SAFETY IN THE HEMATOLOGY

LABORATORY
SAFETY PRACTICES AND OCCUPATIONAL HAZARDS
STANDARD PRECAUTIONS

 Universal Precautions
 Says that all blood, body fluids, and unfixed tissues are to be handled
as though they were potentially infectious.
 apply to the following potentially infectious materials: blood, semen,
vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, any
body fluid with visible blood, any unidentified body fluid, unfixed slides,
microhematocrit clay, and saliva from dental procedures.
 This is followed to protect medical professionals from the risk of
acquiring blood borne pathogens (e.g. HBV, HCV and HIV)
SAFETY PRACTICES
1. Handwashing is one of the most important safety practices. Hands must be
washed with soap and water. If water is not readily available, alcohol hand
gels (minimum 62% alcohol) may be used. Hands must be thoroughly dried.
2. Eating, drinking, smoking, and applying cosmetics or lip balm must be
prohibited in the laboratory work area.
3. Hands, pens, and other fomites must be kept away from the worker’s mouth
and all mucous membranes.
4. Food and drink, including oral medications and tolerance testing beverages,
must not be kept in the same refrigerator as laboratory specimens or
reagents or where potentially infectious materials are stored or tested.
5. Mouth pipetting must be prohibited.
SAFETY PRACTICES
6. Needles and other sharp objects contaminated with blood and other
potentially infectious materials should not be manipulated in any way.
Such manipulation includes resheathing, bending, clipping, or
removing the sharp object. Resheathing or recapping is permitted
only when there are no other alternatives or when the recapping is
required by specific medical procedures.
7. Contaminated sharps (including, but not limited to, needles, blades,
pipettes, syringes with needles, and glass slides) must be placed in a
puncture-resistant container that is appropriately labeled with the
universal biohazard symbol or a red container that adheres to the
standard. The container must be leak-proof
SAFETY PRACTICES
8. Procedures such as removing caps when checking for clots, filling
hemocytometer chambers, making slides, discarding specimens,
making dilutions, and pouring specimens or fluids must be performed
so that splashing, spraying, or production of droplets of the specimen
being manipulated is prevented. These procedures may be
performed behind a barrier, such as a plastic shield, or protective
eyewear should be worn.
9. Personal protective clothing and equipment must be provided to the
worker.
PERSONAL PROTECTIVE EQUIPMENT

A. OUTER COVERINGS
 gowns, laboratory coats, and sleeve protectors, should be worn when there is a
chance of splashing or spilling on work clothing.
 The outer covering must be made of fluid-resistant material, must be long-sleeved,
and must remain buttoned at all times.
 If contamination occurs, the personal protective equipment should be removed
immediately and treated as infectious material.
 If cloth coats are worn, the coats must be laundered inside the laboratory or
hospital or by a contracted laundry service and are not to be taken home.
 should be removed before the worker leaves the laboratory; it should not be worn
into public areas.
PERSONAL PROTECTIVE EQUIPMENT

B. GLOVES
 Gloves must be worn when the potential for contact with blood or body fluids
exists (including when removing and handling bagged biohazardous material and
when decontaminating bench tops) and when venipuncture or finger sticks are
performed.
 Limitation: gloves do not prevent needle sticks or other puncture wounds
 Gloves must be changed after each contact with a patient, when there is visible
contamination, and when physical damage occurs.
 Gloves should not be worn when “clean” devices, such as a copy machine or a
“clean” telephone, are used.
 Gloves must not be worn again or washed.
PERSONAL PROTECTIVE EQUIPMENT

