Phlebotomy Today

Top Ten Ways to Injure a Patient, Pt. 1

Each year, specimen collection personnel who deviate from the standard for the procedure injure hundreds if not thousands of patients. Do you know the standard to which you will be held accountable? Do your coworkers? Does your staff or trainees? Could your procedure manual stand up to scrutiny should a patient be injured and seek compensation? The answers to these and other questions will determine your vulnerability to a phlebotomy-related lawsuit.

To assess your potential to inflict injury on a patient during phlebotomy---and that of those you manage or teach, size-up the expertise where you work or teach against this top-ten list.

10. Reinvent the procedure

When an established procedure is tinkered with, things go wrong. Over the years, myriad homespun innovations have attempted to modify a standard that was first introduced in 1980. Such “field modifications” we have heard of include:

• Using two tourniquets, one above the antecubital and one at the wrist;
• Routinely drawing from an artery instead of a vein;
• Allowing blood to openly drip into the collection tube from the hub of an inserted needle;
• Applying petroleum jelly or hand lotion to a skin puncture site prior to the puncture so that the blood “beads up” as it emerges;
• Tying a tourniquet around the elbow to hold the gauze in place as a substitute for direct pressure prior to bandaging;
• Forcibly bending a needle into a 45-degree angle before use “to establish a lower angle of insertion”;
• Plunging serum tubes into ice immediately after filling “to expedite clotting”;
• Combining the contents of two tubes (of either the same type or different) into one until a full tube can be submitted for testing;
• Applying a tourniquet under the armpit instead of several inches above the antecubital area;
• Entering the vein at a 90-degree angle.

Crazy? You bet. If you're wondering "who would do such a thing?", so are we. But we've heard of these very techniques being used on patients by healthcare professionals who should know better.

Such “homemade phlebotomy” only serves to increase one’s vulnerability to liability should an injury and/or complications occur. It is imperative that all laboratory procedure manuals reflect the prevailing standard of care as established in the literature and CLSI standards and guidelines, and that any attempt to modify the procedure is disciplined. Failure to enforce the standardized procedure for venipunctures can be seen by a jury as falling beneath the standard of care.

9. Draw from unorthodox sites

Not all veins are fair game. The acceptable sites include the veins of the antecubital area, the back of the hand and the foot and ankle. According to the CLSI standards, veins to the front of the wrist (palm side) or lateral wrists (thumb side) must not be used for venipuncture due the presence of nerves and tendons close to the surface. Veins to the feet and ankles should only be used with physician’s permission. Drawing from veins in sites other than these may subject patients to injury to nerves, arteries, tendon and bone. Regardless of the site of the venipuncture, whenever one is about to insert a needle into a patient’s flesh, one must have a thorough knowledge of the anatomy of that area in order to adequately assess the risk.

8. Seat the patient anywhere

Gravity happens. If it happens to your patient who has just passed out, the consequences can translate into injury and liability if you didn’t position him properly. According to the standards, patients must be recumbent or seated in a chair with arm rests for support in case the patient loses consciousness. This means chairs without arm rests are not acceptable for venipuncture; nor are exam tables unless the patient is recumbent. The standards also require patients with a history of fainting during blood collection procedures to be recumbent.
     Patients have suffered disabling injuries---even spinal fractures and paralysis---after losing consciousness and falling out of chairs without arm rests. Make sure your procedure manuals include this restriction and you are less likely to be subjected to the pain and anxiety that can come from being liable for injuries that result from improper positioning.

Next month, we'll continue our countdown in Part 2 of Top Ten Ways to Injure a Patient.

 

Product Spotlight: Lab Week giveaways

National Medical Laboratory Professionals Week is April 21-27, 2019. Do those who draw blood samples in your facility feel appreciated? Let us help you celebrate those who collect the samples that keep your lab up and running.

If you're looking for giveaways, consider any of our Order of Draw reminders. Pens, badge tags, and pocket-size Tips On Specimen Collection cards are tasteful graphic reminders of one of the most important aspects of drawing blood samples.

