Introduction to Phlebotomy

Chapter Outline 1-1 Introduction (pg. 2)

1-2 History of Phlebotomy (pg. 2)

1-3 Roles and Responsibilities of the Phlebotomist (pg. 3)

1-4 Where Do Phlebotomists Work? (pg. 10)

1-5 Regulatory Agencies (pg. 12)

1-6 Safety and Infection Control (pg. 14)

1-7 HIPAA, Ethics, and Law (pg. 21)

Learning Outcomes Upon completion of this chapter, you should be able to:

_ Describe the evolution of phlebotomy.

_ Describe the roles and responsibilities of the phlebotomist.

_ Discuss professionalism, public image, and customer service as they

relate to the phlebotomist.

_ Identify the various settings where phlebotomists are employed.

_ List the regulating agencies for phlebotomy.

_ Identify safety and infection control practices related to phlebotomy.

_ Describe HIPAA, law, and ethics related to phlebotomy.

2 Chapter 1 Introduction to Phlebotomy

Patient’s Bill of Rights

personal protective equipment




point-of-care testing (POCT)


reference laboratory


Standard Precautions




1-1 Introduction

Phlebotomy simply means to cut into a vein. The term comes from phlebos ,

Greek for “vein” and tome , “to cut.” This invasive procedure (procedure

that invades the body through cutting or puncture) is performed by professionals

known as phlebotomists. Phlebotomists must demonstrate mastery

of the principles and techniques established by the Clinical and Laboratory

Standards Institute (CLSI ), formerly known as the National Committee for

Clinical Laboratory Standards (NCCLS) .

The primary role of a phlebotomist is to obtain blood specimens for

diagnostic testing, either by venipuncture (puncturing the vein) or dermal

puncture (puncturing the skin). Another role of the phlebotomist is to remove

blood from donors for blood transfusions, or from patients with a condition

called polycythemia (overproduction of red blood cells), in which blood must

be removed to decrease the viscosity (thickness) of the blood. Phlebotomists

are also responsible for collecting and properly packaging urine specimens,

accepting incoming specimens (blood and body fluids, etc.), and routing

specimens to the proper departments to be tested and analyzed.

1. Name at least two functions of a phlebotomist.



1-2 History of Phlebotomy

The process of removing blood from the veins is believed to date back as far

as 1400 B.C. , where an Egyptian tomb painting shows a leech being applied

to the skin of a sick person. In the early 1800s leeches were in demand for

the procedure known as bloodletting. Leech farms were unable to keep up

with the demands for medicinal leeches because bloodletting procedures

were so popular.

Bloodletting was thought to rid the body of impurities and evil spirits

or, as in the time of Hippocrates, simply to return the body to a balanced

state. During the 1800s anyone claiming medical training could perform

bloodletting, and barbers most typically performed this procedure. A loss of

approximately 10 milliliters (about two teaspoons) was standard. However,

Chapter 1 Introduction to Phlebotomy 3

it was not uncommon for an excessive amount of blood to be withdrawn

during these procedures. In fact, the untimely death of the first United

States president, George Washington, was thought to be the result of excessive

bloodletting in an attempt to treat a throat infection. Interestingly, the

use of leeches has resurfaced with a new purpose: to remove blood that has

collected at newly transplanted tissue sites, in order to decrease the swelling

following microsurgery. Microsurgery involves reconstruction of small

tissue structures.

Bloodletting also used a process called “venesection,” in which the

vein was pierced with a sharp object to drain blood. The lancet, a very sharp

instrument used for cutting the vein, was the most popular medical instrument

of that time. This method was used because it was thought to have

removed or eliminated any unwanted diseases from the body, and it was

also used as a way to reduce a fever. It is important to note that aseptic, or

microorganism-free, practices were unknown during that time, so the same

lancet was used on several patients without any cleansing. Another method

used for bloodletting at that same time was called “cupping.” This method

produced a vacuum effect by pulling blood to the capillaries under a heated

glass cup, which was placed on the patient’s back to allow the blood to flow

more. Then a spring-loaded box containing multiple blades made slices or

piercings into the skin to produce bleeding. The procedure typically produced

scar tissue.

During the late 1980s and early 1990s, the phlebotomy profession emerged

as a result of technology and expansions of laboratory function. Initially, only

medical technologists and medical technicians were responsible for collecting

blood specimens, but as technology and the health care industry underwent

rapid changes in the past few decades, specimen collection was delegated to

other groups of trained professionals, including the phlebotomist.

1. Name various reasons bloodletting (early phlebotomy) was


Answer the question above and complete the History of Phlebotomy activity on

the Student CD under Chapter 1 before you continue to the next section.