C. EYEWEAR
 face shields, goggles, and masks, should be used when there is potential for
aerosol mists, splashes, or sprays to mucous membranes (mouth, eyes, or nose).
 Removing caps from specimen tubes, working at the cell counter, and
centrifuging specimens are examples of tasks that could result in creation of
aerosol mist.
SAFETY PRACTICES
10. Phlebotomy trays should be appropriately labeled to indicate
potentially infectious materials. Specimens should be placed into a
secondary container, such as a resealable biohazard-labeled bag.
11. If a pneumatic tube system is used to transport specimens, the
specimens should be transported in the appropriate tube (primary
containment), placed into a special self sealing leak-proof bag,
appropriately labeled with the biohazard symbol (secondary
containment).
12. When equipment used to process specimens becomes visibly
contaminated or requires maintenance or service, it must be
decontaminated, whether service is performed within the laboratory
or by a manufacturer repair service.
HOUSEKEEPING
 To prevent contamination, all work surfaces should be cleaned when
procedures are completed and whenever the bench area or floor becomes
visibly contaminated.
 Working areas and benchtops must be disinfected with 10% Sodium
hypochlorite solution.
 The solution must be made fresh daily. Container should be labeled properly
with the name of the solution, the date and time prepared, the date and
time of expiration (24 hours), and the initials of the preparer.
 For aluminum surfaces, other disinfectant solution must be used (phenol-
based disinfectant such as Amphyl, tuberculocidal disinfectants, and 70%
ethanol).
 Disinfection must be done before and after EACH shift.
OCCUPATIONAL HAZARDS
FIRE HAZARD
A good fire safety/prevention plan is necessary and should consist of the following:
1. Enforcement of a no-smoking policy.
2. Installation of appropriate fire extinguishers. Several types of extinguishers, most of
which are multipurpose, are available for use for specific types of fire.
3. Placement of fire extinguishers every 75 feet.
TYPE OF
TYPE OF FIRE
EXTINGUISHER
A fires involving ordinary combustibles such as wood, cloth, or paper
B fires involving flammable liquids, gases, or grease
C energized (plugged-in) electrical fires
D fires caused by powdered metal material
ABC multipurpose extinguishers that handle type A, B, and C fires
FIRE HAZARD
4. Placement of adequate fire detection and suppression systems
(alarms, smoke detectors, sprinklers), which should be tested every 3
months.
5. Placement of manual fire alarm boxes near the exit doors. Travel
distance should not exceed 200 feet.
6. Written fire prevention and response procedures, commonly referred
to as the fire response plan.
7. Fire drills, which should be conducted so that response to a fire
situation is routine and not a panic response. Frequency of fire drills
varies by type of occupancy of the building and by accrediting
agency.
FIRE HAZARD

8. Written storage requirements for any flammable or combustible

chemicals stored in the laboratory. Chemicals should be arranged
according to hazard class and not alphabetically. A master chemical
inventory should be maintained and revised when new chemicals are
added or deleted from the laboratory procedures.
9. A well-organized fire safety training program. This program should be
completed by all employees.
CHEMICAL HAZARDS
General principles that should be followed in working with chemicals are as
follows:
1. Label all chemicals properly, including chemicals in secondary containers,
with the name and concentration of the chemical, preparation or fill date,
expiration date (time, if applicable), initials of preparer (if done in-house),
and chemical hazards (e.g., poisonous, corrosive, flammable). Do not use a
chemical that is not properly labeled as to the identity or content.
2. Follow all handling and storage requirements for the chemical.
3. Store alcohol and other flammable chemicals in approved safety cans or
storage cabinets at least 5 feet away from a heat source (e.g., Bunsen
burners, paraffin baths). Limit the quantity of flammable chemicals stored on
the workbench to 2 working days’ supply. Do not store chemicals in a hood
or in any area where they could react with other chemicals.
CHEMICAL HAZARDS

