system sampling tubes.) Protect key parts (the
needle) from contamination before insertion. Do not re-palpate site after cleansing, even whilst
wearing gloves.

7
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 Non-sterile NITRILE single use gloves must be worn for a phlebotomy procedure and a
disposable apron should be worn. Refer to Aseptic and Clean Technique Procedure SH CP 13
for further guidance. For blood cultures, non-sterile gloves and an apron must be used.

Single use disposable tourniquets must always be used.

5. Assessment and preparation for phlebotomy

5.1 Patient preparation

Phlebotomy is performed to provide diagnostic or therapeutic monitoring information, including
the provision of compatible samples for blood transfusion. It is essential that samples obtained
are accurate and representative of the patient’s true condition and free from contamination.
Correctly matching patient details to the blood sample(s) is absolutely vital.

The procedure must be explained to the patient, discussing the need for the blood sample to be
taken, and informed consent for the procedure must be obtained, also establishing whether the
patient has any known allergies.

If the patient is anxious or expresses that they are needle phobic, or any other condition that
might make phlebotomy difficult they may benefit from a topical anaesthetic. This requires a
prescription. Two possible phlebotomy sites should be chosen for application of the topical
anaesthetic to give the phlebotomist a choice of site. These areas should be covered with a
transparent film dressing, and left for 45-60 minutes as per prescription advice.

Prior to obtaining samples the cream must be removed from the sites.

5.2 Blood form

Before undertaking phlebotomy, a blood form must be completed by a clinician. This form should
contain the rationale for taking blood, the tests that are required and four points of identification of
the patient as well as the signature of the clinician. There should be a clear identification of
clinical need for blood to be drawn.

Ideally the blood form should be present for the procedure to enable accurate identification
checking.

If an order to take blood is given verbally or via telephone, the following needs to be recorded:
 The blood requested and rationale
 Signature of the person (or people) taking the request – ideally this would be two healthcare
professionals
 Whether it is a verbal or telephone request

In the event of a telephone request, the blood form must still be sent with the sample and four
points of identification should still be taken place when labelling blood bottles and checking the
blood form.

Identify patient by the forename and surname, NHS number or hospital number, date of birth and
address (by using open questions).

The correct order of draw must be used when taking blood, to eliminate the risk of additive cross-
contamination during phlebotomy and to reduce the risk of clotting in some blood tubes.

Blood bottles must be labelled immediately, at the patient’s side, by the person who took the
blood to avoid labelling errors (SHOT 2016).

8
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
5.3 Sites for phlebotomy
When undertaking routine phlebotomy,
 First choice is the antecubital fossa with a Vacutainer needle.
 The second choice is the antecubital fossa with a butterfly collection set.
 The third choice is the dorsal aspect of the hand with a butterfly collection system.
 In exceptional circumstances, other alternative sites may be used such as feet. This must be
a clinician’s decision and should only be used by an experienced practitioner upon medical
advice.

When using the dorsal aspect of the hand for phlebotomy, ONLY a butterfly collection system can
be used. Rationale for using any site other than the antecubital fossa must be clearly
documented. When these areas are not available or suitable, then medical advice must be
sought.

Sites considered unsuitable for phlebotomy would include:

 Infection - signs might include redness, hot to touch, tracking, swelling or pain.
 Phlebitis
 Trauma/ burns
 Inflammation
 CVA – although an affected limb could be used if there are no contracture or swelling and
good circulation is present
 Mastectomy with lymph node removal
 Arm with below elbow amputation
 Fracture
 Bruising
 Previous blood sampling or cannulation- causing thrombosed/sclerosed/fibrosed hard veins
 Lymphoedema
 Oedema
 Eczema
 Contractures
 Existing IV lines- avoid arm if IV infusion in progress or cannula in situ
 Fistula site for haemo-dialysis
 Drug users who have over-used veins
 Tattoos

Only two attempts should be made to obtain a blood sample from the patient, using new
equipment on each occasion. If second attempt is unsuccessful, a different competent
practitioner may attempt phlebotomy one more time from a different site. A maximum of three
attempts should be made at any one time. Failed attempts should be documented in the patient
notes. Document the site used and seek further medical advice.

5.4 Sharps
Needle safe devices MUST be used. Sharps should not be passed directly from hand to hand at
any point during the procedure and handling should be kept to a minimum. Sharps should be
disposed of immediately into a sharps container which is at the patient’s side.

Specimens and sharps must be transported safely, with the sharps container aperture closed
between uses, and according to the Transport of Clinical Specimens procedure SH CP 34.

5.5 Blood Cultures

Blood culture samples should only be requested, if systemic and localised bacterial infection,
including suspected acute sepsis meningitis, osteomyelitis, acute untreated bacterial pneumonia,
or fever of unknown origin is suspected. This must be an aseptic technique, and requires
additional equipment.

