Good Laboratory Practice

Tanveer Tara ,Lecturer MLT ,SUIT 1

Phlebotomy
Practical
For
Medical laboratory
TECHNOLOGY
3RD semester

Objectives
• Theory and practice of phlebotomy
• How to interact professionally with patients
• Occupational health hazards and appropriate
precautions
• Phlebotomy equipment and supplies
• Phlebotomy procedures
• Complications of venipuncture and how to handle
them.
• Summary

Theory and Practice of Phlebotomy

What is phlebotomy
• The term phlebotomy refers to the ancient
practice of bloodletting
• Now the term phlebotomy is used for the
withdrawal of blood from a vein, artery, or the
capillary bed for lab analysis or blood
transfusion.
1 Tanveer Tara ,Lecturer MLT ,SUIT 5

Who is a phlebotomist
• Other medical professionals, including
doctors, nurses, technologists, and medical
assistants must also be trained to collect
blood specimens.

What can do phlebotomist
• Collects blood and other specimens
• Prepares specimens for testing
• Interacts with patients & health care
professionals
• plays a vital role in any health care system

My Point of View
• A Medical Technologist / medical field related
person should be competent Phlebotomist

Laboratory work flow cycle

Laboratory Workflow Cycle

Professionalism

Confidentiality
• All employees are responsible for maintaining
confidentiality of medical information

Attitude
• Tone of voice and facial expression will
determine how patients respond to you.
• Always be polite, friendly, calm, and
considerate.

Appearance
• Your personal appearance will also affect the
impression you make. Professional dress.
• Comply with your facility’s dress code and
personal appearance policies.

Safety
Micro-organisms
bloodborne pathogens
contaminated body fluids.

Blood-Borne Pathogens
• Infectious micro-organisms which live in the
bloodstream.
• You can be exposed to bloodborne pathogens
if you are injured with a contaminated needle.
• You can also be exposed if your mucous
membranes, including eyes, mouth, or the
inside of your nose come into contact with
contaminated body fluids.

Training
• Standard Precautions
• Personal Protective Equipment
• Hand Washing
• Hazardous waste disposal
• Needle sticks and prevention act

Standard Precautions

• Potentially infectious body fluids include:
Blood, Semen, Vaginal Secretion, fluids, and
Saliva
• Sweat and tears are not generally considered
infectious.

Personal Protective Equipment

Personal Protective Equipment
• lab coat
• Gloves
• Spectacles
• Face masks ( certain types of isolation)

Hand Washing
• Hand washing is the single most important
infection control measure.
• Wash hands thoroughly before, after, and
between all patient contacts.
• using a paper towel to avoid contamination.

Where to wash

Hand washing
• Remove rings
• Stand by the sink but do not touch it
• Apply soap and rub hands together
• Both sides of the hand, between fingers,
under fingernails
• Rinse hands in a downward motion
• Dry hands with a clean paper towel
• Turn off water with another paper towel

Needlestick

Needle stick Injury
Expose the wound
Cover the wound
Express the wound
Flush Wound for 5 minutes
ReportforMedicalAssistance
Doff Normally
Logandreporttheincident

Hazardous waste disposal
• All needles & other
sharps must be
disposed of in approved
sharps disposal
containers.
• Other contaminated
waste must be
discarded in an
appropriate biohazard
bag.

Medical Waste Disposal

Color Coding

Different Waste Disposals
Container

Waste hazardous Used in KPK

Incineration
The incineration technology used a high
temperature thermal process that can
convert inert material and gases with the
combustion process. It will process the
waste to convert into ash, gas, and heat.

Blood Clot
• When a blood sample is
left standing without
anticoagulant, it forms a
coagulum or blood clot.
• The clot contains
coagulation proteins,
platelets, and
entrapped red and
white blood cells.

Plasma
Blood containing
anticoagulant and
centrifuged ,the above
liquid portion is called
Plasma.

Serum
When a blood
sample is left
standing without
anticoagulant and
centrifuged ,the
above liquid
portion is called
Serum

Equipment

Trays
• Trays should be sanitized
daily using appropriate
disinfectant
• Kept Organized and well-
stocked.

Blood Collection tubes
• glass or plastic tube
with a rubber stopper.
• It has a vacuum so that
blood will flow into the
tube.
• anticoagulants and/or
other chemical
additives.

Blood collection tubes
• Rubber stoppers of
blood collection tubes
are color coded.
• Each type of stopper
indicates a different
additive or a different
tube type.