4. Use adequate ventilation, such as fume hoods, when working with

hazardous chemicals.
5. Use personal protective equipment, such as gloves (e.g., nitrile,
polyvinyl chloride, rubber—as appropriate for the chemical in use),
rubber aprons, and face shields. Safety showers and eye wash stations
should be available every 100 feet or within 10 seconds of travel
distance from every work area where the hazardous chemicals are
used.
6. Use bottle carriers for glass bottles containing more than 500 mL of
hazardous chemical.
CHEMICAL HAZARDS
7. Use alcohol-based solvents, rather than xylene or other particularly
hazardous substances, to clean microscope objectives.
8. The wearing of contact lenses should not be permitted when an
employee is working with xylene, acetone, alcohols, formaldehyde,
and other solvents. Many lenses are permeable to chemical fumes.
9. Spill response procedures should be included in the chemical safety
procedures, and all employees must receive training in these
procedures.
10. Safety Data Sheets (SDS), formerly known as Material Safety Data
Sheets (MSDS), are written by the manufacturers of chemicals to
provide information on the chemicals that cannot be put on a label.
ELECTRICAL HAZARDS

Electrical equipment and outlets are other sources of hazard. Faulty

wiring may cause fires or serious injury. Guidelines include the following:
1. Equipment must be grounded or double insulated. (Grounded
equipment has a three-pronged plug.)
2. Use of “cheater” adapters (adapters that allow three pronged plugs to
fit into a two-pronged outlet) should be prohibited.
3. Use of gang plugs (plugs that allow several cords to be plugged into
one outlet) should be prohibited.
4. Use of extension cords should be avoided.
ELECTRICAL HAZARDS
5. Equipment with loose plugs or unplugged and identified as
frayed cords should not be used. defective, and the problem
6. Stepping on cords, rolling heavy
reported.
equipment over cords, and other 9. Before repair or adjustment of
abuse of cords should be electrical equipment is
prohibited. attempted, the following should
7. When cords are unplugged, the
be done:
plug, not the cord, should be a. Unplug the equipment.
pulled. b. Make sure the hands are
8. Equipment that causes shock or dry.
a tingling sensation should be c. Remove jewelry.
turned off, the instrument
BIOHAZARD – NEEDLE PUNCTURE

 Needle-handling procedures should be written and followed, with special

attention to phlebotomy procedures and disposal of contaminated needles.
 Other items that can cause a puncture similar to a needle puncture:
sedimentation rate tubes, applicator sticks, capillary tubes, glass slides, and
transfer pipettes.
 Most Common Cause: IMPROPER WASTE DISPOSAL
 Failure to check sharps containers on a regular basis and to replace them
when they are no more than three-quarters full encourages overstuffing,
which sometimes leads to injury.
 All needle punctures should be reported to the health services or proper
authorities within the institution.
BLOOD SPECIMEN
COLLECTION
PHLEBOTOMY
PHYSIOLOGIC FACTORS AFFECTING THE RESULTS
POSTURE
 Changing from a supine (lying) to a sitting or standing position results in
a shift of body water from inside the blood vessels to the interstitial
spaces. Larger molecules, such as protein, cholesterol, and iron cannot
filter into the tissues, and their concentration increases in the blood.

DIURNAL RHYTHM
 Morning: Elevated levels of cortisol, thyroid stimulating hormone, and
iron
 Afternoon: Elevated count of Eosinophils
PHYSIOLOGIC FACTORS AFFECTING THE RESULTS

EXERCISE
 May increase the following: creatinine, total protein, creatine kinase,
myoglobin, aspartate aminotransferase, white blood cell count, and
HDL-cholesterol.

STRESS
 Anxiety and excessive crying in children can cause a temporary
increase in the white blood cell count.
PHYSIOLOGIC FACTORS AFFECTING THE RESULTS

DIET
 Fasting means no food or beverages except water for 8 to 12 hours before a blood
draw.
 Post prandial specimen
 Lipemia may affect some tests that require photometric measurement, such as the
hemoglobin concentration and coagulation tests performed on optical detection
instruments.