9
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 If blood cultures are required they should be taken prior to the administration of antibiotics. If a
patient is already on antibiotics, blood cultures should ideally be taken immediately before the
next dose (with the exception of paediatric patients). (DH Saving Lives 2007).

In patients with suspected bacteraemia, it is generally recommended that two sets of cultures are
taken at separate times from separate sites.
DO NOT use existing peripheral lines/cannula or sites immediately above peripheral lines. If a
central line is present, blood may be taken from this and from a separate peripheral site when
investigating potential infection related to the central line; the peripheral vein sample should be
collected first. Identify a suitable phlebotomy site before decontaminating the skin. Avoid femoral
vein puncture because of the difficulty in adequate skin cleansing and disinfection (DH Saving
Lives 2007).

Ideally, remove the plastic cover of the blood culture bottles immediately before collecting the
sample; the top of the bottle will be clean but not sterile. Disinfect the tops of the culture bottles
with a 2% chlorhexidine in 70% isopropyl alcohol impregnated swab. Allow the alcohol to fully
evaporate for 30 seconds before proceeding with obtaining blood culture.

6. Management of potential problems in practice

Venous spasm is a sudden involuntary contraction of the vein, resulting in temporary cessation
of blood flow in the vein caused by fear, anxiety- stimulated by cold or mechanical or chemical
irritation. In the event of venous spasm withdraw the needle and try a different site – using new
equipment – aiming to get the needle into the centre of the lumen.

The reluctant vein: Identify – and address where possible – any factors that are contributing to
the constriction of blood vessels such as anxiety, temperature, mechanical or chemical irritation
as well as the clinical state of the patient e.g. dehydration and deterioration.

When attempting to take blood samples you must only ever have two attempts on a patient. Try
to have both attempts on the same arm so another member of staff can have an untouched arm.
If the second nurse is unsuccessful after one attempt then seek advice from the GP.

Difficulty locating a suitable vein- Application of the tourniquet can promote venous distention.
Lowering the arm below the level of the heart may also help. Vasodilation can be encouraged by
application of a warm pack or immersion of the arm into warm water.

Haematoma is a localised collection of blood outside the blood vessels, due to trauma which
involves blood continuing to seep from broken capillaries. This is the most common complication
arising from venepuncture. Causative factors are generally, poor technique, failure to release the
tourniquet before removing the needle, inadequate pressure on the site after the needle has been
removed, especially in patients receiving anticoagulation therapy. If the patient bends their arm
up following the procedure, this may also lead to extensive bruising; encourage keeping arm
straight and applying direct pressure.

Pain/ nerve injury/ damage to adjacent structures: When inserting a needle into a vein it is
important to look and feel for the valves so that the needle is not inserted into a valve. If this
occurs the patient will experience pain which may be described as an ‘ electric shock’ or a ‘pins &
needles’ sensation if nerve has been injured. Aim to minimise patient anxiety and discomfort.
Consider use of topical local anaesthetic prior to the procedure.

Accidental damage although rare, the nerve, artery or tendon may be punctured. This can cause
pain, damage or excessive bleeding. This can be reduced by spending time ensuring the vein is
identified before cleaning and commencing the procedure. Should this occur, stop, apply
pressure, reassure the patient, obtain help from a colleague if required, document in the patient’s
record report incident.

10
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 Accidental arterial sample – An artery will have a pulse. In the rare event of placing a needle in
an artery rather than a vein, the blood bottle will fill very quickly with bright red, frothy blood. This
sample can still be sent to pathology. On the blood bottle, identify that it is a possible arterial
sample. Once the needle is removed, immediately place a gauze swab with very firm pressure.
Ensure firm pressure is maintained for 15 minutes. If bleeding has not stopped at this point or the
bleeding is excessive, seek medical attention.

Bleeding – Some patients may be taking medications or have conditions that thin their blood and
can cause prolonged bleeding. These medications may include but are not limited to warfarin,
aspirin, heparin and clopidogrel. Identify this risk before undertaking phlebotomy. After
withdrawing the needle, apply firm pressure to the site for 15mins. If bleeding continues, seek
medical attention.

Local and systemic infection – There is a risk of infection and sepsis from the introduction of a
key part (the sterile needle) into a key site (patient’s vein). Phlebotomy must be undertaken as an
aseptic procedure and correct Personal Protective Equipment worn during the procedure. The
patient must be informed of signs of infection post procedure such as redness, swelling,
temperature or feeling unwell. If these occur, they need to seek medical attention.

Errors in collection/ inaccurate labelling – This can lead to samples being discarded by
laboratory; repeat sampling required and delay in patient treatment. Inappropriate blood sampling
such as patient identification errors result in repeated tests and therefore increased risk to the
patient.

