PHLEBOTOMY PRACTICES

DEPARTMENT OF BIOCHEMISTRY,
BASAVATARAKAM INDO AMERICAN CANCER HOSPITAL &
RESEARCH INSTITUTE.
LABORATORY PROCESS

PRE-ANALYTICAL - PHLEBOTOMY

ANALYTICAL – PROCESSING OF SAMPLES

POST-ANALYTICAL – REPORTING/RELEASE
ERRORS IN LABORATORY PROCESS

PRE-ANALYTICAL – UPTO 70 %

ANALYTICAL – UPTO 20 %

POST-ANALYTICAL – UPTO 10 %

PRE-ANALYTICAL – MOST IMPORTANT

DEPARTMENT IN LABORATORY PRACTICE
 VACUTAINER ADDITIVE MODE OF ACTION USES

Red top None Blood clots, and the serum is Chemistries, Immunology and
separated by centrifugation Serology, Blood Bank
(Crossmatch)

Purple EDTA Forms calcium salts to Hematology (CBC) and Blood

top remove calcium Bank (Cross match); requires full
draw - invert 8 times to prevent
clotting and platelet clumping
Light Sodium citrate Forms calcium salts to Coagulation tests , full
blue top remove calcium draw required

Green top Sodium Inactivates thrombin and For lithium level, use sodium
heparin or thromboplastin heparin 
lithium heparin For ammonia level, use sodium
or lithium heparin
Light Sodium Anti-glycolytic agent Glucose, requires full draw 
gray top fluoride and preserves glucose up to 5 (may cause hemolysis if short
potassium days draw)
oxalate
Black top Sodium citrate Forms calcium salts to Wintergreen Sedimentation Rate;
(buffered) remove calcium requires full draw
 ORDER OF DRAW FOR BLOOD COLLECTION TUBES

•BLOOD CULTURE BOTTLES:

•LIGHT BLUE TOP: Sodium citrate. Mix by inverting 8 - 10 times

•RED TOP: Additive none. Mix by inverting 5 times.

•GOLD TOP(GEL SEPERATOR TUBE) : by inverting 5 times

•GREEN TOP: Additive heparin. Mix by inverting 8 - 10 times

•PURPLE TOP: Potassium EDTA:Mix by inverting 8-10 times

•LIGHT GRAY TOP: Sodium fluoride EDTA: 8-10 times

** Blood should NEVER be poured from one tube to another .

ORDER OF DRAW
STEPS OF SAMPLE COLLECTION
Step 1. Assemble equipment

Step 2. Identify and prepare the patient

Step 3. Select the site

Step 4. Perform hand hygiene and put on gloves

Step 5. Disinfect the entry site

Step 6. Take blood

Step 7. Fill the laboratory sample tubes in correct order

Step 8. Clean contaminated surfaces and complete
patient procedure
 REQUIREMENTS FOR PRIMARY SAMPLE COLLECTION

• Hand washing facility

• 70% alcohol and cotton swabs
for skin sterilization
• Tourniquet, Needles & Syringes

• Vacutainers
• Universal safety precautions -
PPE
• Biomedical waste disposal bins
 PATIENT PREPARATION

• Make the patient comfortable.

• Guide the patient before blood collection in terms of diet ,

exercise, drugs intake & time.

• Patient identification . Ask name, age , etc.
• Check MR number
• Ensure the fasting status of the patient .

• A fasting specimen of 10-12 hrs is preferred for some tests.

 PROPER LABELING OF SPECIMENS

•The vacutainers must be labeled with the patient’s name (barcode) written
exactly as it appears on the test request form.

•Label each specimen with the patient’s name, MR no, IP no. and lab no,etc.

•Fix all labels on the sample containers.

•Note date, time of drawn, identity of phlebotomist.

•Fill the TRF properly & completely

CORRECT TRF FORM

The time of specimen collection and

the identity of the phlebotomist
collecting the Primary sample is
recorded.
 PHLEBOTOMY PROCEDURE
• Ensure and confirm the tests in tests requisition form.

• Phlebotomist must wear sterile gloves, and apron (PPE)before collecting the
blood samples from the patient/subject.

• Identify the patient correctly by verifying his/her identity.

• Ensure that the patient is seated comfortably.

• Check for the availability of vein, apply the tourniquet app 3-5 inches above
the antecubital fossa, and clean the area with alcohol swab.

• Ask the patient/subject to hold his fist tightly then insert the needle into a
prominent vein and collect the required amount of blood into the relevant
vacutainer tube.
 VEINS USED FOR DRAWING BLOOD

• MEDIAN CUBITAL VEIN – First

choice, well supported, least apt to
roll

• CEPHALIC VEIN – Second choice

• BASILIC VEIN – Third choice,

often the most prominent vein, but it
tends to roll easily and makes vein
puncture difficult.
• VEIN SELECTION

• Choose the veins that are large and accessible.

• Avoid bruised and scarred areas.
 
• CAN’T FEEL THE VEIN?

• Have the Patient “pump” the hand 3 times.