SMOKING
 Patients who smoke before blood collection may have increased white blood cell
counts and cortisol levels. Long-term smoking can lead to decreased pulmonary
function and result in increased hemoglobin levels.
VENIPUNCTURE
COLLECTION OF VENOUS BLOOD
EQUIPMENTS

TOURNIQUET
 used to provide a barrier against
venous blood flow to help locate a
vein.
 disposable elastic strap, a heavier
Velcro strap, or a blood pressure cuff
 applied 3 to 4 inches above the
venipuncture site and left on for no
longer than 1 minute before the
venipuncture is performed
EQUIPMENTS

COLLECTION TUBES/EVACUATED TUBES

 Evacuated tubes made of glass or plastic with or
without additive content.
 Tubes used for blood collection are called
evacuated tubes because they contain a
premeasured amount of vacuum.
 Most glass tubes are coated with silicone to help
decrease the possibility of hemolysis and to prevent
blood from adhering to the sides of the tube.
 Evacuated tubes are available in various sizes and
may contain a variety of premeasured additives.
 Are color coded in which the stopper color indicates
the type of additive contained in the tube.
ADDITIVES IN TUBES

CLOT ACTIVATORS ANTICOAGULANTS

 accelerates the clotting process and  prevents blood from clotting.
decreases the specimen preparation
 EDTA, citrate, and oxalate remove
time.
calcium needed for clotting by forming
 Examples: glass or silica particles insoluble calcium salts.
(activates factor XII in the coagulation
 Heparin prevents clotting by binding to
pathway) and thrombin (an activated
antithrombin in the plasma and
coagulation factor that converts
inhibiting thrombin and activated
fibrinogen to fibrin)
coagulation factor X.
 Tubes with anticoagulant are either
tested as whole blood or are
centrifuged to yield plasma.
ADDITIVES IN TUBES

ANTIGLYCOLYTIC AGENT SEPARATOR GEL

 Inhibits the metabolism of glucose by  an inert material that undergoes a
blood cells temporary change in viscosity during
the centrifugation process; this enables
 necessary if testing for the glucose level
it to serve as a separation barrier
is delayed
between the liquid (serum or plasma)
 The most commonly used antiglycolytic and cells.
agent is sodium fluoride.
 Because this gel may interfere with
some testing, serum or plasma from
these tubes cannot be used with
certain instruments or for blood bank
procedures.
TUBE GUIDE
COLOR ADDITIVE(S) USE(S)
For serum determinations in chemistry. May be used
for routine blood donor screening and diagnostic
Clot activator and gel for
Gold testing of serum for infectious disease. Tube inversions
serum separation
ensure mixing of clot activator with blood. Blood
clotting time: 30 minutes.
For plasma determinations in chemistry. Tube
Lithium heparin and gel
Light Green inversions ensure mixing of anticoagulant (heparin)
for plasma separation
with blood to prevent clotting.
For serum determinations in chemistry. May be used
Silicone coated (glass)
for routine blood donor screening and diagnostic
Red testing of serum for infectious disease. Tube inversions
Clot activator, Silicone
ensure mixing of clot activator with blood. Blood
coated (plastic)
clotting time: 60 minutes.
TUBE GUIDE
COLOR ADDITIVE(S) USE(S)
Thrombin-based clot For stat serum determinations in chemistry. Tube
Orange activator (with or without inversions ensure mixing of clot activator with blood.
gel) for serum separation Blood clotting time: 5 minutes.
For trace-element, toxicology, and nutritional-
Clot activator (plastic chemistry determinations. Special stopper
serum) formulation provides low levels of trace elements
Royal Blue
(see package insert). Tube inversions ensure mixing
K2EDTA (plastic) of either clot activator or anticoagulant (EDTA) with
blood.
Sodium heparin For plasma determinations in chemistry. Tube
Green inversions ensure mixing of anticoagulant (heparin)
Lithium heparin with blood to prevent clotting.
TUBE GUIDE
COLOR ADDITIVE(S) USE(S)
Potassium oxalate/
sodium fluoride
For glucose determinations. Oxalate and EDTA
anticoagulants will give plasma samples. Sodium
Gray Sodium fluoride/Na2EDTA
fluoride is the antiglycolytic agent. Tube inversions
ensure proper mixing of additive with blood.
Sodium fluoride (serum
tube)
For lead determinations. This tube is certified to
Tan K2EDTA (plastic) contain less than .01 g/mL(ppm) lead. Tube
inversions prevent clotting.
K2EDTA and K3EDTA for whole blood hematology
Liquid K3EDTA (glass) determinations. K2EDTA may be used for routine
immunohematology testing, and blood donor
Lavender
Spray-coated K2EDTA screening.
(plastic) Tube inversions ensure mixing of anticoagulant
(EDTA) with blood to prevent clotting.
TUBE GUIDE
COLOR ADDITIVE(S) USE(S)
For use in molecular diagnostic test methods (such
as, but not limited to, polymerase chain reaction
K2EDTA and gel for
White [PCR] and/or branched DNA [bDNA] amplification
plasma separation
techniques.) Tube inversions ensure mixing of
anticoagulant (EDTA) with blood to prevent clotting.
For whole blood hematology determinations. May
be used for routine immunohematology testing and
Spray-coated K2EDTA blood donor screening.
Pink
(plastic) Designed with special cross-match label for patient
information required by the AABB. Tube inversions
prevent clotting.
TUBE GUIDE
COLOR ADDITIVE(S) USE(S)
Buffered sodium citrate
0.105 M (3.2%) glass
For coagulation determinations. CTAD for selected
0.109 M (3.2%) plastic
Light Blue platelet function assays and routine coagulation
Clear determination. Tube inversions ensure mixing of
Citrate, theophylline,
anticoagulant (citrate) to prevent clotting.
adenosine, dipyridamole
(CTAD)
For use as a discard tube or secondary specimen
Clear None (plastic)
tube.
EQUIPMENTS