Incomplete filling of blood bottle – A blood bottle may not completely fill if the bottle is
damaged, the batch is faulty or the blood bottle is out of date. Always check the expiry dates of
blood bottles before use. Ensure correct storage, avoiding extreme temperatures. In the instance
of a blood bottle not filling completely, remove and discard. Use another bottle of the same colour
to continue the procedure.

7. Training Requirements (refer to TNA in Appendix 1)

All staff must complete the aseptic technique e-learning package and have successfully
completed the aseptic technique e-assessment before attending training – see section 4.1.

If staff have received training within another trust, and can provide evidence of their competency
and training, it may be an option to passport this training to their record.

Prior to undertaking any phlebotomy procedure [including undertaking blood cultures, if

appropriate], all staff must have attended and passed phlebotomy training, be able to
demonstrate clinical competence at a minimum of level 3 competency and have a clear
understanding of the underlying principles of practice.

All staff who take blood samples as part of their job description should attend update training
every three years, as recommended by WHO (2010).Any staff who are not confident or
competent should attend a phlebotomy training course prior to practice and have successfully
completed a period of supervised practice and competency which will include ten successful
supervised withdrawals of blood from the antecubital fossa using a vacutainer needle.

Patients who are detained under the Mental Health Act who require blood sampling – such as to
monitor Clozapine or Lithium levels – may require restraint. Staff undertaking restraint should
have attended and be in date with training in Supporting Safer Services (sSs) and are confident
and competent in undertaking restraint. The staff undertaking the phlebotomy should be
competent and experienced in phlebotomy.

11
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
8. Associated Documents

This policy needs to be read in conjunction with the current organisational policies for:

 Aseptic and Clean Technique Procedure SH CP 13.

 Blood Transfusion Policy SH CP 42
 Clinical record keeping policy SH IG 01
 Consent for Examination and Treatment Policy SH CP 16Hand Hygiene procedure SH CP
12.
 Hand hygiene policy SH CP 12
 Handling and Disposal of Healthcare Waste Policy SH NCP 47
 Mental Capacity Act Policy SH CP 39
 Patient Identification Policy SH CP 127
 Restrictive interventions policy SH NCP 23
 Restrictive practices policy SH NCP 83.
 Standard Precautions procedure SH CP 19
 Sharps and Inoculation management SH CP 14
 Transport of clinical specimens procedure SH CP 34

9. Supporting References

Department of Health. Saving Lives: a delivery programme to reduce Healthcare Associated

Infection including MRSA. (October 2007).

Department of Health. Saving Lives: summary of best practice for blood

cultures. (2011).

Dept. of Health Reference Guide to Consent for Examination or Treatment. (2009).

Epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in

NHS Hospitals in England

Ernst DJ, Calam R NCCLS simplifies the order of draw: a brief history. Medical Laboratory
Observer.( May 2004: 36(5): 26-8).

Golder M, Chan CL, O’Shea S, Corbett K, Chystie IL, French G. Potential risk of cross-infection
during peripheral-venous access by contamination of tourniquets.
The Lancet,Jan (2000; 355(9197):44)

Mental Capacity Act (2005). Department of Health. London: Her Majesty’s stationary office.

Madeo M, Jackson T, Williams C. Simple measures to reduce the rate of

contamination in blood cultures in Accident and Emergency, Emergency Nursing 2011

National Association of Phlebotomists. Phlebotomy Manual 2004.

National clinical policy and procedural guidelines for nurses and midwives undertaking
venepuncture in adults. Office of the nursing services director – Ireland (

Nursing Midwifery Council (2015) The Code

Nursing Midwifery Council. (2009) Standards for Record keeping

.
Norberg A, Christopher NC, Ramundo ML, Bower JR, Berman SA,

12
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 Contamination rates of blood cultures by phlebotomy Vs intravenous
catheter. JAMA, (Feb 12; 2003: 289(6). 726-9).

Rouke C, Bates C, Read RC. Poor hospital infection control practice in

venepuncture and use of tourniquets. Journal of Hospital Infection.
(2001;49: 59-61).

Serious Hazards of Transfusion (SHOT) 9th Annual Report: (2016).

UK Health Departments. Guidance for Clinical Health Care Workers: Protection from Blood-borne
Viruses. Recommendations for the Expert Advisory Group on AIDS and the Advisory Group on
Hepatitis.

Weinbaum FI, Lavie S, Danek M, Sixsmith D, Heinrich GF, Mills SS. Doing it right first time:
quality improvement and the contaminant blood culture. Journal of Clinical Microbiology. (1997:
35(3), 563-5).
Journal. (2005; 22:810-11).

The World Health Organisation (WHO) Best practice in Phlebotomy. (2010)Grey A, Illingworth J.
Right Blood, right patient, right time. Royal College of Nursing (2004).

[Link]

Further Reading
The Blood Safety and Quality Regulations (2005). Her Majestys Stationary Office.