1-3 Roles and Responsibilities of the Phlebotomist

The phlebotomist is a valuable member of the health care team and is

responsible for the collection, processing, and transport of blood specimens

to the laboratory. Entry into phlebotomy training programs usually requires

4 Chapter 1 Introduction to Phlebotomy

a high school diploma or its equivalent. Training programs are typically

offered at hospitals, technical and private schools, and community colleges,

or through continuing education courses. The course can vary from

a few weeks to a few months in length, depending on the program. Several

members of the health care team may be trained to perform phlebotomy,

such as physicians, nurses, medical assistants, paramedics, and patient care

assistants. Just as the role of these health care team members may include

phlebotomy, a phlebotomist may be responsible for performing a variety

of other duties. These may include transporting other specimens—such as

arterial blood, urine, sputum, and tissue—to the laboratory for testing. The

phlebotomist may also be responsible for performing point-of-care testing

(POCT) , such as blood glucose monitoring. Point-of-care testing is performed

at the patient’s bedside or a work area using portable instruments. In

addition, phlebotomists perform quality control testing and various clinical

and clerical duties. Table 1-1 above summarizes the essential duties and

responsibilities of the phlebotomist.

Patient Identification

Prior to any patient procedure, proper identification of the patient is a crucial

aspect of patient safety and a top priority. The National Patient Safety Goals

established by the Joint Commission on Accreditation of Healthcare Organizations

(JCAHO) recommends the use of at least two patient identifiers, not

including the room number, before blood samples are obtained. As discussed

later in this chapter, JCAHO is the organization that sets standards for patient

care in health care facilities. To follow the National Patient Safety Goals and

thus prevent an error, the phlebotomist must carefully identify every patient.

Upon entering the patient area, the phlebotomist must check the

patient identification. In acute care settings, patients will have an armband

or identification label bearing the patient’s first and last name, hospital

number, date of birth, and physician’s name.

Proper identification of the patient is a three-step process (see Figure

1-1 ). First ask the patient to state his or her name and date of birth. (See

Figure 1-2 .) Be sure that you do not call the patient by name prior to this,

because patients with altered mental states may simply repeat the name

they hear. Next, compare the name on the test requisition form/slip to the

TABLE 1-1 Duties and Responsibilities of the Phlebotomist

• Demonstrate professional attire, attitude, and communications

• Know facility’s policies and procedures

• Properly identify patients

• Collect both venous and capillary blood specimens

• Select the appropriate and accurate specimen container for the specified tests

• Properly label, handle, and transport specimens following departmental policies

• Sort specimens received and process specimens for delivery to laboratory


• Perform computer operations and/or update log sheets where required

• Perform point-of-care testing and quality control check

• Observe all safety regulations

Chapter 1 Introduction to Phlebotomy 5

patient’s response (see Figure 1-3 ). Finally, validate patient identification by

checking the medical record number, patient armband, or some other form

of identification such as a driver’s license.

If this three-step process is followed, correct patient identification can

be established, thereby eliminating errors. The presence of doubt at any

point during the three-step check calls for further investigation of the patient’s

identity. If the patient is unable to state his or her name, find another

source such as the nurse or a family member, depending on the setting,

to state the name for you. In a hospital setting, all patients must wear an

identification bracelet. Most hospital policies require that a patient have an

armband in order for any procedure to be done, including phlebotomy. All

laboratory specimens require a physician’s order; therefore a requisition

form will be available for specimens you are to collect. Remember that all

specimens require proper collection, handling, labeling, and transportation

to the laboratory for testing.

Specimen Collection and Handling

Physician orders for laboratory specimens will indicate the type of specimen

and time of collection. Some specimens are ordered as “stat,” which means

they must be collected and transported immediately. Other specimens may

be referred to as routine, and collection times are determined by the facility.

Special laboratory tests require specific times for collection, and these are

referred to as timed tests, which will be discussed in Chapter 6.

Figure 1-1 Follow a three-step process

for correct patient identification.

3. Validate

2. Compare

1. Ask

Three-step process to correct patient identification

Figure 1-2 Have the patient identify

himself by stating his full name and

date of birth.

