Pre-analytical Consideration and

Venipuncture Complications
Pre-analytical Consideration
According to the CLSI, a
standardized
venipuncture procedure
can reduce or eliminate
errors that can affect
sample quality and
patient test results.
Requisition Form
▪ All phlebotomy procedures begin with the receipt of a test requisition form
that is generated by or at the request of a health-care provider.
▪ The requisition becomes part of the patient’s medical record and is
essential to provide the phlebotomist with the information needed to
correctly identify the patient, organize the necessary equipment, collect
the appropriate samples, and provide legal protection.
▪ Phlebotomists should NOT COLLECT A SAMPLE WITHOUT A REQUISITION
FORM.
▪ Phlebotomists should carefully examine all requisitions for which they are
responsible before leaving the laboratory.
Manual Requisition Computer Generated Form (Bar Code)
Requisition Form
The required information on a requisition includes the following:
▪ Patient’s first and last names.
▪ Identification Number (In-patient: hospital-generated; in an
outpatient setting it may be a laboratory-assigned number.)
▪ Patient’s date of birth.
▪ Patient’s location.
▪ Ordering health-care provider’s name.
▪ Tests requested.
▪ Requested date and time of sample collection.
▪ Status of Sample (Stat, Timed, Routine).
Requisition Form
The required information on a requisition includes the following:

▪ Other information that may be present includes the following:

Number and type of collection tubes
Special collection information (fasting sample or latex sensitivity)
Special patient information (areas that should not be avoided)
Billing information
Greeting the Patient
▪ A phlebotomist’s professional demeanor instills confidence and trust in
the patient, which can effectively ease patient apprehension about the
procedure.
▪ When approaching patients, phlebotomists should introduce themselves,
say that they are from the laboratory, and explain that they will be
collecting a blood sample.
▪ The procedure must be explained in nontechnical terms and in a manner
the patient can understand.
▪ The more relaxed and trusting your patient, the greater chance of a
successful atraumatic venipuncture.
Greeting the Patient
▪ Observe any signs on the patient’s
door or in the patient’s room
relaying special instructions, such as
Allergic to Latex, Nothing by Mouth
(NPO), Do Not Resuscitate (DNR),
Do Not Draw Blood from (a
particular) arm, Infection Control
Precautions, or Patient Expired.
Greeting the Patient
Special Situation
▪ Should be gently awakened and given time to become oriented
and have their IDENTITY VERIFIED before the venipuncture is
Sleeping performed and secure their INFORMED CONSENT.
Patients ▪ Blood collection from a SLEEPING PATIENT may result in
identification errors or physical injury to the patient and result in a
charge of assault and battery (Informed Consent).
▪ Unconscious patients should be greeted in the same manner as
Unconscious conscious patients.
Patients ▪ In this circumstance, nursing personnel are often present and can
assist with the patient, if necessary.
Greeting the Patient
Special Situation
▪ It is usually preferable to have a nurse assist with patients on the
psychiatric unit.
▪ These patients are often anxious about the venipuncture procedure
Psychiatric Units and feel more comfortable when a caregiver with whom they are
familiar is present.
▪ Be sure to place blood collection equipment away from the
patient.
▪ Physicians, members of the clergy, and visitors may be present when
the phlebotomist enters the room.
Physicians,
▪ When the physician or clergy member is with the patient, it is
Clergy, Visitors preferable to return at another time, unless the request is for a stat
or timed sample.
Greeting the Patient
Special Situation
▪ Patients are not always in the room when the phlebotomist arrives.
▪ The phlebotomist should attempt to locate the patient by checking
with the nursing station.
▪ If the sample must be collected at a particular time, it may be
Unavailable
possible to draw blood from the patient in the area to which he or
Patient she has been taken.
▪ If this is not possible, the nursing station must be notified and the
appropriate forms completed so that the test can be rescheduled.
▪ The requisition form is usually left at the nursing station.
Patient Identification
▪ The most important procedure in phlebotomy is correct identification of
the patient.
▪ Serious diagnostic or treatment errors and even death can occur when
blood is drawn from the wrong patient.
▪ The Clinical and Laboratory Standards Institute (CLSI) recommends two
identifiers for patient identification.
▪ To ensure that blood is drawn from the right patient, identification is made
by comparing information obtained verbally and from the patient’s wrist
ID band with the information on the requisition form.
Patient Identification
▪ Discrepancies between the patient’s ID
band the requisition must be verified
before blood is drawn. It is estimated
that 16 percent of ID bands contain
erroneous information.
▪ CLSI requires that a caregiver or family
member must provide information on a
cognitively impaired patient’s behalf
before collecting the sample. Document
the name of the verifier.
 Bar Code Technology
▪ Positive patient identification can be made
using barcode technology.
▪ Using a wireless hand-held computer, the
phlebotomist positively identifies the
patient by scanning the bar code on the
patient’s hospital ID band.
▪ The system, which is interfaced with the
laboratory information system (LIS).
Patient Identification
Special Situation
▪ The phlebotomist must contact the nurse and request that the
patient be banded before the drawing of blood.
Missing ID ▪ The nurse’s signature on the requisition form verifying identification
Band should be accepted in only emergency situations or according to
hospital policy.
▪ Patients in psychiatric units often do not wear an identification band.
Unidentified ▪ Both the temporary and permanent identification band must be
Emergency attached to the patient and confirmed before blood may be
collected.
Department
Patients
Patient Identification
Special Situation
▪ Ask the patient’s nurse, relative, or a friend to identify the
Identification of patient by name, address, and identification number or date of
Young, Cognitively birth.
Impaired, or ▪ Document the name of the verifier.
Patients Who Do ▪ This information must be compared with the information on the
requisition and the patient’s identification band.
Not Speak the
▪ Any discrepancies must be resolved before collecting the sample.
Language
Patient Preparation
▪ The pre-examination stage of laboratory testing involves
processes that occur before testing of the specimen.
▪ Errors that occur during this stage often happen during blood
collection and are primarily controlled by the phlebotomist.
▪ The phlebotomist should also be able to recognize various
patient conditions and complications that may occur during or
after blood collection.
Patient Preparation
▪ Numerous pre-examination variables associated with the patient’s
activities before sample collection can affect the quality of the
sample.
▪ Variables: Diet Posture Exercise
Stress Alcohol Smoking
Time of Day Medications Fever
▪ Physiological Variables: Age Dehydration Pregnancy
Altitude Gender Malnutrition
Patient Preparation
B A S A L S T A T E
▪ It refers to an early morning condition before the patient has
eaten or become physically active.
▪ This is a good time to draw blood specimens because the body is
at rest and food has not been ingested during the night.
▪ Normal values (reference ranges) for laboratory tests are
determined from a normal, representative sample of volunteers
who are in a basal state.
 Major Tests Affected by Patient Pre-examination Variables
Variables Increase Values Decrease Values
Glucose, Triglycerides, AST,
Non- Bilirubin, BUN, Phosphorus, Uric
fasting Acid, Growth Hormone,
Cholesterol, HDL, LDL
Prolonged Bilirubin, Ketones, Lactate, Fatty Glucose, Insulin,
Fasting Acids, Glucagon, and Triglyceride Cholesterol
Recent Glucose, Insulin, Triglycerides, Chloride, Phosphorus,
Food Ionized Calcium & Gastrin potassium, Amylase & ALP
Ingestion
 Major Tests Affected by Patient Pre-examination Variables
Variables Increase Values Decrease Values
Albumin, aldosterone, bilirubin,
Posture calcium, cortisol, enzymes,
cholesterol, TAGs, RBCs, WBCs
Creatinine, fatty acids, lactate, AST, Arterial pH and PCO2
Short-term CK, LDH, uric acid, bilirubin, HDL,
exercise hormones, aldosterone, renin,
angiotensin, WBCs
Long-term Aldolase, creatinine, sex
exercise hormones, AST, CK, and LD
 Major Tests Affected by Patient Pre-examination Variables
Variables Increase Values Decrease Values
Adrenal hormones, aldosterone, Serum iron and PCO2
Stress renin, TSH, GH, prolactin, PO2,
and WBCs
Glucose, aldosterone, prolactin, Testosterone
cortisol, cholesterol, TAGs, LH,
Alcohol catecholamine, AST, ALT, Mean
Corpuscular Volume (MCV), HDL,
and iron
 Major Tests Affected by Patient Pre-examination Variables
Variables Increase Values Decrease Values
Fatty acids, hormone levels,
Caffeine glycerol, lipoproteins, and serum
gastrin
Glucose, BUN, TAGS, cholesterol, Immunoglobulins IgA,
ALP, catecholamines, cortisol, IgG, IgM
Smoking hemoglobin, hematocrit, RBCs,
and WBCs
Altitude RBCs, hemoglobin, and hematocrit
 Major Tests Affected by Patient Pre-examination Variables
Variables Increase Values Decrease Values
Age Cholesterol and triglycerides Hormones
Protein, ALP, estradiol, free
Pregnancy fatty
Calcium, coagulation factors,
Dehydration enzymes, iron, RBCs, and
sodium
ACTH, Cortisol, iron & Eosinophils, creatinine, TAGs
Diurnal Variation (A.M.) aldosterone
Diurnal Variation (P.M.) ACP, GH, PTH, TSH
Major Tests Affected by Patient Pre-examination Variables
Variables Increase Values Decrease Values
ketones, bilirubin, lactate, and
triglycerides and decreased
Malnutrition glucose, cholesterol, thyroid
hormones, total protein, and
albumin
insulin, glucagon, and cortisol
Fever levels.
 Major Tests Affected by Patient Medication
Medication Affected Test
Acetaminophen and certain Elevated liver enzymes and bilirubin
antibiotics
Cholesterol-lowering drugs Prolonged PT and APTT
Elevated BUN, creatinine, and electrolyte
Certain antibiotics
imbalance
Corticosteroids and Elevated amylase and lipase
estrogen diuretics
Increased calcium, glucose, and uric acid and
Diuretics
decreased sodium and potassium
 Major Tests Affected by Patient Medication
Medication Affected Test
Chemotherapy Decreased RBCs, WBCs, and platelets
Aspirin, salicylates, and Prolonged PT and bleeding
herbal time supplements
Radiographic contrast media Routine urinalysis
Fluorescein dye Increased creatinine, cortisol, and digoxin
Decreased apoproteins, transcortin,
Oral contraceptives cholesterol, HDL, triglycerides, LH, FSH,
ferritin, and iron
 Major Tests Affected by Technical Variation