13
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
Appendix 1: Training Needs Analysis
If there are any training implications in your policy, please complete the form below and make an appointment with the LEaD department (Louise Hartland,
Quality, Governance and Compliance Manager or Sharon Gomez, Essential Training Lead on 02380 874091) before the policy goes through the Trust policy
approval process.

Training Strategic & Operational

Frequency Course Length Delivery Method Facilitators Recording Attendance
Programme Responsibility
Phlebotomy after
completion of Once after completion of Clinical training Director of Nursing
4 hours Face to face MLE
Aseptic aseptic technique team
Technique
Phlebotomy 3 yearly update following Clinical training
4 hours Face to face MLE Director of Nursing
update initial training team
Directorate Service Target Audience

Adult Mental Health

Specialised Services
MH/LD/TQ21
All Health Care Professionals required to take phlebotomy samples from adult patients as part of their job description
Learning Disabilities

Older Persons Mental

ISD’s
Health

ISD’s Adults

ISD’s Childrens Services

Not applicable

Corporate All
Not applicable

14
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
Appendix 2: Evidence of Clinical Practice

Name: Role:
Base: Date initial training completed:

Date aseptic technique e-assessment passed:

Competency Statement: To become a competent practitioner, it is the responsibility of each person

to undertake supervised practice in order to perform phlebotomy in a safe and skilled manner.
Please document successful phlebotomy attempts. You must have achieved 10 successful attempts
before completing the competency.

Assessors
Performance criteria Assessment method Level achieved Date
signature
Details; gender, age, Comments e.g. number of Pass or fail
vein used insertions, reason
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

15
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
Phlebotomy Clinical practice competencies

Name: Role:
Base: Date initial training completed:

Competency Statement: The participant must perform this activity without assistance and/or direct
supervision (level 3) See page 24 for level descriptors

Assessor/
Performance criteria Assessment method Level achieved Date
Self assessed
The Participant will be able to:
1. The staff member must be able to demonstrate the following clinical skills
a) Identify and select Direct observation and
appropriate equipment questioning
including needle, collection
system, winged needle
collection sets, blood collection
tubes for routine tests.
b) Correctly identify the patient Direct observation
by open questioning, and explain
procedure to gain informed
consent
C) Select suitable phlebotomy Direct observation
sites.
d) Pre-pare puncture site and Direct observation
identify if the patient requires
skin to be cleansed, if so what
to use
e) Correctly apply and use a Direct observation
disposable tourniquet
f) State optimum time for Direct observation
tourniquet application
g) Apply PPE and perform Direct observation
phlebotomy safely using an
aseptic technique
h) Perform phlebotomy safely Direct observation
causing minimum distress to
patient Using appropriate
techniques to reduce distress
and anxiety
i) State the correct filling order Discussion and explanation
of sample tubes (Order of draw)
j) Invert sample tubes to ensure Direct observation
adequate mixing of tube
additive.
k) Did the member of staff Direct observation
remove gloves decontaminate
hands then label all samples
correctly at the patients side
l) Dispose of sharps immediately Direct observation
after use in the correct sharps
bin
m) Does the sample tube show
the following information
Full name
Date of Birth
NHS Number Gender
Date sample taken
Are all details correct
Signature if required
2. Health and safety - Can the member of staff identify:
a) Safe practice when Direct observation
assembling and handling
sharps

16
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 b) Carry out effective risk Direct observation
assessment using appropriate
personal protective clothing e.g.
gloves and apron
c) Name three of the main blood Questioning and answers
borne viruses and their risks
d) State the trust procedure Questioning and answers
when dealing with a sharps
injury
e) Identify potential adverse Questioning and answers
incidents or near misses and
report appropriately
3. Infection Control - The staff member can-
a) Demonstrate effective hand Direct observation
hygiene in accordance with
Trust policy
b) Demonstrate an aseptic Direct observation
technique
c) Identify single use items Questioning and answers
d) Describe how components of Questioning and answers
the technique may change
according to the degree of risk

Date all elements of Competency Tool completed to level 3………………………………………

I confirm that I have attended initial training on …………………………………………………….

and that I am confident and competent in phlebotomy procedure.

Clinician ……………………………………………..Signature………………………………………

Status…………………………………………………. Date…………………………………………..

I confirm that I have assessed the above named Clinician and can verify that he/she demonstrates
competency in phlebotomy practice.

Verifier……………………………Signature………………….. Status………………. Date………..

