Cherie Maguire, MS Research Assistant II Channing Division of Network Medicine The Center For Clinical Investigation

Cherie Maguire, MS
Research Assistant II
Channing Division of Network Medicine
The Center for Clinical Investigation

 What is Phlebotomy
 Safety
 Supplies and Equipment
 Patient Identification/Patient Preparation
 Site Selection /Site preparation
 Proper tourniquet application/Timing
 Vein of choice
 The venipuncture (tube holder, syringe, butterfly)
 Tubes/Order of Draw
 Observation & bandaging
 Disposal of contaminated equipment
 Labeling/Handling requirements
 Troubleshooting/Complications
 Phlebotomy Basics Video
 Practical: Hands-on demonstration and supervised practice
on training models
 Word derived from Greek words
- Phleb – relates to veins
- otomy – relates to cutting
 Theterm phlebotomy refers to the

drawing of blood for laboratory
analysis.
Patient/blood donors
 Exposure to bloodborne viruses through reuse of needles,
syringes and lancets, contaminated work surfaces
 Sterile single-use devices only
 Safety-engineered devices
 Clean work surfaces with disinfectant
 Infection at blood sampling site

 Perform hand hygiene
 Clean patient's skin with 70% isopropyl alcohol and allow to dry
 Use sterile needle and syringe removed from the packaging just
before use
 Pain at blood sampling site
 Well-trained person should take the blood sample
 Venipuncture is less painful than heel-pricks in neonates
 Use needle of smaller gauge than the selected vein
 Hematoma or thrombus
 Enter vessel at an angle of 30 degrees or less
 Use gauge of needle smaller than the vein
 Apply pressure to a straight arm for 3–5 minutes after drawing
blood
 Extensive bleeding
 Take a history to identify patients on anticoagulants and with a
history of bleeding
 Use a gauge of needle smaller than the vein
 Nerve damage
 Avoid finger-pricks for children
 Use antecubital vessels when possible
 Avoid probing
 Vasovagal reaction - Syncope, fainting

 Hydrate patient, take postural blood pressure if dehydrated
 Reduce anxiety
 Have patient lie down if the person expresses concern
 Provide audio-visual distraction
 Allergies
 Ask about allergies to latex, iodine and alcohol before starting the
procedure
Healthcare worker
 Needle or sharps injury during or after the procedure,
Breakage of blood containers, Splashes (rare)
 Use safety devices such as needle covers, tube holders that
release needles with one hand and safety lancets
 Avoid two-handed recapping and disassembly
 Place sharps container in sight and within arm's reach
 Dispose of used sharps immediately
 Exposure to blood
 Hepatitis B vaccination
 Wear gloves and PPE
 Use evacuated tubes and transfer devices when drawing multiple
tubes
 Follow protocol for exposure to body fluids and report incident,
even if post-exposure prophylaxis is not desired
 Cover broken skin area with a waterproof dressing
HIV
Hepatitis B Virus (HBV)
Hepatitis C Virus (HCV)