Variables Increase Values Decrease Values

Prolonged Tourniquet Albumin, Enzymes, Lactate,
Application Cholesterol, K, TP, AST, Bilirubin
K, Ammonia, Phosphate, Iron,
Hemolysis
Mg, ALT, AST, LD, ALP, CK
IM Injection Creatinine Kinase, LDH
Cleansing Agents Phosphorus, Uric Acid &
(Betadine) Potassium (
Site Selection
▪ The preferred site for venipuncture is the antecubital fossa
located anterior and below the bend of the elbow.
▪ Three major veins— the median cubital, the cephalic, and the
basilic—are located in this area and, in most patients, at least one
of these veins can be easily located.
▪ Vein patterns vary among individuals. The most often seen
arrangement of veins in the antecubital fossa are referred to as
the “H-shaped” and “M-shaped” patterns.
SPECIAL SITUATIONS IN PHLEBOTOMY
 SPECIAL SITUATIONS IN PHLEBOTOMY
Discontinue IV for 2 minutes
IV Line on both
Collect sample below the IV site
Arms
Initial sample (5mL) → discard
Increased:
Glucose (10% contamination w/ 5% dextrose →
I Increased blood glucose by 500 mg/dL)
IV Fluid Chloride, Potassium, Sodium
Contamination
Decreased:
Urea, Creatinine
COMPLICATIONS OF BLOOD SAMPLE
COLLECTION
 COMPLICATIONS OF BLOOD SAMPLE COLLECTION
A. Immediate Local Complications
1. Localized Hemoconcentration or Venous stasis
▪ Increased in the proportion of formed elements in the blood
due to prolonged application of tourniquet
▪ Remedy: One minute application of tourniquet
2. Syncope or Fainting
▪ Due to sudden decrease of blood supply to the brain
▪ Remedy: Let the patient lie down, Give spirit of ammonia
 COMPLICATIONS OF BLOOD SAMPLE COLLECTION
B. Delayed Local Complications
1. Thrombosis of Veins
▪ Formation of blood clots inside the lumen of the vein due to
trauma
2. Thrombophlebitis
▪ Inflammation of the vein due to thrombus as manifested by an
inflammatory reaction on the outer skin surface
3. Hematomas
▪ Blue or black skin discoloration commonly due to repeated
trauma or puncture of the veins.
Hematomas
Errors in technique that cause blood to
leak or be forced into the surrounding
tissue and produce hematomas include:
1. Failure to remove the tourniquet before
removing the needle.
2. Applying inadequate pressure to the site
after removal of the needle.
3. Bending the arm while applying
pressure.
4. Excessive probing to obtain blood.
Hematomas
Errors in technique that cause blood to leak
or be forced into the surrounding tissue and
produce hematomas include:
5. Failure to insert the needle far enough into
the vein.
6. Inserting the needle through the vein.
7. Selecting a needle too large for the vein.
8. Using veins that are small and fragile.
9. Accidentally puncturing the brachial artery
 COMPLICATIONS OF BLOOD SAMPLE COLLECTION
C. General Delayed Complications
1. Serum Hepatitis/HBV
2. HIV/AIDS

