PRINCIPLES OF MEDICAL LABORATORY SCIENCE PROFESSION (LABORATORY)

MODULE 3: VENIPUNCTURE AND TOTAL TESTING PROCESS

PART 1: TOTAL TESTING PROCESS INTERNAL QUALITY CONTROL (IQC) (INTRALAB)

QUALITY MANAGEMENT
• Activities within an institution that guaranteed
• “coordinated activities to direct and control an products/results produced are of quality.
organization with regard to quality” • System for • Set of procedures employed by laboratory staff for
continuously analyzing, improving and reexamining continuous and immediate monitoring of lab work.
resources, processes and services within an organization • • All possible variables that can influence the results are
Primary objective is to achieve the best possible outcome checked against standard for verification.
• address all aspects of laboratory operation to assure o Blank reagent
accuracy and reliability of results. o Control reagent (Positive and Negative control)
• Has two categories: • Allows us to release reliable test results.
o Quality Assurance
o Quality Control
ETERNAL QUALITY ASSESSMENT

QUALITY ASSURANCE • Aka EXTERNAL QUALITY CONTROL OR PROFICIENCY TESTING

• Another party is involved outside of the organization that
• sum of all activities and procedures undertaken by medical assesses the quality of the system/products/results of our
laboratories to improve the quality and clinical usefulness institution.
of laboratory test results. • Check the performance of laboratories.
• includes training of personnel, purchase and • Involved periodic and retrospective evaluation of the
maintenance of equipment and reagents, the analytical performance of the laboratory (proficiency panels)
process itself, and reporting and interpretation of results • Its objective is to establish inter-laboratory comparison.
• Interpretation of results fall on the responsibility of a • Proficiency-testing programs provide samples of
Physician/Clinician UNKNOWN concentration of analytes to participating
o As medical technologists, we still need to know the laboratories.
interpretations of the results, but we cannot tell • PURPOSE: to evaluate the ability of laboratory personnel to
these interpretations to the patient. achieve the correct analysis
• Participation in these programs is usually government
mandated with the premise that acceptable performance
QUALITY LABORATORY SERVICES LEAD TO THE:
indicated proficiency in a patient specimen analysis.
• Establishment of an accurate diagnosis in a patient
• Institution of appropriate treatment
NEQAS (National External Quality Assessment Schemes)
• Proper assessment of prognosis
• Confirmation of successful treatment Research Institute for Bacteriology, Myco-VIro, TB,
• Detection of the source of infection (environmental Tropical Medicine Parasitology, BLOOD UNITS
analysis) Lung Center of the
Clinical Chemistry
• Early diagnosis of an outbreak or an epidemic Philippines
• Tracing of the spread of infection to control it National Kidney and
Hematology
• Identification of the role of the environmental factors Transplant Institute
San Lazaro Hospital
HIV, HBV, SYP, HCV
QUALITY CONTROL (STD AIDS Cooperative Generally, all STIs are sent
Central Laboratory) here
• Used to monitor the analytical process to ensure that the
test results meet their quality requirements.
• Primary quality characteristic that is monitored is the
deviation of an analytical measurement from the expected
or true values/results.
• Has two components:
o Internal Quality Control
o External Quality Assessment

Cis and Trans | BSMT 2B&C

 INTERNATIONAL LABORATORY STANDARDS PATIENT IDENTIFICATION

ISO 9000-QMS • Diet restrictions (fasting, water intake)

• Special cases (Dialysis px, Diabetic px, Medications, etc.)
• International Organization for Standardization • Knock, greet, introduce self and department and the
purpose.
Clinical Laboratory Standards Institute (CLSI)
• Correct patient identification is crucial in ALL phases of
• Follow by the Philippines examination.
• 2022 National Patient Safety Goals suggests "at least 2
Other Standards followed by the PH: identifiers."
o Name, age, or birthdate
• ISO 15189:2012 - standard followed by all clinical
o Address and ID number
laboratories.
o Driver’s license or any ID
• ISO 17025: 2017 - standard followed by all testing and
o Hospital registration number (arm band or
calibrating laboratories.
bracelet)
• If a patient is identified by nurse/guardian: document the
one who confirmed the identity.
TOTAL TESTING PROCESS
• Room number or bed number SHOULD NEVER be used as

• Multistep process that begins and ends with the needs of identifier.

the patient. • Do not show the requisition slip prior to identity

• Series of steps that allows careful planning using confirmation

interdisciplinary team and principles to improve the overall • Do not base identity on records or charts.

process in the clinical laboratory and provided the optimal • Never collect specimen from a patient whose identity has

patient care. not been confirmed.

• Provides a comprehensive working model for evaluating

the components of a laboratory's efficiency in testing.
ERRORS IN THIS STEP CAN LEAD TO:

• Loss of life from Acute Hemolytic Transfusion

PHASES OF TOTAL TESTING PROCESS:
• Delayed diagnosis

• Pre-analytical • Treatment of wrong patient for the wrong disease

• Analytical
• Post-Analytical
PATIENT ASSESSMENT AND PHYSICAL DISPOSITION

ASSESS THE IDENTIFIED PATIENT WITH THE FOLLOWING:

a. Age and Gender

b. Geographic location like altitude, temperature and
humidity
c. Body position (Sitting, Standing, Lying)
d. Diet and dehydration
e. Diurnal/Circadian Variations
f. Drug therapy
CATEGORIES OF PRE-ANALYTICAL