6 Chapter 1 Introduction to Phlebotomy

Blood specimens provide important information that assists with the

diagnosing, monitoring, and treatment of patients. The two most commonly

used methods today for the collection of blood specimens are venipuncture

and dermal puncture (also called a microtechnique or microcollection; see

Table 1-2 ). Venipuncture involves the insertion of a sharp object (typically a

sterile hollow core needle) into a vein to allow blood to flow into a syringe or

vacuum tube. Dermal puncture requires the use of a lancet or other puncture

device to prick the skin, usually the finger, for the removal of a much smaller

specimen of capillary blood. Other sites for dermal puncture include the

heel (used for infants) and earlobe. The phlebotomist must perform these

tasks with confidence and expertise to ensure patient comfort. Skill is required

and must be obtained through practice and experience.


Department of Laboratory Medicine

Figure 1-3 Compare the

information from the laboratory

requisition slip with the patient


Patient Identification

In addition to asking the patient to state his or her name and birth date,

the phlebotomist is required to check the armband and/or other qualifying

documents, such as the requisition form, prior to drawing the patient’s

blood. Obtaining blood from the wrong patient constitutes an act of

negligence (error or wrongdoing) and can result in disciplinary action.


Most people do not like having their blood drawn because of the potential discomfort,

so professionalism and good interpersonal skills are critical attributes.

Having a well-groomed and professional appearance demonstrates to others a

sense of pride in oneself, the workplace, and one’s overall profession.

Chapter 1 Introduction to Phlebotomy 7

Becoming certified or licensed as a phlebotomist can also send an

important message to the patient and in turn the patient will have more

confidence in your abilities. The patient will also perceive that you are an

expert in your field. Membership in a professional organization will enhance

the phlebotomist’s professionalism by encouraging participation in continuing

education activities such as workshops and seminars, and providing

access to journals containing information regarding new developments in

the field, as well as new regulations at the state and national levels.

Public Image

First impressions are very important. Your appearance is the first statement

sent to those around you. Phlebotomists are expected to be clean, well groomed,

and appropriately dressed for the work setting. Lack of good personal hygiene

or proper dress can give a negative impression to an already anxious patient.

Many institutions require that phlebotomists wear a lab jacket and specified

shoes in order to meet Occupational Safety and Health Administration

(OSHA) guidelines. OSHA is responsible for minimizing the risks and injuries

to employees. Compliance with the dress code established by your facility

is important for establishing a professional public image. Depending on the

setting, the phlebotomist may be the only laboratory contact person a patient

encounters, so a positive public image is important not only for the credibility

of the individual, but for the laboratory department and institution as well.

Communication and Customer Service

The ability to communicate and provide customer service are important skills

for the phlebotomist. Communication can be verbal or nonverbal. Verbal

TABLE 1-2 Two Common Collection Methods

Venipuncture Insertion of needle

into a vein to allow

blood flow into a

vacuum tube or


Dermal puncture Use of a lancet or

puncture device

to prick the skin

to remove small

specimen of

capillary blood

8 Chapter 1 Introduction to Phlebotomy

refers to the use of language or words to express ideas. The phlebotomist must

be able to communicate using nonmedical terms so patients can understand

what is being said to them. Some health professionals will continue to use

medical terms in the presence of the patient. For example, using the term

“venipuncture” with a patient instead of simply telling the patient that you

will be “obtaining some blood” can create a block in communication. The

phlebotomist must be capable of explaining procedures to patients of various

ages in order to gain their confidence and cooperation. Never give false

reassurance to patients by making statements such as, “You won’t even feel

it,” because most patients feel some level of discomfort during phlebotomy

procedures. Avoid using slang or “street” talk because different words have

different meanings to different individuals. Address patients by name, avoiding

inappropriate terms such as “honey” or “sweetie.” Excessive talking is

also to be avoided because it tends to be annoying to patients wanting and

needing rest. It is best to speak using a calm and clear voice with a tone

appropriate to patient need (e.g., a louder volume for a patient who is hard of

hearing). The health care industry is service oriented, meaning that we want

our customers (patients) to be pleased with both the services we provide and

the manner in which they are delivered. This is customer service.

Using Proper Communication

The phlebotomist may be required to obtain blood from patients who are

unable to communicate as a result of a stroke or other medical condition.

Regardless of the patient’s inability to communicate, the phlebotomist is

expected to provide the same greetings, introductions, and explanations.

The mere fact that a patient cannot respond does not necessarily mean that

he or she cannot hear! Do not talk in the presence of comatose patients as

if they cannot hear you.