PREVENTION:
Use of disposable syringe or vacutainer set (Follow the
procedures from the Universal Precautions in handling
infectious specimens).
 GUIDELINES FOR
SPECIMEN HANDLING
AND PROCESSING
SPECIAL TEST REQUIREMENTS
BLOOD SAMPLES
Guidelines for Specimen Handling and Processing
▪Transport blood specimens carefully to avoid hemolysis.
▪Protect tubes for bilirubin, carotene from light.
▪Transport samples for ACTH, lactic acid, ammonia, blood
gases in ice slurry.
▪Maintain tubes in vertical position to promote complete
clotting.
Guidelines for Specimen Handling and Processing
▪Allow serum and gel separator tubes to clot for 30-60 min
before centrifugation to avoid fibrin strands.
▪Centrifuge within 2 hours of collection.
▪Spin most tubes at 1,000-1,300 RCF for 10-15 min.
▪Spin citrate tubes at 1,500 RCF for 15 min to produce
platelet-poor plasma.
Guidelines for Specimen Handling and Processing
▪Don’t re-spin primary tubes. Can cause hemolysis. If re-
centrifuging is necessary, transfer serum/plasma to
another tube.
▪Keep tubes capped during centrifugation to avoid loss of
CO2, change of pH, evaporation, or aerosol formation.
Guidelines for Specimen Handling and Processing
▪Don’t re-spin serum separator tubes. Serum in contact
with RBC’s under gel can be expressed and increased
potassium
▪Separate serum or plasma from cells within 2 hour of
collection (exception: centrifuged gel tubes)
▪When transferring samples to secondary containers,
aspirate to avoid cellular contamination. Don’t pour.
Guidelines for Specimen Handling and Processing
▪Separated serum/plasma may be kept at RT for 8 hr or
at 2-8 deg celsius for 48 hours. For longer storage,
freeze at -20 deg celsius. Avoid repeated freezing and
thawing.
▪Lipemic specimens can be ultracentrifuged at 105 x g
to remove chylomicrons (triglycerides).
▪Don’t freeze whole blood
PHLEBOTOMY SOURCES OF ERROR
 PHLEBOTOMY SOURCES OF ERROR

LIPEMIA OR LACTESCENSE/Milky or Lipemic Plasma

▪ occurs when blood samples are obtained 1-2 hours after eating a fatty meal
▪ It causes interference with large number of chemical analyses because of
turbidity. (Amylase, Bilirubin, Protein).
EXAMPLES OF CRITERIA FOR SPECIMEN REJECTION
1. Unlabeled or mislabeled samples.
2. Inadequate volume and collection in the wrong tube and outdated
blood tube.
3. Hemolysis, Lipemia, Clotted blood in an anticoagulant tube
4. Improper handling during transport, such as not chilling the sample
5. Samples without a requisition form.
6. Contaminated sample containers
7. Delays in processing the sample.
TECHNICAL ERROR FOR FAILURE TO COLLECT BLOOD
TECHNICAL ERROR FOR FAILURE TO COLLECT BLOOD