1. Our Order of Draw Badge Tags attach to your staff's or students' ID clip or lanyard so the order of draw is always in front of them.
2. Put an Order of Draw Pen in every pocket so the correct order in which tubes must be filled is also right at their fingertips.
3. The Phlebotomy Tips card is a pocket reminder of key concepts in phlebotomy including the order of draw, and tips on specimen collection. The reverse shows the anatomy of the antecubital area featuring veins, arteries, and nerves.
4. The Lab Draw Answer Book is the gift that keeps on giving ANSWERS. Almost 400 to be exact. Put this in the hands of your top performers. If you have an entire staff of top performers, quantity discounts are available.

We've been helping you educate for over 20 years. Now let us help you celebrate.

 

Test Talk: Gastrin

A new column that features a different laboratory test each month, what it measures, why physicians order it, and any collection handling restrictions and requirements that must be met.

  When a physician orders a gastrin level, he/she is typically diagnosing peptic ulcers, gastritis, bowel obstruction, diarrhea, or abdominal pain. It is also used to diagnose Zollinger-Ellison (Z-E) Syndrome, a condition associated with the formation of pancreatic and duodenal tumors that produce excess gastrin. 

Gastrin is a hormone. Normally it's produced in the stomach and regulates acid production during digestion. The gastrin level in the blood is diurnal (changes according to the time of day). It's at its highest during the day and lowest between 3 and 7 a.m. It also rises and falls in the blood stream according to food intake. When the patient fasts, gastrin rises in the blood. After meals, it relocates to the gut where its needed. When the serum gastrin is elevated, interpretation must include an analysis of the gastrin within the patient's gastric contents. 

When patients develop "gastrinomas", i.e., tumors that produce an overabundance of gastrin, (ZE Syndrome), it leads to multiple complications including peptic ulcers, the discomfort from which is what typically prompts patients to seek medical evaluation. However, most stomach ulcers are not due to gastrinomas, but Helicobacter pylori infections.

More than half of gastrinomas are malignant, causing cancer that can spread to other parts of the body. That's why it's important to make sure samples are drawn and processed precisely as recommended. Disregarding the fasting requirement and sample handling specifics can prevent the physician from diagnosing the condition, potentially causing a life-threatening delay in diagnosis and treatment.

Gastrin samples are typically drawn from patients who have fasted for 12 hours and restricted alcohol intake for 24 hours. The sample is drawn into heparinized tubes, but serum is acceptable in some systems. (Always follow your facility's sample requirements.) Regardless of the tube, gastrin is only stable for two hours, and must be immediately placed on ice for transport. The sample should be centrifuged in less than two hours and the serum/plasma frozen or tested immediately.   

Bibliography:

• LabTestsOnline. American Association for Clinical Chemistry. AACC. www.labtestsonline.org. Accessed 3/6/2019.
• Wu A. Tietz Clinical Guide to Laboratory Tests---Fourth Edition. Elsevier. St. Louis, Missouri. 2006. 
• World Health Organization. Use of Anticoagulants in Diagnostic Laboratory Investigations. WHO. Geneva, Switzerland. 2002. 

 

How High Are Your Standards?

 

 

From the Editor's Desk

Friends,

Can we start 2019 over again? Seriously, it's not been very nice to me. 

It all began on January 28. I just landed at the Detroit airport during a major snowstorm, took a shuttle to my car and found the battery was dead. Forty-five minutes later, still under blizzard conditions, I headed west for a meeting in Grand Rapids taking place the next morning. Just outside of Lansing, the expressway was shut down in both directions due to a five-semi pileup. They routed traffic through the city where road crews weren't keeping up with the accumulating snow. It was there, on the corner of Willoughby and Cedar, my car blew its radiator, dumping coolant and transmission fluid onto the snow below turning it to a shade of green nearly identical to color of the traffic light I was suddenly unable to obey. Despite the cacophony of horn-layers behind me---likewise rerouted and likewise unable to obey the signal, but because of me---I was going nowhere and so were they.

I called a tow truck, cancelled the meeting, found a hotel and hunkered, down but not out. Even though my plans were scuttled and my car disabled, I found comfort in knowing I wasn't the driver that caused five semis to pile up and block both sides of an expressway for hours. I only blocked an intersection for thirty minutes. Perspective.

Early the next day, the service manager at the local Honda dealership let me know it would take $800 to get me back on the road. My heart sank. With no other option, I okayed the repair, which he said could be finished by the end of the day. Keeping good his promise, he called at 4 p.m, but with more bad news.
   "Your radiator is fixed and the car is driveable, but when we took it on the test drive the power steering went out. You now need a new power steering rack, which will run another $1800."
    "Keep it," I said."I'm not putting one more dime into that vehicle. I'm done."

