8 Phlebotomy Certification Practice

Prepare and identify the patient

Before collection, review the test request, required specimens, timing, and preparation instructions, such as fasting or a timed draw. Explain the procedure, provide privacy, and position the patient safely. If fainting is a concern, have the patient seated or lying down.

Confirm the patient and collection site

Ask the patient to state identifying information and compare it with the wristband or approved record. Use at least two patient-specific identifiers; a room or bed number is not an identifier. Stop and resolve any discrepancy before collecting. For example, if the stated date of birth does not match the wristband, do not collect until the discrepancy is resolved.

Check whether the intended arm or site has a restriction, such as an infusion, injury, or medical-access device, and follow facility policy. Gather and check supplies before beginning.

Use standard precautions

Treat blood and other potentially infectious material as potentially hazardous. Perform hand hygiene and wear gloves; use additional personal protective equipment when a splash or other exposure is possible. Use safety-engineered devices when available.

Activate the needle’s safety feature immediately after withdrawal and discard the needle directly into an approved sharps container. Never recap, bend, or break a contaminated needle, and do not pass a used needle to another person. If a needlestick or other exposure occurs, promptly wash or flush the area and report it immediately so the facility’s exposure-response process can begin.

Perform routine venipuncture

For a routine evacuated-tube collection, first confirm the patient’s identity and collection requirements, explain the procedure, perform hand hygiene, put on gloves, and prepare the equipment. Apply the tourniquet above the site and palpate for a suitable vein. If it has been in place for about one minute, release it and reapply only as needed.

Clean the site with the appropriate antiseptic and let it dry. Do not touch the cleaned site unless using an approved sterile technique. Anchor the vein, insert the needle bevel up, and collect the required tubes in the correct sequence. Release the tourniquet once blood flow is established or before withdrawing the needle. Remove the final tube, withdraw the needle, activate the safety feature, and discard the needle immediately.

Apply clean gauze and ask the patient to hold pressure with the arm extended. Check that bleeding has stopped before the patient leaves. Label every specimen at the collection site in the patient’s presence, following laboratory policy, and record collection details as required.

If the patient feels faint, stop the draw, safely remove the tourniquet and needle, apply pressure, and protect the patient from falling. Call for assistance and follow site procedures; do not leave the patient alone or ask them to stand and walk.

Follow the order of draw

The usual venous order of draw is intended to reduce additive carryover between tubes:

1. Blood culture bottles or tubes.

2. Sodium citrate tubes, commonly light blue.

3. Serum tubes, with or without clot activator or gel, commonly red, gold, or tiger-top.

4. Heparin tubes, commonly green.

5. EDTA tubes, commonly lavender, pink, or pearl.

6. Glycolytic-inhibitor tubes, such as sodium fluoride/potassium oxalate, commonly gray.

Tube colors are common conventions, not a substitute for checking the tube label. Follow local procedures for tubes not listed and for special collections. Capillary collections use a different sequence, so follow the laboratory’s capillary order of draw.

For example, collecting a light-blue citrate tube after an EDTA tube can allow EDTA carryover to interfere with some results. Identify tubes before collection and follow the approved sequence.

Select a collection method

Choose the collection method appropriate to the specimen and patient, and follow laboratory procedures:

• Evacuated-tube system: The tube fills by vacuum. Use the correct tube and fill it to its intended volume.

• Syringe: Use a safe transfer device to move blood into tubes. Never force blood through a needle into a tube.

• Winged collection set: This may be useful for some difficult or small veins. If a citrate tube is the first specimen collected through tubing containing air, a discard tube may be needed to ensure the citrate tube fills correctly; follow laboratory procedure.

• Capillary puncture: This is often used for small-volume testing or when appropriate for the patient. Select an approved site, wipe away the first drop when the protocol calls for it, avoid excessive squeezing, and follow the capillary order of draw.

Handle and process specimens

Fill tubes to the required volume. This is especially important for citrate tubes because the blood-to-additive ratio matters. Gently invert additive-containing tubes the number of times specified by the manufacturer or laboratory procedure; do not shake. Mix anticoagulant tubes to distribute the additive and do not allow them to clot. Clot-activator tubes must be allowed to clot as directed before centrifugation.

Understand the specimen types

• Serum is the liquid remaining after blood clots and is separated from the clot, usually by centrifugation.

• Plasma comes from anticoagulated blood, retains clotting factors, and is separated from cells by centrifugation.

• Whole blood remains unseparated for tests that require blood cells and liquid together.

Centrifuge only when indicated, using the specified time, force, and tube setup. Balance the centrifuge according to its instructions. If serum or plasma must be transferred to a secondary container, use an appropriate labeled container and avoid disturbing or transferring cells.

Keep specimens at the required temperature and deliver them within the required time. Processing and storage requirements vary by test: consult the laboratory’s specimen directory rather than assuming that all blood samples should be chilled or centrifuged.

Label, transport, and assess specimens

Label specimens promptly at the collection site using the required identifiers and any additional information required by the laboratory, such as collection time or source. Match each tube to the test request before transport. Use leak-resistant packaging and required biohazard markings; special shipping rules apply to specimens sent outside the facility.

A specimen may be rejected or require recollection if it is mislabeled or unlabeled, collected in the wrong tube, insufficient, clotted when anticoagulated blood is required, leaking, or otherwise unsuitable under laboratory criteria. Never guess at the identity of an uncertain specimen or relabel it by assumption. Stop, secure the specimen, and contact the laboratory or supervisor for direction. If an EDTA tube required for an anticoagulated specimen is visibly clotted, follow rejection and recollection procedures rather than shaking, transferring, or trying to repair it.

Prevent common collection problems

Recognize common problems and use the specified prevention or response:

• Hemolysis: It can alter results for some tests. Use an appropriate needle and technique, and avoid forceful transfer or vigorous shaking.

• Clotted anticoagulant specimen: It may be unsuitable. Mix gently and promptly as directed, and check for clotting when required.

• Underfilled citrate tube: The blood-to-additive ratio may be incorrect. Allow the tube to fill to its intended mark and ask the laboratory about an underfilled tube.

• Prolonged tourniquet application: It can affect some measurements and make collection uncomfortable. Keep application brief and release promptly.

• Wrong order of draw: Additive carryover may affect results. Follow the approved sequence and identify tubes before collection.

• Mislabeling: It risks assigning results to the wrong patient. Label at the collection site and verify identifiers against the patient and request.

When a patient’s identity or specimen quality is uncertain, stop and ask the laboratory or supervisor rather than guessing.

• Patient identification