Patients receive not only the spoken message but also the nonverbal

cues sent by the phlebotomist (see Table 1-3 ). Nonverbal communication

begins with attire and includes overall mannerisms or behaviors. Maintaining

eye contact during patient interactions is a positive nonverbal response

that assists with establishing trust. During the initial greeting, displaying a

smile, maintaining erect body posture with relaxed arms, and avoiding the

patient’s personal space are usually well received. Personal space refers to the

TABLE 1-3 Nonverbal Communication: Positive versus Negative Gestures

Positive Negative

• Good body posture • Drooping shoulders with head held low

• Eye contact • Looking down or away from patient

• Neat, well-groomed appearance • Dingy, wrinkled lab coat; too much jewelry

• Respecting personal space • Immediately approaching patient’s space

before greeting and explaining procedures

Chapter 1 Introduction to Phlebotomy 9

proximity or distance between individuals a person prefers when interacting

with others. Many people feel uncomfortable when strangers approach them

and enter their personal space. Appropriate distance for personal space or

proximity varies based on gender, culture, and personal preference.

To provide positive communication and customer service, upon

approaching any patient, the phlebotomist should properly introduce himor

herself, state the purpose of the visit, and request that the patient state his

or her full name and date of birth. Patients will generally respond with a verbal

or nonverbal gesture such as a nod of the head, indicating acknowledgment

of the phlebotomist’s presence. Once the initial greeting is established,

it is acceptable and necessary to come in closer proximity to the patient’s

bedside or chair, depending on the workplace setting. In addition to professionalism

and positive communication, customer service requires common

courtesy. As mentioned earlier, when patients are having blood drawn,

they may be anxious and not in the best of moods. They may be concerned

about the results or just frightened. You can help their experience by being

empathetic to their situation by observing their behavior, listening to their

concerns, and addressing any situation promptly and effectively. You should

approach any problem with flexibility and the obligation to find a resolution.

For one example of proper customer service, see the Troubleshooting Box:

Providing Customer Service .

Providing Customer Service

The patients you draw blood from are your customers. Having patients is

what provides you a job, so your patients/customers should be satisfied

with your service. Customer service involves providing customer satisfaction

through professionalism, positive communication, and an attitude

that promotes resolution to problems when they occur.

Question: You are working alone in a busy laboratory because two other

phlebotomists have called in sick. The laboratory waiting area is crowded.

You expect another phlebotomist to arrive in about 20 minutes. What could

you do to promote positive customer service?

Checkpoint 1. Name at least three duties and responsibilities of a phlebotomist.



10 Chapter 1 Introduction to Phlebotomy

1-4 Where Do Phlebotomists Work?

There are two main categories of health care delivery systems in the United

States, inpatient and outpatient services. Phlebotomists are employed in

both of these settings as well as in select special settings. Hospitals, nursing

homes, and rehabilitation centers are examples of inpatient facilities.

Outpatient settings include physician offices, home health care agencies,

ambulatory care centers, reference laboratories (off-site labs), and blood

banks. Other special settings include veterinary offices, health maintenance

organizations (HMOs), and the American Red Cross, to name a few.


The phlebotomist may be privy to laboratory results. If you disclose results

of any laboratory test, you will have breached patient confi dentiality and

may be subject to disciplinary or legal action or even a monetary fi ne.

Inpatient Facilities

Phlebotomists employed at inpatient facilities work directly with several

members of the health care team (see Figure 1-4 ). Most hospitals have their

own laboratories, which are referred to as “clinical” laboratories because they

perform a wide range of tests in all specialties and subspecialties, such as

_ hematology (the study of blood and blood-forming tissues)

_ microbiology (the study of microscopic organisms)

_ chemistry (the evaluation of the chemical constituents of the human


_ immunology (the study of the body’s resistance to disease and defense

to foreign substances)

_ histology (the study of human body tissues and cells)

2. A patient is having blood work done during her lunch hour and

has waited 25 minutes before being called back for her blood to be

drawn. How can you implement customer service in this situation?

Answer the questions above and complete the Roles and Responsibilities of the

Phlebotomist activity on the Student CD under Chapter 1 before you continue to

the next section.

Chapter 1 Introduction to Phlebotomy 11

_ serology (the identification of antibodies in the blood’s serum)

_ urinalysis (the examination of urine for physical, chemical, and microscopic


_ toxicology (the detection and study of the adverse effects of chemicals

on living organisms)

_ blood banking

Physicians order specific tests to assist with the evaluation of the patient’s

condition, and the phlebotomist’s role is to collect the blood, properly

label the specimen, and transport it to the laboratory. At some inpatient

facilities, phlebotomists are also responsible for performing point-of-care

testing, such as blood glucose monitoring. Point-of-care testing can assist

the physician in making diagnoses more quickly, which often reduces the

length of stay for hospitalized patients.

Being a member of the health care team may require that the phlebotomist

assume other responsibilities such as basic patient care services

at inpatient facilities. Some of these may include delivering meal trays and

assisting with the transportation of patients from one department to another.