And done I was. It had been a great car, don't get me wrong. But it's best years and most of its value were well behind her. Besides, I had just wasted $800 on a new radiator and wasn't about to waste another $1800 just to find out what major system was going to go out on the next test drive. I know a money pit when I see one, and this had all the markings. I asked the service manager if he wanted the car in exchange for my repair bill, but it wasn't even worth that much in its current condition. I ponied up the $800 and arranged for it to be donated to a local charity that fixes cars up and gives them to those who are struggling.

Having the rental car for a week allowed me get home and to shop online at my leisure for replacement transportation without the pressure of desperation. After a diligent search, I found one of the same make and model I had just used up, only younger and with a lot more life left. It was even the same color. It would be my 15th since I bought my first car from my brother in 1972. Only two of them were brand new vehicles, the rest were "pre-owned" as they say. That's an average of one car every 3.1 years. This one should be good for at least that long, Now that I have a garage for only the second time in my life, I could take better care of it and squeeze out an extra year or two. At least that was my thinking.

Just seventeen days after driving it off the lot, I was coming home from the post office when a sheet of ice lifted off the top of a box truck heading toward me in the other lane and smashed down hard onto my new-to-me car, smashing the grill, hood and windshield into smithereens. It hit like a ton of bricks, stunning me into disbelief. I managed to pull over and assess the damage. The driver of the box truck never stopped. He probably never knew it happened. 

There's probably a lesson in all this. Two candidates come to mind. The first is that no matter how bad you have it, someone has it worse. When I think of the pileup on the interstate that caused my detour, my day ended up with a disabled vehicle and a cancelled meeting. There were at least five drivers whose big rigs and their cargo were severely damaged. Their day was far worse than mine. The next day there would be a 40-car pileup on the same expressway. I would not be among them.

The second takeaway from all this is that I can't always control what happens to me, but I can control how I react to it. Fortunately, anger is not my strong suit, but it seems to be for a lot of people. I've been through enough airport delays to see anger on full display. But it's rarely necessary, isn't pretty, seldom helps, and is always at the expense of your dignity. When my car stranded me in a blizzard, then ice crushed my newer car weeks later it was distressing for sure, but not something to be angry about. I'm grateful to have been wired that way. Threaten my wife or kids, though, and I'll short circuit before your very eyes.

They say good things come in threes. This issue of Phlebotomy Today marks the beginning of its 21st year of publication. That's three sets of seven years. Although 2019 may not have been very nice to me so far, at least I still get to pen this column and serve some of the most dedicated people in healthcare. The way I choose to react to that is with gratitude. But they also say bad things come in threes. So far this year, two of my cars have met with great misfortune. I'm choosing to react to that by driving my wife's car for a while.

 

Respectfully,

Dennis J. Ernst, editor
phlebotomy@phlebotomy.com 

 

What Should We Do?: Permission on ankle draws

Dear Center for Phlebotomy Education:

When drawing from a lower extremity I understand that we must have the physician’s permission.But if the patient has multiple physicians, which one provides permission? How long is the standing order good for? Must it be in writing? Where/how do we document permission and what must the documentation include? I'm sorry for all the questions, but I'm having trouble converting the CLSI standards into policy. What should we do? 

Our Response:

Don't apologize. We give questions from our readers a high priority.

When patients have multiple physicians, it's really up to the facility as to which one to obtain permission from. We recommend going to the patients primary care provider first. If the ordering physician is not the patient's primary physician, but has no qualms about providing permission, you should accept it. Any physician who doesn't feel he/she is the appropriate clinician, or who doesn't want to be held responsible for any complications, probably won't give permission, and will defer to another treating physician. 

Just make sure the permission is in writing, as required by the standards. The form in which written permission is granted is up to your facility. Whether it's in writing or electronically conveyed, just make sure it's retrievable for future draws and in case any questions, challenges, or complications arise. Unless stated otherwise, you can assume it's indefinite. But it would be a good practice to reaffirm permissions on a regular basis. Should the patient develop diabetes, feet/ankle draws should no longer be performed. Unless the physician reviews the permission regularly, draws to the lower extremities could lead to complications that were not a risk when permission was originally established.
   Lastly, the standards don't specify what should be included in the permission, but we recommend it identifies the patient, the physician and the date of permission at a minimum.