 HBV poses a greater risk than HIV
 HBV vaccination is available to all
employees through Occupational
Health
 No vaccination available for HCV or
HIV
 Post exposure treatment is available
through Occupational Health
 According to the Centers for Disease Control
and Prevention (CDC), about 385,000 sharps
injuries occur annually to hospital
employees.
 Potential Hazard
Exposure to blood and other potentially
infectious materials (OPIM) because of:
 Unsafe needle devices.
 Improper handling and disposal of needles
and other sharps.
 Factors affecting likelihood of
exposure/needlestick
 The type and design of device
 Skill level/training of user
 How quickly the safety mechanism is
activated
 Proper use of safety device
 Access to biohazard box
 Loss of focus/distractions
 Brigham and Women's Hospital
provides and requires that safe
needle/sharp practices and/or
devices be used in all procedures
requiring the use of needles.
 http://www.bwhpikenotes.org/Employee_Resources/Healt
h_Safety/NeedleSafety/default.aspx
h_Safety/NeedleSafety/FAQ.aspx
h_Safety/NeedleSafety/Documents/protection.pdf
 Standard Precautions are designed both to
prevent transmission of bloodborne pathogens to
health care workers (previously covered under
universal precautions) and to prevent hospital
spread of pathogens between patients via hands
of health care workers. Standard Precautions
apply to all patients regardless of their diagnosis
or presumed infection status. Good hand
hygiene (handwashing/hand antisepsis) is the
standard of quality patient care.
 Observe universal (standard) safety precautions. Observe all applicable isolation
procedures. PPE's will be worn at all time.
 Wash hands in warm, running water with the chlorhexidine gluconate hand washing
product (approved by the Infection Control Committee), or if not visibly
contaminated with a commercial foaming hand wash product before and after each
patient collection.
 Gloves are to be worn during all phlebotomies, and changed between patient
collections.
 Palpation of phlebotomy site may be performed without gloves providing the skin is
not broken.
 A lab coat or gown must be worn during blood collection procedures.
 Needles and hubs are single use and are disposed of in an appropriate 'sharps'
container as one unit. Needles are never recapped, removed, broken, or bent
after phlebotomy procedure.
 Gloves are to be discarded in the appropriate container immediately after the
phlebotomy procedure. All other items used for the procedure must be disposed of
according to proper biohazardous waste disposal policy.
 Contaminated surfaces must be cleaned with freshly prepared 10% bleach
solution. All surfaces are cleaned daily with bleach.
 In the case of an accidental needlestick, immediately wash the area with an
antibacterial soap, express blood from the wound, and contact your supervisor.
If you are exposed to blood or visibly bloody fluids from:
 Needlestick, or cut from sharp object
 Splash to eyes, mouth, nose, or open cut
 1. Wash or flush affected area
 2. Page STIK Beeper - #3 STIK (37845)
 3. Notify your supervisor
 4. Obtain evaluation and treatment in Occupational Health
 Business Hours:
 M-F, 7am to 4:00pm
BWH Occupational Health Services,
10 Vining Street, Suite 104, in the Neville Building.
The phone number is 617 732-6034.
 Off Hours: Emergency Department
 It is important to report exposure within 1-2 hours. You may
need immediate treatment.
 Needles
 Safety Needles, 22g or less
 Butterfly needles, 21g or less
 Syringes
 Blood Collection Tubes
 The vacuum tubes are designed to draw a predetermined volume
of blood. Tubes with different additives are used for collecting
blood specimens for specific types of tests. The color of the
rubber stopper is used to identify these additives
 Antiseptic. Individually packaged 70% isopropyl alcohol wipes
 Tourniquets. Latex-free tourniquets are available
 2x2 Gauze or cotton balls
 Sharps Disposal Container. An OSHA acceptable, puncture
proof container marked "Biohazardous"
 Bandages or tape
 Verify patient name and date of birth &/or
medical record number
 Gain the patient's confidence and assure
him/her, although the patient will feel a little
pinch it will be of short duration.
 Depending on study and tests to be done – ask
whether patient is fasting
 Seated Patient - arm extended to form a
straight-line form shoulder to wrist. Supported
by the armrest; not bent at the elbow.
 Lying down - Ask the patient - lie on back in a
comfortable position. Place a pillow under the
arm – if needed
 Extensive scarring or healed burn areas
should be avoided
 Specimens should not be obtained from the
arm on the same side as a mastectomy
 Avoid areas of hematoma
 If an IV is in place, samples may be obtained
below but NEVER above the IV site
 Do not obtain specimens from an arm having
a cannula, fistula, or vascular graft.
 Allow 10-15 minutes after a transfusion is
completed before obtaining a blood sample
 Vein Selection
 Palpate and trace the path of veins several times
with the index finger. Unlike veins, arteries
pulsate, are more elastic, and have a thick wall.
 Thrombosed veins lack resilience, feel cord-like,
and roll easily.
 If veins are not readily available - massaging the
arm from wrist to elbow. Tapping sharply at the
vein site with the index finger a few times will
cause the vein to dilate. Application of heat to
the site may have the same result.
 Lowering the extremity over the bedside or arm
rest will allow the veins to fill to capacity.
 The larger median cubital, basilic and cephalic
veins are most frequently used, but other may
be necessary and will become more prominent if
the patient closes his fist tightly.
 At no time may phlebotomists perform

venipuncture on an artery.
 At no time will blood be drawn from the feet.

 Which Is The Best Vein For Venipuncture?
 The median cubital vein lies inside the

cubital fossa anterior to the elbow and is the
most common and easiest site of incision:
 It is not surrounded by large innervation
meaning that the pain is minimal
 It lies very close to skin surface allowing
optimal visibility and less complications.
 First Choice – Median Cubital Vein
 Usually large and palpable (though not always
visible)
 Supported by subcutaneous tissue
 Least apt to Roll
o Second Choice – Cephalic Vein
 Runs down the thumb side of the arm
 Less support and rolls easily
o Basilic Vein often most prominent
 Least Desirable
 Rolls Easily
 Used as last resort
 Preferred Veins –
3 to 4 inches (7.5 to 10.0 cm) above
the venipuncture site
 Maximum Time - One minute
 For
preliminary vein selection – release
and reapply after 2 minutes
 Applied
with enough tension to
compress the vein
 Tying a Tourniquet
 Practice Tying a tourniquet on your
neighbor’s arm
 Finding Veins
 Can you find, see, feel your veins?
 Your neighbor’s veins?
 Cleansing
Method for Routine
Venipuncture
 Alcohol prep pad- using a circular motion
from the center outward
 Allow the area to dry
 If site is touched, the site must be
cleansed again before the needle is
inserted.
 BD Vacutainer Push Button Blood
Collection Set – Butterfly Needles
 Features
 Engineered with a retractable needle
 Push button activation system allows
needle to remain in vein while
depressing button
 Needle will retract automatically from
vein
Always used with a barrel
Twist needle until tight
Winged infusion set – Activate
safety device by pushing button
Warn subjects they will hear a
click
 Attach the appropriate needle to the hub by
removing the plastic cap over the small end of the
needle and inserting into the hub, twisting it tight.
 Remove plastic cap over needle and hold bevel up.
 Pull the skin tight with your thumb or index finger
just below the puncture site.
 Holding the needle in line with the vein, use a quick,
small thrust to penetrate the skin and enter the vein
in one smooth motion at approx 30 degree angle
 Holding the hub securely, insert the first vacutainer
tube following proper order of draw into the large
end of the hub penetrating the stopper. Blood should
flow into the evacuated tube.
 After blood starts to flow, release the tourniquet and
ask the patient to open his or her hand.
When blood flow stops, remove the tube by holding
the hub securely and pulling the tube of the needle.
Check protocol / manual of procedure
 Blood culture vials or bottles, sterile tubes