LAVENDER
• EDTA to prevent clotting
• hematology studies.
• Must be inverted after
filling.
• Should be filled up to
mark

Sizes
• Adult:3 - 10 ml
• Pediatric 2 - 4 ml.
• Tubes for fingersticks or
heelsticks ½ or less

LIGHT BLUE
• sodium citrate.
• coagulation (clotting)
studies.
• Should be filled up to
mark
• must be inverted
immediately after filling

GREEN
• sodium or lithium
heparin
• for tests requiring
whole blood or plasma
such as ammonia

RED
• No additives
• Blood bank tests,
toxicology, serology
• Must not be inverted
after filing

GRAY
• Inhibitor for glycolysis +
anticoagulant
• Sodium Fluoride
+potassium oxalate.
• glucose levels.

YELLOW
• Acid citrate dextrose
• Inactivates
complements
• DNA studies, paternity
testing

ROYAL BLUE
• heparin or Na EDTA
anticoagulants
• Tube is designed to contain
no contaminating metals
• Trace element and
toxicology studies

Blood Culture Bottles
• Different blood culture
bottles are used for
aerobic, anaerobic, and
pediatric collections.

Blood collection tubes: Safety
• The rubber stopper is
positioned inside the
plastic shield

Order of draw

Expiration Dates

Needle Syringe11

Syringes with built-in safety devices

Needles

Needles
• Different sizes.
• size =gauge.
• The larger the needle, the smaller the gauge
number.
• 21 or 22 gauge needle is mostly used.

Single Draw Needle
• Single draw needles are
of the type that fit on a
syringe, and can be
used only to fill the
syringe to which they
are connected.

Multiple Draw Needle
• Used with vacuum
collection tubes.
• They have a retractable
sheath over the portion
of the needle that
penetrates the blood
tube.

Butterfly Needle
• Winged infusion set
• Difficult venipunctures
including pediatric
draws
• with a syringe or a
holder and vacuum
collection tube system.
• 21, 23, or 25 gauge.

Lancets
• Lancets are used for
difficult venipunctures,
including pediatric
draws.

Tourniquets
• Vein easier to SEE, FEEL,
and PUNCTURE

Sterilization

Bandaging Material

Gloves
• Gloves must be worn
for all procedures
requiring vascular
access.
• Non-powdered latex
gloves are most
commonly used;

Beaking Method
• Beaking method was
invented by Sean G.
Kaufman
• CEO and Founding
Partner, Behavioral-
Based Improvement
Solutions
• https://www.youtub
e.com/watch?v=YfGi
vTv3wbc
10

Beak Method
1. Make an L
2. Give me five
3. With index figure and thumb-Pinch and
scoop with your middle figure
4. Form a beak
5. Pull the glove over the beak
6. Remove glove
7. With index figure remove other gloves.
http://www.depts.ttu.edu/ehs/academicsafety/posters/beaking-glove-removal.pdf

Collecting Blood11

Greeting
• Always greet patient in a professional, friendly
manner.
• A good initial impression will earn the patients
trust, and make it easier and more pleasant to
draw a good specimen.
• Knock on the patient’s door before entering.
• Identify yourself by name and department.
• Explain the reason for your presence.

• The more relaxed and trusting your patient,
the greater chance of a successful atraumatic
venepuncture.
• Good verbal, listening, and nonverbal skills are
very important for patient reassurance
TechnicalTip

Patient Identification
• Make sure the name, medical record number,
and date of birth on your order/requisition
match those on the patient’s armband.
• Verify the patient’s identity by politely asking
them to state their full name.

• Properly identifying patients and specimens is
probably the single most critical part of your
job.
• The consequences of misidentifying a
specimen can be life threatening.

• Never rely on the patient name on the door or
above the bed. Patients are frequently moved
from room to room.

• A hospitalized patient must always be
correctly identified by an ID band that is
attached to the patient.
TechnicalTip

Wash hands

Apply gloves

• Patients are often reassured that proper
safety measures are being followed when
gloves are put on in their presence.
TechnicalTip

Position the Patient
• Comfortable position
• Turn the arm so that the wrist and palm face
upward, and the antecubital area is accessible.
• When supporting the patient’s arm, do not
hyperextend the elbow. This may make vein
palpation difficult.

Applying the tourniquet
• Tie the tourniquet just above the elbow.
• The tourniquet should be applied a maximum
of 1 – 2 minutes.

• After applying the
tourniquet, you may ask
the patient to make a
fist to further distend
the arm veins.

• Patients often think they are helping by
pumping their fists
• This is an acceptable practice when donating
blood, but not in sample collection as this can
lead to haemoconcentration.
TechnicalTip

Choose a site
• The median cubital vein
• If not accessible: Cephalic vein, or the Basilic
vein.
• If not accessible: veins on the back of the
hand.
• Use a much smaller needle for these hand
veins.