NEEDLES
 Venipuncture needles are sterile and
are available in a variety of lengths and
gauges (bore or opening size).
 The gauge number of a needle is
inversely related to the bore size: the
smaller the gauge number, the larger
the bore.
 Needles for drawing blood range from
19 to 23 gauge. The most common
needle size for adult venipuncture is 21
gauge with a length of 1 inch.
MULTISAMPLE NEEDLES
EQUIPMENTS

WINGED BLOOD COLLECTION SET

(Butterfly)
 A winged blood collection set or
butterfly consists of a short needle with
plastic wings connected to thin tubing.
 Winged blood collection sets are useful
in collecting specimens from children or
other patients from whom it is difficult to
draw blood.
 EQUIPMENTS

EVACUATED TUBE SYSTEM (ETS)

 Evacuated tube system needles
are designated as multisample
needles.
 Multisample needles have the
stopper puncturing needle
covered by a rubber sheath that is
pushed back when a tube is
attached and returns to full needle
coverage when the tube is
removed.
 This prevents leakage of blood
when tubes are being changed
EQUIPMENTS

SYRINGES
 Syringes may be useful in drawing
blood from pediatric, geriatric, or other
patients with tiny, fragile, or “rolling”
veins that would not be able to
withstand the vacuum pressure from
evacuated tubes.
EQUIPMENTS
SOLUTIONS FOR SKIN ANTISEPSIS
 70% Isopropyl alcohol – MOST
COMMON
 The phlebotomist must use a non-
alcohol-based antiseptic to collect
blood for a legal blood alcohol level.
(Povidone-iodine)
 Blood Culture: two-step procedure with
30 to 60-second scrub with 70% alcohol
followed by cleansing with 1% to 10%
povidone-iodine pads, tincture of
iodine, chlorhexidine compounds, or
another isopropyl alcohol prep
ORDER OF DRAW

1. Blood culture tube (yellow stopper)

2. Coagulation tube (light blue stopper)
3. Serum tube with or without activator
(red, gold, red-gray marbled, orange, or
yellow-gray stopper)
4. Heparin tube (green or light green
stopper)
5. EDTA tube (lavender or pink stopper)
6. Sodium fluoride with or without EDTA or
oxalate (gray stopper)
VENIPUNCTURE IN CHILDREN