Competent –
Review Dates: Clinician Signature Verifier signature Comments
Yes / No

17
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
Appendix 3: Evidence Based Guidelines for Practice – Phlebotomy Procedures

Procedure for Vacutainer and Butterfly collection system phlebotomy

Action Rationale
Check the sample request form and To ensure the request form is complete
ensure all required / relevant information and accurately matches the
has been entered. This should contain: patient’s personal identification
 The rationale for taking blood details.
 The tests that are required
 Four points of identification of the patient
 The signature of the clinician.
There should be a clear identification of clinical need
for blood to be drawn.
Equipment required for Venous Blood Sampling To ensure the procedure has no
 Sample request form. unnecessary interruption and that all
 Single use disposable tourniquet. correct equipment is ready before
 Clean single use non sterile NITRILE procedure to promote aseptic
gloves and consider disposable apron. technique.
 Appropriate skin cleansing agent such
as 2% Chlorhexidine gluconate and 70%
Isopropyl alcohol wipe or Povidone
Iodine, if the patient is an in-patient on a
ward, or if the patient is immuno-
compromised.
 Vacuum system components and
appropriate sampling tubes. (All must be
in date and if a butterfly system is to be
used, then an additional tube is required
to remove air from the butterfly system
prior to samples being obtained).
 Gauze swabs.
 Appropriately labelled and tagged
Sharps box.
 Plastic, wipe clean tray or identified
prepared area, cleaned with Clinell
universal sanitising equipment wipes
should be used to prepare equipment
area.

All components must be within date.

Identify the patient by their first name, surname and To ensure correct identification of the
date of birth, NHS number if available (verbally patient and avoid erroneous results.
wherever possible using open questioning
technique). Check these details match exactly with
the request form.
In-patients must be wearing a name band and the
details including hospital number checked.
Any discrepancy, no matter how slight e.g. spelling
error, must be clarified before procedure is
performed.
Explain the procedure to the patient allowing time To obtain the patients informed consent.
for the patient to discuss previous difficulties or To ensure patient cooperation and
anxieties. Obtain informed consent. reduce anxiety.
Observe the patients skin: If the patient has fragile This is to identify the correct site

18
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 skin, and/or thin skin consider using a winged needle
(Butterfly) collection system with extension tubing if
competent and confident to do so.
Cleanse tray or identified area with Clinell universal As per Aseptic technique and clean
wipe and allow to air dry. technique procedure SH CP 13.

Place equipment / collection system onto clean tray or

dedicated area and ensure the sharps bin is located
close by to ensure easy, safe access for immediate
disposal of needle.
Decontaminate hands following the Trust Hand To reduce risk of infection.
Hygiene Procedure with soap and water or alcohol
hand sanitizing foam if visibly clean
Put on an apron and clean non sterile NITRILE gloves As per Aseptic technique and clean
in order to connect needle to Vacutainer. Do not technique procedure SH CP 13.
unsheathe the needle at this point.
Position patient comfortably with the appropriate limb To ensure comfort of the patient and
below the level of the heart, on a supported pillow or reduce risk to staff.
phlebotomy chair.
Consider your own safety and moving and handling
position when preparing to undertake phlebotomy.
If anaesthetic cream has been used, remove dressing To ensure no contamination of site.
and wipe the sites with a clean swab.
Apply single use disposable tourniquet 10cm above To avoid discomfort for patient and
insertion site. Do not leave tourniquet on for more ensure a suitable site.
than 60 seconds.

For very fragile skin, place a piece of single use To prevent fragile skin being damaged
gauze or single use paper towel between the by tourniquet
tourniquet and the skin to prevent the skin from
tearing.

When selecting a vein, palpate potential sites, by

looking and feeling for veins. They should feel
springy when depressed and refill immediately when
released. Avoid nodules (valves) in the veins and
junctions where veins meet. Ensure there is no
pulse felt before considering the site for phlebotomy.
Suitable sites include the antecubital fossa, and the
dorsal aspect of the hand.

Should these sites not be available or suitable then

medical advice must be sought. When accessing from
a non-recommended site, documentation must contain
who granted permission and rationale.

Remove the tourniquet.

Never attempt blood sample collection from any To minimise risks to the patient.
limb with an IV infusion, previous lymph node
removal or any oedema or current fracture.
For ROUTINE samples, if required (for in patients or To reduce risks of infection and cross
those visibly contaminated) cleanse the proposed contamination.
puncture site with 2% Chlorhexidine gluconate and
70% Isopropyl alcohol wipe for at least 30 seconds
and allow air-drying for at least 30 seconds.
19
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 In the event of patient allergy to chlorhexidine, use
povidone iodine as an alternative cleanser if
compatible with equipment (see manufacturers
guidelines).
Assemble needle and holder at the patient’s To ensure sterile needle is used each
bedside / drawing area. Do not unsheathe until time.
ready to use.
To maintain vacuum in bottle
Do not attach blood bottle until after needle is
inserted.
Re-apply single use disposable tourniquet 10cm To ensure patient comfort, safety and
above insertion site. Do not leave tourniquet on for reduce erroneous results through
more than 60 seconds as this will affect blood haemo-concentration.
sample quality and results.