Got a challenging phlebotomy situation or work-related question? Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)  

 

Advice From the OSHA Expert

Dan the Lab Safety Man

When I perform safety rounds with phlebotomists, I include OSHA’s Chemical Hygiene (or Laboratory Standard), and the Hazard Communication Standard in my focus. Whether or not you spend time in the clinical laboratory, it may come as a surprise to you that there is information about chemical hazards that you need to know.

The Hazard Communication Standard states that you have a right to know about all of the dangers in your workplace, and your employer is responsible to train you about the risks in order to provide a safe working environment. One way to do that is to be educated about any chemicals or reagents that are stored or used in your work area. In blood collection areas, there may be cleaning supplies (such as bleach), peroxides and rubbing alcohols, and the Chemical Hygiene Standard applies to these as well. Through your facility’s Chemical Hygiene Plan, a Chemical Hygiene Officer should be named, and that person is responsible for managing and updating an inventory of all chemicals stored and used. If you do not know who that person is, make sure you find out.

Container labeling is an important aspect of the Chemical Hygiene Plan. All chemicals are required to have a label that contains the identity of the chemical, the manufacturer, hazard warnings, and target organs affected if exposed. Secondary containers used to pour off or store chemicals, such as 10% bleach solution for routine disinfection, need to be properly labeled as well with the name of the chemical, concentration, route of entry, health hazard, physical hazard, target organs affected, lab name, lot number and expiration date. Alternatively, secondary containers can be identified by chemical name and a completed National Fire Protection Association (NFPA) or Hazardous Materials Identification System (HMIS) label.

Knowledge of how to interpret Material Safety Data Sheets (MSDS) and ready access to these important documents 24/7 should be part of your initial and annual safety training program. If there is a chemical spill or exposure, using MSDS is your best resource for treating the affected employee or cleaning up a potentially hazardous spill.

If you work in a clinical laboratory, you already know there are many chemicals and reagents present that can pose a safety risk. Just remember that if you work in a blood collection center or as a traveling phlebotomist, there may be chemicals in those environments as well. Make sure you are properly educated about the existing hazards and how to respond should there be a chemical spill or exposure. If this is news to you, ask your employer how OSHA’s Hazard Communication and Chemical Hygiene Standards can keep you safe.

Bibliography

• US Department of Labor and Occupational Safety and Health Administration (OSHA). 29 CFR 1910.1200 Hazard Communication. Link. Accessed 3/5/2019.
• US Department of Labor and Occupational Safety and Health Administration (OSHA). 29 CFR 1910.1450 Occupational Exposure to Hazardous Chemicals in Laboratories. Link. Accessed 3/5/2019.
• US Department of Labor and Occupational Safety and Health Administration (OSHA). Hazardous Chemicals in Labs, OSHA Fact Sheet. Link. Accessed 3/5/2019.

You can contact Dan Scungio, “Dan the Lab Safety Man” at samaritan@cox.net.

 

The Empowered Healthcare Manager

Every month we run an excerpt from our editor's popular blog, The Empowered Healthcare Manager. 

Why You Must Play Favorites

In his book Mandatory Greatness, Dale Dauten says "never trust a manager who loves everything you do." Not only shouldn't the manager be trusted, he shouldn't be believed.  No manager loves everything any employee does. It's a question of tolerance.

While he might love most of what his good employees do, the empowered manager tolerates the rest because there is little that requires tolerating. (Good employees don't give him much to tolerate.) High performers deserve high tolerance; low performers require low tolerance. That means you should react differently to the same mistake committed by different employees. Favoritism? You bet.

Your best employee is going to stumble now and then. She will likely be harder on herself than you could ever be. She gets a pass from you. That doesn't mean you don't acknowledge the error, but you don't come down hard either. She's already doing that with herself.

Your lowest performer stumbles more often than not. She's not likely to be hard on herself at all, and accepts her flawed self as-is, not demanding any more. Since she doesn't come down hard on herself, you have to if you ever hope to mentor her into a high performer. 

A high performer misidentifies a patient for the first time in years and she gets written up. A low performer misidentifies her third one this year and gets fired. It's favoritism, pure and simple.

You favor quality.
You favor six sigma.
You favor that which doesn't derail processes, threaten your team, or harm your patients.