 Pediatric phlebotomy requires experience, special skills, and a tender

touch.
 Ideally, only experienced phlebotomists should draw blood from
children; however, the only way to gain experience is through
practice.
 Smaller gauge (22- to 23-gauge) needles are employed.
 Use of a syringe or winged blood collection set may be advantageous
for accessing small veins in young children.
 Use of special stickers or character bandages as rewards may serve as
an incentive for cooperation
COMPLICATIONS ENCOUNTERED IN
VENIPUNCTURE
ECCHYMOSIS (BRUISE)

 MOST COMMON complication

encountered
 It is caused by leakage of a small amount
of blood in the tissue around the
puncture site.
 Prevention: applying direct pressure to
the venipuncture site with a gauze pad.
 NOTE: Bending the patient’s arm at the
elbow to hold the gauze pad in place is
not effective in stopping the bleeding
and may lead to bruising.
HEMATOMA

 A hematoma results when leakage of a large amount

of blood around the puncture site causes the area to
rapidly swell.
 Can result in bruise formation, cause pain and possible
nerve compression and permanent damage to the
patient’s arm.
 Hematomas most commonly occur when the needle
goes through the vein or when the bevel of the needle
is only partially in the vein and when the phlebotomist
fails to remove the tourniquet before removing the
needle or does not apply enough pressure to the site
after venipuncture.
FAINTING (SYNCOPE)

 Prevention: Before drawing blood, the

phlebotomist should always ask the patient
whether he or she has had any prior episodes of
fainting during or after blood collection.
 If the patient begins to faint, the phlebotomist
should remove and discard the needle
immediately, apply pressure to the site with a
gauze pad, lower the patient’s head, and loosen
any constrictive clothing.
 The phlebotomist should also notify the
designated first-aid providers at the facility.
HEMOCONCENTRATION

 Hemoconcentration is an increased concentration of cells, larger

molecules, and analytes in the blood as a result of a shift in water
balance.
 Can be caused by leaving the tourniquet on the patient’s arm for too
long.
 The tourniquet should not remain on the arm for longer than 1 minute.
 If it is left on for a longer time because of difficulty in finding a vein, it
should be removed for 2 minutes and reapplied before the
venipuncture is performed.
HEMOLYSIS

 Hemolysis is the rupture of red blood cells with the consequent

escape of hemoglobin.
 Causes: use of too small needle for phlebotomy; drew the blood
through an existing hematoma; pulled back too quickly on the
plunger of a syringe; forced blood into a tube from a syringe by
pushing the plunger; mixed a tube too vigorously; or
contaminated the specimen with alcohol or water at the
venipuncture site or in the tubes.
 Physiologic cause: presence of hemolytic anemia; hemolytic
transfusion reaction.
 Hemolyzed specimens can alter test results, such as levels of
potassium, lactate dehydrogenase, and aspartate
aminotransferase, which can result in patient treatment errors.
PETECHIAE

 Petechiae are small red spots

indicating that small amounts of
blood have escaped into the
skin.
 Indicates a possible hemostasis
abnormality and should alert the
phlebotomist to be aware of
possible prolonged bleeding.
ALLERGIES

 Some patients may be allergic to

skin antiseptic substances and
adhesive bandages and tape
 Determine if the patient has a
latex sensitivity before the
phlebotomy procedure.
 Use hypoallergenic tape or apply
pressure manually until the
bleeding has stopped completely.
NERVE DAMAGE

 The phlebotomist must select the

appropriate veins for venipuncture
and should not blindly probe the
arm with the needle or try to laterally
relocate the needle.
 Signs: Patient complain about
shooting or sharp pain, tingling, or
numbness in the arm.
SEIZURES
 Patients occasionally experience
seizures because of a preexisting
condition or as a response to the
needle stick.
 If a seizure occurs, the phlebotomist
should immediately remove and
discard the needle, apply pressure
with a gauze pad, and notify the
nurse or designated first-aid
providers at the facility. The
phlebotomist should also ensure the
patient’s safety by preventing injury
from nearby objects.
PHLEBOTOMY IN SPECIAL
SITUATIONS
EDEMA