• Don’t overdue it because over-pumping can
create heam concentration.
• Have the patient dangle arm below the heart
level for 1-3 minutes.
• Warm the area with a hot pack or warm, moist
cloth heated to approximately 42 oC
• If all else fails, consult another technician for
their opinion and/or intervention.
 VENIPUNCTURE SITE SELECTION

AREAS TO BE AVOIDED :

• Extensive scars from burns and surgery

• Hematoma

• Intravenous therapy (IV) / blood transfusions

• Cannula/fistula

• Edematous extremities
 CLEANING THE SITE

• Clean the puncture site with 70% Isopropyl alcohol or

alcohol swabs.

• Rub the alcohol swab in a circular motion moving

outward from the site; use enough pressure to remove all
perspiration and dirt from the puncture site.

• After cleansing do not touch the site, if the vein must be

repalpated, the area must be cleansed again.
 PIERCING THE SKIN

• Hold the prepared holder with the bevel up.

• Use the thumb of the nondominant hand

below the puncture site to anchor the vein and
pull the skin taut.

• The needle entering the site should not touch

the thumb of the phlebotomist.

• Position the needle in the same direction as

the vein, enter the skin and penetrate the vein
at a 30 degree angle in one swift, smooth
motion to decrease the patient discomfort.
 REMOVING THE NEEDLE

•Gently release the tourniquet , not more than

one minute.

•Remove the last tube from the needle

•Withdraw the needle in a single quick

movement

•Quickly place clean gauze over the site, and

apply pressure.

•You may ask the patient to continue

applying pressure until bleeding stops.
•Never ask patient to bend the arm.
 NEEDLE DISPOSAL

• Remove the needle from the holder if appropriate, and

properly discard it in an approved sharps disposal
container.

• Discard all waste and gloves in the appropriate bio hazard

waste container.

• Wash hands and apply sterilizer lotion.

 IF AN INCOMPLETE COLLECTION,THEN...

• Try another tube. Use a smaller tube with less vacuum. There
may be no vacuum in the tube being used.

• Re-anchor the vein. Veins sometimes roll away from the point
of the needle and puncture site.

• Pre-warm the region of the vein to reduce vasoconstriction and

increase blood flow.

• Have the patient drink fluids if dehydrated.

 UNWANTED EFFECTS OF FAULTY SAMPLE
COLLECTION

Poor venepuncture practice may result in:

• Bruising, haematoma and injury to anatomical

structures in the vicinity of the needle entry: Apply
anti-coagulant ointment on the sample collection site.

• Fainting : Call doctor

 THE INTEGRITY OF THE SPECIMEN

• The right patient.

• The right container.

• The right time.

• Use correct technique/site.

• Label correctly and completely.

• Avoid hemolysis.
 COMMON ERRORS IN SPECIMEN
COLLECTION………
• Non fasting specimen when test requires fasting
• Hemo-concentration from prolonged tourniquet tying

• Unsterile container for culture

• Exposure to light / extreme temperatures [vitamins]

• Improperly timed specimens / Delayed delivery to

laboratory
 COMMON ERRORS IN SPECIMEN
COLLECTION:REJECTION OF SAMPLES

• Mis-identification of patient

• Discrepancies between requisition & specimen label

• Unlabeled or mislabeled specimen

• Short draws / wrong anticoagulant to blood ratio
• Mixing problems / clots
• Wrong tubes / wrong anticoagulant
• Hemolysis
 HAEMOLYSIS:

Means lysis of RBC which affects certain test

results like Potassium, Magnesium, Iron, LDH,
Phosphorus, Ammonia & Total protein.
The serum/plasma will appear red instead of straw
colored
Causes of haemolysis :
• Needle gauge too thin
• Syringe plunger pulled back too fast
• Expelling blood vigorously in the tubes
• Mixing tubes vigorously
• Collecting blood before alcohol has dried at
venipuncture site
IMPROPER MIXING AND OVER/UNDER FILLING

• Clots in anticoagulated specimen

• Failure to mix or inadequate mixing of samples collected
into additive tubes.
• There is clumping of red cells
• Over or under filling of anticoagulant tubes.
• Incorrect blood to additive ratio will adversely affect the
laboratory test results.
• Use pediatric vacutainers for children.
• INSUFFICIENT SAMPLE (QNS):When many tests are
ordered on the same patient, be sure to know the amount of
sample needed for each test.

• WRONG TUBE: Sample collected in wrong vacutainer for test

ordered.

• IMPROPER STORAGE & TRANSPORT: Certain tests must

be collected and placed on ice, protected from light, or be kept
warm after collection.
 CRITICAL ALERT RESULTS

• Some laboratory results are life-threatening to patients

unless something is done promptly. Such results/reports
are termed as critical /alert results.
• Critical /alert results once received in the nursing station
must be communicated/informed urgently to the
corresponding doctor without fail.
• List of critical results is available in all nursing stations.
 MAKE USE OF DOS & PSCM

• The entire list of laboratory tests is available in

soft copy format on your desktop systems
named as DIRECTORY OF SERVICES-DOS.

• The details of sample collection is given in

the primary sample collection manual,
available as PSCM file on the system.
PRIMARY SAMPLE COLLECTION
MANUAL : PSCM
DIRECTORY OF SERVICES:DOS
DIRECTORY OF SERVICES:DOS
DIRECTORY OF SERVICES:DOS
THANK YOU !