Across much of the lab industry, robotics, automation and advanced technology have eliminated a significant amount of the manual labor required of laboratorians--particularly the tedious, repetitive tasks and those requiring a high level of precision, leaving room for human mistake. Aside from new designs of needles making blood draws safer for the phlebotomist and patient alike, phlebotomy has remained largely untouched by technological advancements.

Dennis J. Ernst, MT(ASCP), director, Center for Phlebotomy Education, explained it succinctly: "Phlebotomy remains a largely manual procedure," he said. "It's safe to say it will never be automated. That means we can't engineer human error out of the equation like robotics and instrumentation have done for the analytical phase."

Phlebotomy errors are a grave concern with regards to patient safety. Minimizing mistakes in phlebotomy must be approached from other angles if automation can't provide the solution. Thus, needlestick safety devices, education and training are the most important components in minimizing human mistakes in blood draws.

Focus on Training
Most errors that occur, Ernst said, are due to inadequate training and improper procedure. He listed some common problems as filling tubes in the wrong order, under-filling tubes, improper mixing, inadequate centrifugation, delays in processing and labeling errors.

The best way to reduce these human errors is through comprehensive training and continuing education-this will always be necessary in the preanalytical phase, Ernst added.

Competency assessments and discipline for infractions should be included in that kind of ongoing education. "Assessments should include not only an observation of a routine venipuncture, but the successful completion of a written or oral exam," Ernst recommended. "There are so many important details, the retention of which you'll never measure by simply watching a routine draw. You have to go deeper."

When one first begins performing blood draws, proper training does not ensure correct procedure is still followed years down the road. Details can easily fall to the wayside, and phlebotomists--as well as nurses and others who perform blood draws--may become too comfortable. Phlebotomy performance evaluations should be considered just as important as any other competency exam and should be an integral part of each annual review.

More challenges lie in the fact that requirements for phlebotomy education, certification and licensure vary by state. Further, phlebotomists often aren't overseen by the lab director. Some facilities don't have phlebotomists; instead, nurses perform blood draws. This can make maintaining training programs challenging. Uniform standards and a structured program are necessary to ensure education is ongoing and regular competency assessments are given.

Extra effort must be put forth to ensure specimens are safely and properly collected in a manner that does not compromise the sample's integrity. Procedure manuals, posters outlining important steps and fill order, and an emphasis on the phlebotomist's importance are all helpful steps in maintaining patient safety and sample integrity.

Identity Crisis
Identification errors are a common culprit in phlebotomy mistakes. The problem has been given much attention and is a strategic focus for general error reduction in some hospitals. Identification errors can best be minimized by paying careful attention, using multiple identifiers and labeling blood tubes while the patient is present. Technological advances have assisted in minimizing identification errors, particularly through barcode technology.

When used most efficiently, barcode labeling in phlebotomy ensures positive patient identification and makes sure each sample is being properly processed at collection. Barcode systems allowing for entering of information and printing labels at the point of care have played a vital role in the reduction of identification errors.

Barcoded wristbands allow a phlebotomist to ensure he's drawing from the right patient when the bar code is scanned by a handheld reader. Portable printers can immediately print out a corresponding label to go directly onto the sample tube. This makes it simple for the phlebotomist to label tubes while the patient is present--a necessary part of accurate identification.

Barcode technology also can be employed for tracking the sample after the blood draw. A sample's location can be verified and a specimen management system can track which tests are to be performed on which sample.

An Important Link
In most cases, the phlebotomist is the only contact a patient has with the lab. As part of what should be an ongoing, concerted, industry-wide initiative to raise awareness and appreciation of the clinical laboratory, phlebotomists play a vital role as the link between patient and lab. Ensuring competency of phlebotomists can help bolster the public's image of the lab.

Phlebotomy is "perhaps the most underestimated procedure in healthcare," Ernst said; phlebotomists, therefore, may also be underrated in their facility, but by doing conscientious work and avoiding errors through rigorous training and continuing education, phlebotomists can prove their worth and strengthen the image of the entire clinical lab.

A discussion of the phlebotomist's role as a link between the patient and the lab, however, must include another ongoing issue-it is becoming common for other healthcare staff to do the work of phlebotomists, rather than retaining a full-time phlebotomy staff when budgets are already crunched.