DO NOT RE-PALPATE THE PUNCTURE SITE

after cleansing. All phlebotomy procedures must be To prevent cross infection to ensure
performed as an ‘aseptic technique’. aseptic technique

Do not ask patient to vigorously open and close

their hands. To prevent erroneous results
Using correct ‘aseptic technique’, stabilise the vein To perform safe phlebotomy without
at the distal end – below the point of entry – by contaminating puncture site.
slightly stretching the skin.
Using a Vacutainer needle:
1. Take blood samples ensuring correct order To prevent contamination by sample
of draw as per local pathology guidance tube additives or bacteria.
2. Insert needle (bevel uppermost) through the
skin at an angle of 15 degrees.
3. Advance in to the vein (a flashback of blood
can be seen if using flash back needle, at this
point).
4. Attach first blood bottle into the vacutainer
holder with free hand, keeping the hand
holding the needle still.
5. Release the tourniquet
6. Remove initial blood sample and connect
subsequent sample tube(s) if required. When
sample has been removed from the patient
gently invert sample tube five to eight times
times to mix blood with tube additives as per To mix sample with any tube additives.
pathology order of draw guidance.
7. Place swab over the puncture site and
withdraw needle and holder in a continuous To prevent blood from leaking from the
straight line and operate the sharp safe puncture site.
mechanism..
8. Do not press firmly on the swab until after the
needle has been removed.
9. Dispose of the needle and holder immediately To prevent needle stick injury. To
into the sharps box without disconnecting. dispose of sharp at point of use in
10. Maintain pressure on the puncture site for accordance with Handling and Disposal
approximately 3 minutes. The patient may do of Healthcare Waste policy.
this providing they are willing and the
healthcare professional is satisfied they are
able to do so.
20
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 11. Advise patient to keep limb extended at this To avoid pain and trauma to the
point. Do not bend the limb. puncture site

Using a butterfly needle:

1. If the back of the hand is to be used as a To prevent contamination by sample
phlebotomy site ONLY a winged needle tube additives or bacteria.
(Butterfly) collection system with extension
should be used. To ensure the needle does not move
2. Take blood samples ensuring correct order within the vein causing the vein to spasm
of draw as per local pathology guidance or pain for the patient.
3. Insert needle (bevel uppermost) through the
skin at an angle of 15 degrees.
4. Advance in to the vein (a flashback of blood
can be seen at this point).
5. Attach first sampling tube using free hand,
keep the hand holding the needle still.
6. Discard the first tube as soon as blood To ensure that the blood bottle fills to the
enters the bottle to prime the line. If this is top by removing the air in the tube,
not undertaken, the bottle will not fill to the avoiding an insufficient sample being
appropriate level, due to air in the tubing sent to the pathology laboratory.
being released into the bottle and the sample
will be rejected.
7. Attach another tube of the same colour as
the discarded bottle.
8. Release the tourniquet
9. Remove initial blood sample and connect To mix blood bottle additives and to
subsequent sample tube(s) if required. When avoid haemolysis
sample has been removed from the patient
gently invert sample tubes five to eight times to
mix blood with tube additives as per pathology
order of draw guidance.
10. Withdraw needle using the sharp safe
mechanism, keeping the butterfly wings static.
Withdraw needle with the hand closest to the
sharps bin for safe disposal.
To prevent blood from leaking from the
11. Cover the site with a gauze swab.
puncture site.
12. Dispose of the needle and holder immediately
into the sharps box without disconnecting.
13. Maintain pressure on the puncture site for To prevent needle stick injury. To
approximately 3 minutes. The patient may do dispose of sharp at point of use in
this providing they are willing and the accordance with Handling and Disposal
healthcare professional is satisfied they are of Healthcare Waste policy.
able to do so.
14. Advise patient to keep limb extended at this To avoid pain and trauma to the
point. Do not bend the limb. puncture site.
Remove gloves and discard into the waste bin, To accurately identify and match all
decontaminate hands at the bedside/clinical area samples to the patient thus avoiding
and immediately label all samples. These must be clinical errors.
labelled at the patient side ensuring four points of
identification, signature, date and time.
To avoid errors attributed to patients
Pre-labelled tubes must not be used. with same / similar names.

Unlabelled or incorrectly labelled / illegible samples

will not be processed. There will be no opportunity
to change or add anything once the sample arrives
21
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 in the laboratory.
Recheck puncture site before leaving patient and To maintain asepsis and ensure no
apply a suitable dressing. In the event of bleeding ongoing bleeding
after 15mins, seek medical attention.
Remove remaining PPE and decontaminate hands.

BLOOD CULTURE SAMPLES

Only doctors and specially trained nurses may take To ensure correct technique due to
blood samples for blood cultures. higher risk of procedure
These can only be taken using a butterfly system
with a blood culture conversion collection
system.