 Coagulation tube (light blue top) - Routine
PT/PTT may be performed if blue top is first
tube collected. If using butterfly- collect red
top first
 Serum tube with or without clot activator or
silica gel (Red or Gold)
 Heparin tube (Green top)
 EDTA (Lavender top)
 Glycolytic inhibitor (Gray top)
http://www.questdiagnostics.com/dms/Documents/tes
t-center/order_of_draw.pdf
 Place a gauze pad over the puncture site and
remove the needle. Dispose of the syringe and
needle as a unit into an appropriate sharps
container
 Immediately apply slight pressure. Ask the

patient to apply pressure for at least 2 minutes.
 When bleeding stops, apply a fresh bandage,

gauze or tape.
 Label all tubes immediately after collection with
patient's name, medical record, location, date,
time, and your initials. Samples for crossmatch
or type & screen also need the Blood Bank band
number.
 Never prelabel tubes. Do the labeling
immediately after taking the specimen.
 Unlabeled or Improperly Labeled Tubes or
Specimens Cannot be Accepted By the
Laboratory
 All specimens must be sealed inside a plastic
biohazard bag before being transported to the
Laboratory.
 If a blood sample is not attainable
 Reposition the needle.
 Ensure that the collection tube is completely
pushed onto the back of the needle in the hub.
 Use another tube as vacuum may have been
lost.
 Loosen the tourniquet.
 Probing is not recommended. In most cases,
another puncture in a site below the first site
is advised.
 A patient should never be stuck more than
twice unsuccessfully by a phlebotomist.
 If necessary, bring to phlebotomy
 Identifysubject (Name, DOB, MR#)
 Ask subject about
Allergies – latex, iodine,
Problems with fainting, dizziness
Preferred arm
Fasting, Hydration
 Make subject comfortable/feel relaxed
 Wash hands
 Apply gloves
 Apply tourniquet 3-4 inches above site
 Vein selection
 Cleanse with alcohol
 Use Standard Precautions
 Draw blood using standard procedure:
15-30 degree angle, bevel up
 Release tourniquet (1 min – 2 min max)
 Invert tubes 8 times
 Remove needle
 Ask subject to apply pressure
 Discard needles in sharps container
 Label tubes
 Apply tape/bandage over gauze
 Remove gloves
 Wash hands
 Process, Store, Ship blood per
protocol
https://www.youtube.com/watch?v=RKuUPO6NNcU
2D version of the Oakland University School of Health

Sciences blood draw training video. This video contains
entirely original work. Similarity with any other products is
coincidental.
 Hands-on demonstration and supervised
practice on training models
THANK YOU !
 Stabilize extremity
 Vein selection
 Tourniquet application
 Insert needle at 15-30 degree angle, bevel up
 Follow order of draw
 Mixes tubes by inverting 8 times
 Release tourniquet after 1-2 minutes
 Place gauze over site
 Remove needle
 Discard needle/barrel in sharps container
 Ask subject to apply pressure/elevate arm
 Label tubes
 Apply tape/bandage over gauze

Cherie Maguire, MS Research Assistant II Channing Division of Network Medicine The Center For Clinical Investigation

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Cherie Maguire, MS Research Assistant II Channing Division of Network Medicine The Center For Clinical Investigation

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Cherie Maguire, MS

The Center for Clinical Investigation

 Theterm phlebotomy refers to the

 Infection at blood sampling site

 Vasovagal reaction - Syncope, fainting

Hepatitis B Virus (HBV)

Hepatitis C Virus (HCV)

 At no time may phlebotomists perform

 At no time will blood be drawn from the feet.

 The median cubital vein lies inside the

 Maximum Time - One minute

 Blood culture vials or bottles, sterile tubes

 Immediately apply slight pressure. Ask the

 When bleeding stops, apply a fresh bandage,

2D version of the Oakland University School of Health

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