Prioritizing safety in phlebotomy: An overview of best practices

Safety is an important concern for both patients and phlebotomists (and other healthcare providers who perform blood draws). Many avoidable errors that pose significant risks to the patient and the phlebotomist can occur during the collection and handling of blood specimens. When standards aren’t implemented, it becomes more likely that patients will be injured, biologically representative specimens won’t be obtained from patients, and test results won’t be comparable from one facility to another.¹ Throughout this article, “must” is used to indicate a requirement to be followed in order to conform to the standard and from which no deviation is permitted, while the term “should” allows for user discretion.

Each year, specimen collection personnel who deviate from the standard for the phlebotomy procedure injure patients. Some of the most frequent mistakes that can lead to a breach in patient safety are as follows:²

• Misidentifying the patient/mislabeling the specimen
• Probing instead of surrendering to a missed vein
• Attempting to draw blood from the first vein found
• Disregarding patient-reported shooting pain during blood draw
• Bandaging in a hurry/not applying pressure to the blood draw site following the procedure
• Drawing from an artery
• Turning ones back on a patient
• Improper positioning of the patient
• Drawing from unorthodox sites

Implementation of a quality management system (QMS) (now referred to as a management system [MS] by ISO) is required for a laboratory to fulfill quality objectives.³ The MS can be divided into 12 quality system essentials (QSEs), which are the foundational building blocks that support the laboratory’s path of workflow.⁴

Facilities and safety for phlebotomy

QSE “Facilities and Safety Management” relates to the laboratory’s physical environment and the maintenance and safety programs needed to support it. The facility must ensure that the physical environment for venipuncture procedures and the safety program reflect MS requirements. Facilities must have a policy that includes the disinfection of phlebotomy trays and carts, equipment, and outpatient collection stations on a scheduled basis and, at minimum, whenever contaminated with visible blood or other potentially infectious material.

Specific requirements and recommendations for QSE “Facilities and Safety” for phlebotomy follow.

Hand hygiene

When performing phlebotomy, always change gloves between patients, when glove integrity has been compromised, or when gloves become visibly contaminated. The room should have facilities to allow the phlebotomist to wash their hands between patients.¹ Wash hands with soap and water after glove removal and before donning new gloves. Hands should also be washed at the following times:⁵

• After touching potentially infectious materials.
• After removing gloves.
• After the completion of work (e.g., when completing procedures in one laboratory area and moving to another area to perform different work).
• Before leaving the laboratory.
• Before eating, drinking, smoking, applying makeup, applying lip balm, changing contact lenses.
• Before and after using lavatory facilities.

Venipuncture chairs 

Venipuncture chairs should be designed for the maximum comfort, accessibility, and safety of the patient and phlebotomist. Both armrests of the chairs should be adjustable so the best venipuncture position for each patient can be achieved. Chairs without arms do not provide adequate support for the arm or protect fainting patients from falls and must not be used. If the chair has wheels, the chair must be secured to prevent movement during the procedure.¹

Phlebotomy area

The collection area must be set up to facilitate patient monitoring throughout the procedure. In addition, the following elements should be considered when designing the phlebotomy area:¹

• A central desk should be considered to serve as a dedicated area for processing daily and future test requests. It should contain a telephone system for handling emergency test request calls, including a paging system for contacting any phlebotomist who is collecting specimens outside the central area. The central desk may also be used to greet patients and to enter their information into the paper or electronic database.
• Phlebotomists should perform venipuncture in a clean, well-lit, quiet, and private environment. Reasonably soundproof rooms for pediatric patients should be considered.
• Work benches and tables should be set up in an ergonomic manner for the phlebotomist to function with minimum physical stress. Supplies should be placed within reach.
• The storage area should be large enough to accommodate necessary supplies.
• Counter space should be adequate and clean for efficient specimen sorting, labeling, and handling.
• The reception and collection areas should be designed for maximum protection of patient privacy and confidentiality.

Accessibility

Facilities should be designed and furnished to accommodate any patient. Considerations need to reflect regional guidelines and standards. The following considerations are highly recommended:⁶  

• Allow or make modifications to policies, practices, and procedures to make healthcare services fully available to individuals with disabilities.
• Remove physical barriers to services when possible. If not possible, offer adequate services without barriers to ensure safe delivery of specimen collection services in an alternate setting or location. 
• When redesigning and building new facilities, it is recommended that applicable regional guidelines and standards regarding accessibility be consulted.

The facility should have the following:

• An entrance of sufficient width to allow access to the outpatient phlebotomy area.
• A clear path to the collection station.
• Adequate space on either side of the phlebotomy chair, wheelchair, stretcher, table, etc., to allow for safe and effective transfers and collection of blood specimens. Do not place a phlebotomy chair, wheelchair, or table against a wall in such a way that it prohibits access to one side of the patient. 
• Suitable devices, such as a mobile phlebotomy chair arm for wheelchair-bound patients, to ensure an adequate and safe surface to complete the procedure.
• A minimum space of 30 inches (76 cm) wide and 48 inches (122 cm) deep on one side of the phlebotomy chair (e.g., accessible to a patient on crutches). 
• Sufficient turning space in the phlebotomy area or room for a patient in a wheelchair to make a 180° turn.
• At least one bariatric-size chair for patients who need additional space. 
• Reclined or reclining furniture in the vicinity to lay a patient in a recumbent or semirecumbent position due to syncope risk. In large outpatient collection centers, two recliners or a suitable alternative are recommended in case one is occupied. 
• Hydraulic chairs to raise and lower patients to adequate height, which may help prevent back problems for the phlebotomist. 
• Wedges, blankets, pillows (with disposable case), and other devices that may be helpful in positioning a patient.
• Phlebotomy chairs with movable arms and reticulating surfaces to help move patients to and from the chair.

Conclusion

Many avoidable errors can occur during the collection and handling of blood specimens. Following established standards can reduce these errors and improve safety for patients and phlebotomists.

References

1.   CLSI.  DOCPROPERTY "DOCTITLE"  \* MERGEFORMAT Collection of Diagnostic Venous Blood Specimens. 7th ed. CLSI standard  DOCPROPERTY "DOCNUMBER"  \* MERGEFORMAT GP41. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.

2.   Phlebotomy-Related Injuries: is your next patient at risk? Center for Phlebotomy Education. https://www.phlebotomy.com/phlebotomy-related-injuries.html. Accessed June 15, 2023.

3.   ISO. Medical laboratories – Requirements for quality and competence. ISO 15189. Geneva, Switzerland: International Organization for Standardization; 2022.

4.   CLSI. A Quality Management System Model for Laboratory Services. 5th ed. CLSI guideline QMS01. Wayne, PA: Clinical and Laboratory Standards Institute; 2019.

5.   CLSI. Protection of Laboratory Workers From Occupationally Acquired Infections; Approved Guideline—Fourth Edition. CLSI document M29-A4. Wayne, PA: Clinical and Laboratory Standards Institute; 2014.

6.   US Department of Justice. 2010 ADA Standards for Accessible Design.

http://www.ada.gov/regs2010/2010ADAStandards/2010ADAStandards.pdf. Accessed June 15, 2023.