Blood culture samples are subject to contamination To prevent contamination of blood

with normal skin flora or other bacteria that can culture samples by skin flora or those
contaminate intravenous lines. As a result of this associated with indwelling venous
potential contamination, it is essential that blood access devices.
cultures are only obtained by direct venepuncture
using a strictly aseptic technique and non-sterile
gloves.

NOTE: Blood cultures should not normally be taken To avoid contamination sterile bottles
through a pre-existing venous access device (VAD) from unsterile sampling tubes.
unless the line is suspected to be associated with
sepsis. In which case, another blood culture, taken
by peripheral phlebotomy should also be collected.
This must be performed as a full aseptic procedure
using non-sterile gloves and an apron. The extra-
luminal component of the VAD must be thoroughly
decontaminated using 2% Chlorhexidine solution in
70% isopropyl alcohol wipe for at least 30 seconds
and allowed to air-dry for 30 seconds prior to use.

In the event of patient allergy to chlorhexidine, use

povidone iodine as an alternative cleanser if
compatible with equipment (see manufacturers
guidelines).

Blood culture samples must be drawn before any

other samples following the correct order of draw
(Aerobic (BLUE) followed by Anaerobic (RED) via a
winged needle (Butterfly), Luer adaptor and culture
bottle holder.

Bottles must be visually inspected to ensure To ensure no contamination of sample or

colorimetric disc in base of bottle is a blue/green cross infection
colour prior to use. A yellow colour indicates the
contents are unsterile.

 Check the bottle expiry date.

 Discard any bottles which appear cracked or
where the cap seals are not intact.

22
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 To prevent the inadvertent intravenous
Bottles must be held upright and never inverted injection of culture medium.
during sampling.
Technique
Gather and check all equipment required to perform To avoid unnecessary interruptions.
procedure
Equipment required To ensure correct equipment prepared
 Request form signed by medical and uninterrupted procedure
practitioner
 Non sterile gloves and disposable apron
 Skin cleanser and equipment cleanser
containing Chlorhexidine solution 2% in
isopropyl alcohol70% single use wipes or
povidone iodine solution in instance of
allergy.
 Single use disposable tourniquet
 Sterile winged needle collection system for
blood cultures (Butterfly).
 Blood culture bottles – one aerobic, one
anaerobic – check colorimetric indicator
discs to ensure sterility and check expiry
date. Discard bottles where caps are not
intact.
 Other blood bottles as required
 Sharps bin and suitable clinical waste bag.
Cleanse tray or identified area with Clinell universal A ensure good aseptic technique and
wipe and allow to air dry. safe use of equipment

Place equipment / collection system onto clean tray or

dedicated area and ensure the sharps bin is located
close by to ensure easy, safe access for immediate
disposal of needle.

Also check the blood culture bottles to ensure they are To prevent incorrect blood results
in date
Blood culture samples must be drawn before any To ensure no cross contamination of
other samples and the procedure must adhere to an samples
aseptic technique as these samples are subject to
contamination with normal skin flora.

When the potential site is identified, position patient To ensure comfort of the patient and
comfortably with appropriate limb below the level of reduce risk to staff.
the heart, on a supported pillow or phlebotomy chair.
Consider your own safety and moving and handling
position when preparing to undertake phlebotomy.
If anaesthetic cream has been used, remove dressing To ensure skin is clean and there is no
and wipe the sites with a clean swab. cross contamination
Apply single use disposable tourniquet 10cm above To avoid discomfort for patient
insertion site. Do not leave tourniquet on for more
than 60 seconds.

When selecting a vein, palpate potential sites, by To ensure the correct access point is
looking and feeling for veins. They should feel selected
springy when depressed and refill immediately when
released. Avoid nodules (valves) in the veins and
junctions where veins meet. Ensure there is no
23
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 pulse felt before considering the site for phlebotomy.
Suitable sites include the antecubital fossa, and the
dorsal aspect of the hand.

Should these sites not be available or suitable then To ensure clear clinical rationale and
medical advice must be sought. When accessing from good documentation
a non-recommended site, documentation must contain
who granted permission and rationale.

Remove the tourniquet.

Never attempt blood sample collection from any To minimise risks to the patient.
limb with an IV infusion, previous lymph node
removal or any oedema or current fracture.
If required for in patients or those visibly To reduce risks of infection and cross
contaminated, cleanse the proposed puncture site contamination.
with 2% Chlorhexidine gluconate and 70% Isopropyl
alcohol wipe for at least 30 seconds and allow air-
drying for at least 30 seconds.

In the event of patient allergy to chlorhexidine, use To avoid allergic reaction

povidone iodine as an alternative cleanser if
compatible with equipment (see manufacturers
guidelines).
In line with the SHFT aseptic technique policy a sterile To reduce risk to staff and patient
procedure should be followed to obtain blood cultures
to reduce the risk of sample contamination.