 Swelling caused by an abnormal

accumulation of fluid in the
intercellular spaces of the tissues.
 Most common cause: is infiltration of
the tissues by the solution running
through an incorrectly positioned
intravenous catheter.
 Edematous sites should be avoided
for venipuncture because the veins
are hard to find and the specimens
may become contaminated with
tissue fluid.
OBESITY

 veins may be neither readily

visible nor easy to palpate
 The phlebotomist should not
probe blindly in the patient’s arm
because nerve damage may
result.
BURNED, DAMAGED, SCARRED, AND OCCLUDED VEINS

 Burned, damaged, scarred, and

occluded veins should be
avoided because they do not
allow the blood to flow freely
and may make it difficult to
obtain an acceptable
specimen.
INTRAVENOUS THERAPY

 Drawing blood from an arm with an

intravenous (IV) infusion should be
avoided if possible; the phlebotomist
should draw the blood from the
opposite arm without the IV.
 If unavoidable, draw blood below the
IV line and note on the requisition and
the tube that the specimen was
obtained from an arm into which an IV
solution was running, indicating the arm
and the location of the draw relative to
the IV.
MASTECTOMY PATIENTS

 Consult the attending physician before

blood is drawn from the same side as a
prior mastectomy (removal of the
breast), even in the case of bilateral
mastectomies.
 The pressure on the arm that is on the
same side as the mastectomy from a
tourniquet or blood pressure cuff can
lead to pain or lymphostasis from
accumulating lymph fluid.
 The other arm on the side without a
mastectomy should be used.
CAPILLARY BLOOD COLLECTION
SKIN PUNCTURE
SKIN PUNCTURE

 Skin puncture is the technique of choice to obtain a blood specimen from newborns
and pediatric patients.
 Adult skin puncture may be used in patients who are severely burned and whose
veins are being reserved for therapeutic purposes; in patients who are extremely
obese; and in elderly patients with fragile veins.
 Blood obtained from skin puncture is a mixture of blood from venules, arterioles,
capillaries, and interstitial and intracellular fluids.
 The phlebotomist should note that the specimen was obtained by skin puncture
because those specimens may generate slightly different test results.
COLLECTION SITES

INFANT
 lateral (outside) or medial (inside) plantar
(bottom) surface of the heel

CHILDREN OLDER THAN 1 YEAR AND ADULTS:

 palmar surface of the distal portion of the
third (middle) or fourth (ring) finger on the
nondominant hand
NOTE:

 Warm the puncture site to increase blood flow sevenfold. (commercial

heal warmer or wash cloth for 3-5 minutes)
 Cleanse the area with 70% isopropyl alcohol. (Povidone-iodine should
not be used because of possible specimen contamination, which
could falsely elevate levels of potassium, phosphorus, or uric acid)
PRECAUTIONS

 Heel punctures in infants should not be made more than 2 mm deep

because of the risk of bone injury and possible infection (osteomyelitis).
 The phlebotomist should not puncture an area that is swollen, bruised,
infected, or already has been punctured.
 In addition phlebotomists should not perform skin puncture in patients
with edema, dehydration, or poor peripheral circulation because
specimen integrity and test accuracy may be compromised.
 The first drop of blood should be wiped away with a clean gauze pad
to prevent contamination of the specimen with tissue fluid and to
facilitate the free flow of blood.
EQUIPMENTS
ORDER OF DRAW:
1. Tube for blood gas
analysis
2. Slides, unless made from
specimen in the EDTA
microcollection tube
3. EDTA microcollection
tube
4. Other microcollection
tubes with
anticoagulants
5. Serum microcollection
tubes
REASONS FOR SPECIMEN REJECTION

 Test order requisition and the tube identification do not match.

 Tube is unlabeled, or the labeling, including patient identification
number, is incorrect.
 Specimen is hemolyzed.
 Specimen was collected at the wrong time.
 Specimen was collected in the wrong tube.
 Specimen was clotted, and the test requires whole blood or plasma.
 Specimen was contaminated with intravenous fluid.
 Specimen is lipemic.