Anyone who accuses you of it needs to know it's not the person you favor, but what the person is delivering... and what they are not.

 

Subscribe to The Empowered Healthcare Manager blog.

 

The Empowered Healthcare Manager

Being Firm

A good question to ask all applicants is when was the last time you had to be firm with someone? It reveals character, the ability to stand up for what's right, the strength to defend (laws, rules, a code-of-conduct, decency, oneself, etc.).

It's also good for managers to ask themselves the same question. 

It's a mistake to think empowerment can only be bestowed. True empowerment comes from within. Sure, administrators have to empower their managers, but if the manager shrinks from using it, he/she remains a mere manager, destined to be yoked to a legacy of having been promoted by mistake.

Empowered healthcare managers, on the other hand, accept the gift of empowerment and give themselves permission to transform their position, their staff, and their organization. They give themselves permission to be firm. Here's what it sounds like:

• No, you can't have that day off. It will compromise the team.
• If I hear one more whisper of gossip, you'll be suspended.
• I've told you three times to hem up the cuffs of your scrubs. Find some safety pins and pin them up now. The next time you come in with them sweeping the floor you'll be sent home.
• I appreciate you letting me know of problems that require my attention. Going forward, I'd like for you to also to propose solutions at the same time. 

Firm is the enemy of mediocrity; mediocrity is the enemy of the empowered. The enemy of your enemy is your friend.

Subscribe to the Empowered Healthcare Manager blog.

What Should We Do?: Butterfly overuse

Question: Are there benchmarks on the percentage of straight vs butterfly needles that should be used? We'd like to see how we compare on in-house patients, outpatients, and nursing home usage. We conducted a study here that found 57% of draws were done using butterflies. Once people were aware and conscious of the issue, we were able to improve our numbers. We don't want to have to sign out butterfly needles yet as they do in other places. Do you have any ideas or tricks you can suggest to help us keep the rate dropping?

Our response: We are not aware of any national statistics on butterfly usage overall, much less on specific patient populations. We've conducted numerous surveys, however, and wrote many articles on the topic in this newsletter. (See links below.) We feel your 57% is high for an acute care facility. It's hard to believe most of your patients require them. You are to be commended for taking steps to get the rate down, as it is a hugely expensive problem. 

Assume you pay 20 cents for every tube holder/needle assembly and $1.25 for every butterfly set. For every phlebotomist who uses a butterfly when a tube holder assembly would suffice, you lose $1.05.

Now assume your phlebotomists average 6 patients per hour throughout the day. For an 8-hour day, that's 48 patients. If they're using butterfly sets on half the patients, and only half of them actually require it, it's costing your facility $12.60 per person for every 8-hour shift. Multiply that by the number of shifts and the number of phlebotomists at your facility, and over the course of a year you're burning through $5000 unnecessarily. Plug in your own numbers, but it's easy to find that butterfly overuse costs the average employer hundreds of dollars every day, and tens of thousands every year. Ouch.

You've probably already taken some of these steps, but we recommend bringing everyone together and articulate the problem in resource management you are experiencing, and how its crippling your facility. (Don't be afraid to mention how perpetuating butterfly overuse prevents administration from approving raises and benefit packages.) Let them know they are the collective solution, and you really need their help. The team, management included, have to feel this is only conquerable as a team. No individuals are exempt.

Set your benchmark, then set incremental goals, and your overall goal. Be ambitious and aggressive. Report progress, or lack thereof, toward the goal weekly from the outset, then monthly once you're getting good traction. Just like hemolysis and blood culture contamination, this is about process improvement, and the effort never ends. Above all, reward your team early and often when progress is made. Without it, your efforts will be futile. 

[Editor's note: each year, one of the most highly acclaimed presentations at the Phlebotomy Supervisor's Boot Camp is the "Squandered Resources and Low Hanging Fruit" presentation where we articulate strategies in detail to reduce butterfly overuse, hemolysis rates and blood culture contamination rates.]

 Related articles appear in these back issues of Phlebotomy Today-STAT!:

• April, 2007
• December 2008
• March 2010
• May 2010
• March 2011

Got a challenging phlebotomy situation or work-related question? Email us your submission at WSWDpanel@phlebotomy.com and you just might see it as a future case study. (Names and identifiers will be removed to assure anonymity.)