Dennis J. Ernst, MT(ASCP)

Editor's Note: This article was adapted for ADVANCE from a series of articles originally published in Phlebotomy Today.

Do you know everything you need to know about drawing blood to prevent an injury from a venipuncture gone bad? You may seldom miss a vein, but if you miss one of these questions, you shouldn't draw blood from one more patient until you fully understand the answer and why it's important to every patient that you do.

Question 1: If you miss the vein, what are the limits to needle relocation?

Even the best in the business don't always access the vein immediately upon needle insertion. What you do when you miss a vein can make the difference between a successful venipuncture and a permanently disabled patient. It's all about the basilic vein.

The basilic vein is located on the inside or medial aspect of the antecubital area. If you extend your arm outward with your palm facing up, the basilic is on the pinky side of the antecubital. Properly trained specimen-collection personnel know the nerves pass through the antecubital area in close proximity to the basilic vein, and realize how vulnerable they are to a wayward needle.

Before deciding to relocate a needle that has missed a vein, keep in mind the Clinical and Laboratory Standards Institute's (CLSI) venipuncture standard sets limits to needle relocation. The document specifically states side-to-side needle relocation should never be attempted in an effort to access the basilic vein because of the close proximity of nerves and the brachial artery, and that probing for any vein is unacceptable.

Photo by Amber Bramble

In one study, 90 percent of patients who experienced symptoms of neurological injury were able to trace the onset of their symptoms to needle movement while in the arm. Venipuncture-induced nerve injuries lead to sensory changes including numbness, tingling and burning sensations. Those that don't resolve lead to disabling conditions such as Type II Complex Regional Pain Syndrome, and, frequently, litigation.

Question 2: What is the maximum angle at which a needle should be inserted into the vein?

According to CLSI and most textbooks, the proper angle of needle insertion is 30 degrees or less. If a patient is injured and it can be shown the angle of insertion was excessive, the facility may be liable for the injury. If you teach venipunctures, realize many of your new employees or students won't know what 30 degrees looks like, so simply stating the limit may not be enough. Consider taking a digital image of a needle positioned at a 30-degree angle to the arm and put it in their course materials or on a projected slide. The CLSI venipuncture standard (H3) has an illustration that might be helpful. In the absence of a visual, simply instruct your staff or students to enter the skin at the lowest angle possible.

Question 3: What is a "two-point check" for bleeding, and why is it required before bandaging?

If you've ever rushed through a venipuncture, you could easily leave or dismiss a patient before bleeding has stopped. According to the CLSI venipuncture standard, those who draw blood samples must make sure bleeding has ceased and observe for hematoma formation before bandaging the puncture site. It also states the collector should watch for excessive bleeding, and having the patient bend his/her arm up is not an acceptable substitute for direct pressure. Failure to perform this two-point check can lead to hemorrhaging, which can not only cause extensive, unsightly bruising, but induce a compression nerve injury with long-term complications.

How long should you watch? Long enough to be sure the vein won't continue oozing blood after you've left the patient. Watch the site for at least 10 seconds to see what happens when pressure is removed.

Question 4: How can you prioritize the antecubital veins according to risk?

Do you draw from the first vein you find in the antecubital area regardless of its location? If so, today's a great day to abandon that practice. As mentioned in Question No. 1, the basilic vein carries a higher risk of arterial and nerve injury than other antecubital veins. That's why the standards say to select a median or cephalic vein before drawing from the basilic. In fact, the standard states emphatically that draws to the basilic vein should only be considered if no other vein is more prominent. Upon applying the tourniquet, if the basilic vein is the best or only one available, you are obligated to look at the other arm unless conditions preclude its consideration. Draw from the basilic vein only when no other vein is accessible.

Question 5: What constitutes proper patient identification?

Up to 16 percent of identification bracelets contain erroneous information. Don't trust them.

According to CLSI, identify outpatients by asking for their name, address, unique identification number and/or birth date. Have them spell their last name where possible. Compare the information given with the information on the order, requisition and identification band if available. For inpatients, if the bracelet is not attached to the patient, the sample should not be drawn until it is in place. If patients are unconscious, cognitively impaired or have other communication barriers, seek confirmation of their bracelet from a caregiver or family member and document the name of the verifier. Any discrepancy should be resolved and corrected prior to sample collection. Don't just ask patients to affirm the name you verbalize, but ask them to state their name. Patients who are hard of hearing may respond affirmatively just to be polite. Whether they're a stranger or your neighbor, they expect to be asked to state their name.

Question 6: How can you best protect fainting patients from injury?

Studies show that 2.5 percent of patients will pass out during or immediately following a blood collection procedure. Anticipating a loss of consciousness means making sure every patient you draw is either lying down or seated in a chair with armrests. Drawing patients who sit upright in their hospital bed, on an exam table, or in any chair without side supports is against the standards. It also means never leaving the patient's side throughout the procedure in case they pass out and fall forward.

Ask patients if they've ever fainted getting their blood drawn and if they feel all right before releasing them from your care. Always be on guard for signs preceding fainting, like pallor, perspiration, anxiety, lightheadedness, hyperventilation and nausea.

Question 7: What do you do when the patient expresses shooting pain?

Should the patient express excruciating pain during venipuncture, even tingling or numbness in the hand or fingers, the draw must be discontinued and a second attempt made, preferably in a different location. Any other reaction can bring liability. These signs indicate nerve involvement, which could lead to permanent injury should the needle remain in the area.

Question 8: When should tubes containing blood samples be labeled?

Blood tubes and patient labels are like a bride and a groom at the altar. If they leave before being joined together as one, they cannot be considered to belong to each other. Once blood samples are walked away from the patient without being labeled, they should be discarded, redrawn and labeled in his presence. CLSI mandates not only this, but also the labeled tubes be compared to the patient's ID band or shown to the patient for confirmation they are labeled correctly when possible. Establish a zero-tolerance policy for not labeling tubes at the patient's side and you provide the best protection against misidentified samples, transfusion deaths and patient mismanagement.

Concepts Reinforced

If you've answered these eight questions correctly, congratulations. If you've missed one or more, brush up on the correct answer before you draw one more patient. To apply this information at your facility, pick two questions each month and make them the topic of your monthly staff meeting or inservice. You'll reinforce concepts everyone who works with you and for you must know and apply, while making your facility less vulnerable to the liability that comes with inflicting injuries to patients. 

Dennis J. Ernst is the director of the Center for Phlebotomy Education Inc. and publisher of the Phlebotomy Today family of e-newsletters. He also wrote, directed and produced a DVD to help healthcare facilities prevent patient injuries during venipuncture procedures and subsequent litigation titled "Avoiding Phlebotomy-Related Lawsuits." The second edition was just released, and is available from the Center at www.phlebotomy.com, or by calling 866-657-9857.