Basal State OTHER FACTORS THAT MAY AFFECT PATIENT' PRE-ANALYTICAL

VARIABLES:
• Resting metabolic state of the body in the morning after
fasting for approximately 12 hours. • Physiological conditions like exercise, fever, jaundice and
pregnancy
• Smoking
Pre-analytical or Pre-examination Phase • Jaundice - yellow discoloration of the skin and mucus
membranes due to bilirubin.
• Begins when a test is ordered and ends when the testing
begins

Cis and Trans | BSMT 2B&C

 SPECIMEN COLLECTION QUALITY CONCERNS:

• Identify which type of collection you need to do. • Hemoconcentration

• Check for an problem sites and VADs (Vascular Access • Partially filled tubes
Devices • Specimens Contamination
• Blood Specimens • Wrong/expired collection tubes
o Venipuncture • Turbidity (Lipemia)
o Capillary puncture • Hemolysis
• Non-blood specimen: • Icteric serum/plasma
o Urine
o Stool CAUSES OF HEMOLYSIS:

o Other body fluids (CSF, Peritoneal etc..)

• Equipment choice is not based on the patient's vein
• Syringe pulled too fast
PROBLEM SITES DURING BLOOD COLLECTION: • Prolonged tourniquet application
• Improper angle of needle
• Burns, scars, and tattoos - risk of contamination • Alcohol has not dried
• Damaged veins - you cannot get blood from exact same • Tube shaken vigorously
spot from previous blood collection site. • Improper handling and transport of specimen
• Edema - lymph fluid in the intradermal area
• Hematoma and Bruises
• Mastectomy - removal of breasts PART 2: VENIPUNCTURE

• Obesity – either veins are too deep or too superficial.

• The process of collecting or drawing blood from a vein
• Vascular Access Devices
• The most common way to collect blood specimen
o Arteriovenous shunt, fistula or graft
o Syringe
o NEVER collect blood from a patient with fistula
o Butterfly
• Heparin or Saline lock
o Evacuated Tube System
• Intravenous sites
• Previously active IV site Phlebotomy
• Central venous access devices
• Umbrella term
• Venipuncture and Arterial puncture
PATIENT COMPLICATIONS AND CONDITIONS • describes the act of removing blood from a patient using a
needle. This can be for the purposes of laboratory testing
• Allergies to equipment and supplies
as a diagnostic tool
• Excessive bleeding or pain during/after collection
• Fainting or Syncope Phlebotomist
• Nausea and vomiting
• Petechiae and Purpura • a medical professional who is trained to perform blood
draws on children and adults.

PROCEDURAL ERROR RISK SYRINGE METHOD

• Traditional and common method in venipuncture

• Hematoma Formation
• Iatrogenic anemia ADVANTAGES:
• Inadvertent arterial puncture
• Infection • Suited for fragile veins
• Nerve injury • Phlebotomist can be able to control the pressure when
• Reflux of additive drawing blood

DISADVANTAGE:
SPECIMEN QUALITY CONCERNS
• Pose hazards because of the extra step involved in
Plasma Serum transferring specimen from syringe to tubes
is the liquid, cell-free part of is the liquid after • Delay may cause clotting
blood that has been treated coagulation of blood • Carry over of additives
with anticoagulant No fibrinogen and other
clotting factor

Cis and Trans | BSMT 2B&C

 PARTS OF A SYRINGE STEPS IN VENIPUNCTURE

• Divided into two parts: Needle and Syringe

NEEDLE

HUB

• It starts with hub where the needle attaches to the syringe

via a screw type mechanism
• It is where the backflow of blood is observed when
1. Test requisition
performing venipuncture
- Never collect from a patient without requisition form.
• Note: Backflow is an indicator at which you already have
2. Greeting the Patient
entered the vein of the patient.
3. Patient Identification
SHAFT 4. Patient Preparation
5. Tourniquet applications & Cleansing
• Equivalent to the actual length of the needle
6. Equipment selection and assembly
• Metal’s length starting from the hub going to the bevel
7. Performing the venipuncture

BEVEL 8. Disposal of needle

9. Transferring of specimen
• Slanted end of the needle 10. Labeling
- Labeling contains the ffg but not limited to
LUMEN/BORE
o Full name of p
o Age & Se
• Hollow space within the needle
o Date of Extractio
• Determines the thickness/gauge of the hole or of the
o Time of Extractio
needle itself
o Initial of phlebotomis
• It’s the one measured: 21 ,22, and so on gauges
o Laboratory Tests requeste
o Px identification (if in-patient)
SYRINGE 11. Disposing used supplies

• It has two parts : Graduated barrel and Plunger.

GRADUATED BARREL

• Holds the fluid being contained in the syringe

• Holds the fluid being aspirated or administered
• Measured in cubic centimeters (cc) or milliliters (mL)

PLUNGER

• Rod-like device that creates a vacuum inside the syringe

when being pulled so thus fills the syringe with the fluid
being aspirated
• Rod-like device that fits tightly into the barrel. Pulling on the
plunger creates a vacuum,

Cis and Trans | BSMT 2B&C

TROUBLESHOOTING A FAILED VENIPUNCTURE

• Tube position
• Needle position
• Collapsed vein
• Tube Vacuum

POINTS TO REMEMBER:

• Be attentive to the fill rate and volume

• Proper Labeling
• Optional information: specimen type, test requested, room
number
• Never pre-label tubes
• Avoid using cotton after venipuncture.
• Do patient assessment after venipuncture.

SPECIMEN REJECTION

• Discrepancy in requisition and labelled tubes

• Illegible or identity lacking
• Inadequate volume
• Hemolyzed, wrong collection tubes, improper
transportation, clotted specimens
• Patient not following diet restrictions
• Wrong timing of collection

Cis and Trans | BSMT 2B&C