• Using the nondominant hand routinely for
palpation may be helpful when additional
palpation is required immediately before
performing the puncture.
• Often, a patient has veins that are more
prominent in the dominant arm.
TechnicalTip

Never
• Scarred, abraded, or inflamed skin
• Arms containing IV catheters
• Oedematous arms
• Occluded Veins
• Shunts
draw from these areas

Cleansing the site
• Isopropyl alcohol swab
• Outward expanding spiral starting with the
actual venipuncture site.
• Allow the alcohol to dry:-
1-disinfect the site
2-prevent a burning sensation

• Patients are quick to complain about a painful
venipuncture. The stinging sensation caused
by undry alcohol is a frequent, yet easily
avoided, cause of complaints.
TechnicalTip

Holders
• A plastic holder must be
used with the
evacuated tube system.

Attach needle to holder , Hold vein in place,

Place tube into holder Insert needle

Push tube into holder
• Gently push the tube
onto the needle holder
so that the catheter
inside the needle holder
penetrates the tube.
• Blood flow should be
visible at this point.

Multiple Tube Collection
If you are drawing more
than one tube:
• Keep a firm grip in the
needle holder while
pressing down on the
patients arm.
• Use your other arm to
interchange tubes.

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
biohazardous waste container.
• Wash hands.

Removing the Needle
• Gently release the tourniquet before the last
tube of blood is filled
• Remove the last tube from the needle
• Withdraw the needle in a single quick
movement

Apply Pressure
• Quickly place clean gauze over the site, and
apply pressure.
• You may ask the patient to continue applying
pressure until bleeding stops.

• Allow tubes to fill until the vacuum is
exhausted to ensure the correct blood to
anticoagulant ratio.
TechnicalTip

TROUBLESHOOTING

Blood won’t flow
If you do not see blood flow, the tip of the
needle:
1. May not yet be within the vein.
2. May have already passed through the vein.
3. May have missed the vein entirely.
4. May be pushed up against the inside wall of
the vein.

Incomplete collection or no blood is obtained:
• Change the position of the needle. Move it
forward (it may not be in the lumen)

• or move it backward (it may have penetrated
too far).

• Adjust the angle (the bevel may be against the
vein wall).

• Loosen the tourniquet. It may be obstructing
blood flow.
• Try another tube. There may be no vacuum in
the one being used.
• Re-anchor the vein. Veins sometimes roll away
from the point of the needle and puncture
site.

Other Problems
• A hematoma forms under the skin adjacent to
the puncture site - release the tourniquet
immediately and withdraw the needle. Apply
firm pressure.

Other Problems
• The blood is bright red (arterial) rather than
venous. Apply firm pressure for more than 5
minutes

• The practice of quickly applying tape over the
gauze without checking the puncture site
frequently produces a hematoma
TechnicalTip

Proper labeling generally includes:
• Patient’s first and last name
• Hospital identification number
• Date & time
• Phlebotomist initials
• Your institution may provide bar coded
computer generated labels that contain this
information.

Syringe Specimen Collection
• Small or delicate veins
that might be collapsed
by the vacuum of the
evacuated tube system.
• May also be used to
collect blood culture
specimens.

Finger stick-Specimen collection
• A safety Lancet, which
controls the depth of
incision
• Finger-sticks should not
be performed on
children under one year
of age.

Finger stick
• If possible, use the fourth
(ring) finger or the middle
finger.
• Many patients prefer that
you use fingers on their
nondominant hand.
• Choose a puncture site near
the right or left edge of the
finger tip.
• Clean the site as you would
for routine venipuncture.

Finger stick
• Select a safety lancet
appropriate for the size of
the patient’s finger.
• You may warm the finger
prior to puncture to
increase blood flow.
• Make the puncture
perpendicular, rather than
parallel, to the finger print.

Finger stick
• Wipe away the first
drop of blood using
gauze to remove tissue
fluid contamination.

Finger stick
• Collect blood into an
appropriate tube.
• Label specimens
appropriately.
• Make sure bleeding has
stopped. Apply an
adhesive bandage if
necessary.
• Discard sharps
appropriately.

Heel stick neonatal blood collection
• These devices are
designed to control the
depth of incision, since
going too deep into an
infant’s heel could
injure the heel bone,
and cause osteomyelitis
(bone infection).

Heel stick
• Firmly grasp the infants
foot.
• Do not use a tourniquet.
• The heel may be warmed
with a cloth to help increase
blood flow.
• Wipe the collection site
with an alcohol prep pad,
and allow the alcohol to dry.
• Wipe the site with sterile
cotton or gauze, to be sure
all the alcohol has been
removed.

Heel stick
• Puncture the left or
right side (outskirt) of
the heel, not the
bottom of the foot.
• Wipe away the first
drop of blood since it
may contain excess
tissue fluid or alcohol
which could alter test
results.

Heel stick
• Collect the blood into
the appropriate tube.
• Do not: Squeeze the
infant’s foot too tightly
and wipe with alcohol
during the collection.