Sterile winged needle collection system (Butterfly) To ensure no damage to vein and correct
should be used when obtaining ALL blood culture equipment use
specimens.
Put on non-sterile gloves and disposable apron To ensure aseptic technique
Reapply disposable tourniquet 10cm above To ensure patient comfort, safety and
insertion site. Do not leave tourniquet on for more reduce erroneous results through
than 60 seconds as this will affect blood sample haemo-concentration.
quality and results.

DO NOT RE-PALPATE THE PUNCTURE SITE

after cleansing. All phlebotomy procedures must be To prevent cross infection
performed as an ‘aseptic technique’.

Do not ask patient to vigorously open and close To prevent erroneous results
their hands.
Assemble needle and holder at the patient’s To ensure sterile needle is used each
bedside / drawing area. Do not unsheathe until time.
ready to use.

Do not attach blood bottle until after needle is To maintain vacuum in bottle
inserted.
Using correct ‘aseptic technique’, stabilise the vein To perform safe phlebotomy without
at the distal end – below the entry site – by slightly contaminating puncture site.
stretching the skin.
Using a butterfly needle:

1. If the back of the hand is to be used as a To prevent contamination by sample

phlebotomy site ONLY a winged needle tube additives or bacteria.
(Butterfly) collection system with extension
24
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
 should be used. To ensure the needle does not move
2. Take blood samples ensuring correct order within the vein causing the vein to spasm
of draw as per local pathology guidance – or pain for the patient.
starting with blood cultures
3. Insert needle (bevel uppermost) through the
skin at an angle of 15 degrees.
4. Advance in to the vein (a flashback of blood
can be seen at this point).
5. Insert blood culture bottle onto Blood culture To prevent the inadvertent intravenous
vacutainer receiver ensuring bottle upright to injection of culture medium.
avoid risk of inserting chemicals from the bottle
into the patient. Obtain aerobic sample first.
Use gauge on the label to measure volume
obtained (a minimum of 5mls is required per
bottle).
6. Remove tourniquet.
7. Holding culture bottle upright obtain anaerobic
sample. Use gauge on label to measure
sample obtained (min 5mls).
8. If other blood samples are required insert
sample tubes in correct order of draw.
9. Remove needle and apply direct pressure to
To prevent blood from leaking from the
the puncture site.
puncture site.
10. Dispose of the needle immediately into the
sharps bin.
11. Maintain pressure on the puncture site for To prevent needle stick injury. To
approximately 3 minutes. The patient may do dispose of sharp at point of use in
this providing they are willing and the accordance with Handling and Disposal
healthcare professional is satisfied they are of Healthcare Waste policy.
able to do so.
12. Advise patient to keep limb extended at this To avoid pain and trauma to the
point. Do not bend the limb. puncture site.
Remove gloves and apron into waste bin and then To prevent infection and contamination
decontaminate hands at the patient’s bedside
/drawing area,

Immediately label all samples at the bedside / drawing To ensure correct identification of patient
area. and prevent labelling errors.

The sample tube and request form should include the To ensure four point identification and all
surname, first name, date of birth, and NHS number the relevant information to prevent
or hospital number, the date the time the specimen samples being rejected by the laboratory
was obtained and the healthcare professionals or incorrect patient identification
signature and any other relevant clinical information.
Recheck the puncture site before leaving the patient To ensure the patient’s comfort and no
and apply a suitable dressing bruising or bleeding
Ensure the sample is packed correctly with To ensure good infection control and
accompanying request form, and sent to the appropriate transport of specimen
laboratory immediately or made ready for collection.
After blood cultures have been taken the procedure To ensure good record keeping
should be documented clearly in the patients’ medical
notes.

25
SH CP 83 Phlebotomy Protocol
Version 4
October 2018
Appendix 4

Level of Competency Rating Scale

Level Descriptor
0 Cannot perform this activity to participate in the clinical environment

1 Can perform this activity but not without constant supervision and assistance

2 Can perform this activity with basic understanding of theory and practice
principles, but requires some supervision and assistance

3 Can perform this activity with understanding of theory and practice principles
without assistance and/or supervision

4 Can perform this activity with understanding of theory and practice principles
without assistance and/or supervision at an appropriate pace and adhering
to best practice guidelines.

5 Can perform this activity with thorough understanding of theory and practice
principles without assistance and/or supervision at an appropriate pace and
adhering to best practice guidelines. Additionally demonstrating initiative and
adaptability to special problem situations

6 Can perform this activity with thorough understanding of theory and practice
principles, without assistance and/or supervision, at an appropriate pace,
adhering to best practice guidelines. Demonstrating initiative and adaptability
to special problem situations and can lead others in performing this activity.

26
SH CP 83 Phlebotomy Protocol
Version 4
October 2018