Heel stick
• After collection is
completed, apply
pressure to the
puncture site with a
sterile gauze pad until
bleeding has stopped.
• Do not apply an
adhesive bandage to an
infant’s foot since it
may injure its delicate
skin.

Heel stick

Butterfly
• Butterfly needles
(winged infusion set)
• are available in smaller
gauges, and are used to
draw venous blood
from children, and
adults with difficult
veins.

Butterfly
• Butterfly needles come
attached to a small tube
which may be
connected to:
• An evacuated tube
holder, or A syringe.

Butterfly

Special situations

Patients refusing blood work
• If someone hesitates to let you collect a blood
specimen, explain to them that their blood
test results are important to their care.
• Patients have a right to refuse blood tests
• If the patient still refuses, report and
document patient refusal

Fainting
• Rarely, patients will faint during
venipuncture.
• It is therefore important that patients are
properly seated or lying in such a way during
venipuncture so that if they do faint, they
won’t hurt themselves.
• self-limited

Fainting; what to do?
• Gently remove the tourniquet and needle from the
patients arm, apply gauze and pressure to the skin
puncture site.
• Call for help.
• If the patient is seated, place his head between his
knees.
• A cold compress on the back of the neck may help to
revive the patient more quickly.
• You should have ammonia inhalant or spirit Ammonia

Unsatisfactory Specimens
• They can cause misleading laboratory results
• Must be rejected by the laboratory.
• The patient must then undergo another
venipuncture to get a better specimen.
• It costs time & money to redraw the specimen.
• The credibility of the laboratory is reduced if too
many unsatisfactory specimens are drawn.

Causes of Unsatisfactory Specimens

Hemolysis

Hemolysis
• Hemolysis means the breakup of fragile red
blood cells within the specimen, and the
release of their hemoglobin and other
substances, into the plasma.
• A hemolyzed specimen can be recognized
after it is centrifuged by the red color of the
plasma.

Causes of Hemolysis
• Using a too small needle for a relatively bigger
vein
• Pulling a syringe plunger too rapidly
• Expelling blood vigorously into a tube,
• Shaking a tube of blood too hard.
• Hemolysis can cause falsely increased
potassium, magnesium, iron, and ammonia
levels, and other aberrant lab results.

Clots
• Blood clots when the coagulation factors
within the plasma are activated.
• Blood starts to clot almost immediately after it
is drawn unless it is exposed to an
anticoagulant.
• Clots within the blood specimen, even if not
visible to the naked eye, will yield inaccurate
results.

Causes of Clots
• Inadequate mixing of blood and anticoagulant
• Delay in expelling blood within a syringe into a
collection tube

Insufficient volume
• short draws will result in an incorrect ratio of
blood to anticoagulant, and yield incorrect
test results.
• Short draws can be caused by:
• A vein collapsing during phlebotomy.
• The needle coming out of the vein before the
collection tube is full.
• Loss of collection tube vacuum before the
tube is full.

Insufficient volume

Labeling Errorrs
• Labeling errors are the most common cause of
incorrect laboratory results.
• If detected, the incorrectly labeled specimen
will be rejected.
• If undetected, it will produce incorrect results
which might adversely affect your patient’s
care.

Causes
• Failure to follow proper patient identification
procedure.
• Failure to label the specimen completely and
immediately after collection.

Ten Commandments
I. They shall protect thyself from injury
II. They shall identify thy patients
III. They shall stretch the skin at the puncture site
IV. They shall puncture the skin at about a 15 degree angle
V. They shall glorify the median vein
VI. They shall invert tubes containing anticoagulants immediately
after collection
VII. They shall attempt to collect specimens only from an acceptable
site
VIII. They shall label specimens at the bedside
IX. They shall know when to quit
X. They shall treat patient's like they are family

Summary Of Venipuncture Technique
1. Requisition form.
2. Greet the patient.
3. Identify the patient.
4. Reassure the patient and explain the procedure.
5. Prepare the patient.
6. Select equipment and supplies.
7. Wash hands and apply gloves.
8. Apply the tourniquet.
9. Select the venepuncture site.
10.Release the tourniquet.
11.Cleanse the site.
12.Assemble equipment.

13.Reapply the tourniquet.
14.Confirm the venipuncture site.
15.Examine the needle.
16.Anchor the vein.
17.Insert the needle.
18.Push the evacuated tube completely into adapter.
19.Gently invert the specimens, as they are collected.
20.Remove the last tube from the adapter.
21.Release the tourniquet.
22.Place sterile gauze over the needle.
23.Remove the needle, and apply pressure.
24.Activate needle safety device.

25.Dispose of the needle.
26.Label the tubes.
27.Examine the patient’s arm.
28.Bandage the patient’s arm.
29.Dispose of used supplies.
30.Remove and dispose of gloves.
31.Wash hands.
32.Complete any required paperwork.
33.Thank the patient.
34.Deliver specimens to appropriate locations.

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