Professional conduct must be exhibited at all times.

Outpatient Facilities

The fastest-growing outpatient settings are ambulatory care centers. These

sites are walk-in facilities that patients can come to after business hours and

on weekends. Lab tests are ordered to assist with the diagnosis and treatment

of minor conditions. Outpatient laboratories usually perform tests involving

chemistry, hematology, urinalysis, serology, and microbiology. Phlebotomists

in these settings may also be responsible for performing other basic

patient care duties such as obtaining vital signs and transporting patients

for other procedures such as X rays.

Physician offices are also outpatient facilities. Phlebotomists or medical

assistants certified in phlebotomy are usually responsible for collecting and

Figure 1-4 An inpatient laboratory

is known as a clinical laboratory and

performs a wide range of laboratory


12 Chapter 1 Introduction to Phlebotomy

labeling a variety of specimens in the physician’s office that are then transported

to a reference laboratory for testing. In order for a physician’s office laboratory

to perform basic lab tests in their office, it must have “waived status” granted

by the Clinical Laboratory Improvement Act (CLIA). A waived test is granted

according to the difficulty in performing the test. Waived tests present much

less risk to the patient because they performed on small amounts of blood or

other specimens that are easier to obtain such as urine. The number of waived

tests has increased. (See Figure 1-5 .) Now tests such as nasal smears, for the

presence of eosinophils to determine if infection is present, and cholesterol

levels are approved in-office tests. So depending on the facility of employment,

a phlebotomist may be required to perform some of these tests, as well as quality

control checks on any test he or she performs.

Other outpatient facilities such as blood banks and the American Red

Cross employ phlebotomists to collect blood. The blood collected will become

a donor unit that might be used for a blood transfusion. Phlebotomists

working for agencies are often hired to go into patient homes to collect blood

specimens. As health care delivery systems continue to change, more care

is being provided to patients in nursing homes and in their own residences.

Some medical centers are now providing mobile venipuncture, where

the phlebotomist goes to the patient’s home to obtain blood specimens.

Additionally, phlebotomists are hired by insurance agencies to perform inhome

phlebotomy as a way of determining overall health before an insurance

policy is written. Regardless of the work setting, proper collection, labeling,

and handling of all specimens are critical to ensure accurate results and to

prevent the need for having to repeat the test unnecessarily.




1. What is meant by a waived test and where would a waived test

most likely be performed?

Figure 1-5 A physician office

laboratory performs “waived” tests

or ones that carry fewer risks to the


Chapter 1 Introduction to Phlebotomy 13

1-5 Regulatory Agencies

Regulatory agencies routinely visit and inspect laboratories and medical

offices to evaluate quality control and assurance. Laboratory facilities

must have quality assurance programs in place to ensure that tests are

effective and accurate. Quality assurance will be discussed in more detail

in Chapter 7.

The 1988 Clinical Laboratory Improvement Amendment (CLIA’88), a

revision of CLIA’67, was established to ensure that all laboratories receiving

federal funds, regardless of size, type, or location, would meet the same

standards and be certified by the federal government. This legislation, which

became effective in 1992, serves as the main regulatory body for all laboratories,

as well as establishing qualifications for phlebotomists. Classifications

of laboratories are based on the complexity of testing performed and the associated

patient risks if the tests are not performed properly. Some laboratories

are categorized as “waived,” and are not subject to inspections because they

perform only simple tests that have minimal associated patient risks, such

as dipstick urine testing. Other laboratories are classified as “moderately

complex” or “highly complex,” and both undergo inspections. Inspections

are stricter for higher complexity laboratories. Personnel qualifications are

specified for various levels of test complexity, which are outlined in the

CLIA’88 regulations. Failure of any institution to comply with these regulations

may result in termination of Medicare and Medicaid reimbursements,

as well as loss of privilege to perform the procedure.

Hospital laboratories and physician office laboratories are governed by

regulations that provide rules and guidelines for quality patient care. The

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

and the College of American Pathologists (CAP) are two accrediting agencies

that help ensure a high standard of care for patients. The main accrediting

agency for hospitals is the JCAHO. Physician offices must keep records for

quality control, temperature readings, and equipment maintenance logs.

In addition to the federal government, other agencies responsible for

overseeing aspects of the phlebotomy role include the Centers for Disease

Control and Prevention (CDC), the Occupational Safety and Health

Administration (OSHA), the Clinical and Laboratory Standards Institute

2. List and describe the common departments of a hospital laboratory.

Answer the questions above and complete the Where Do Phlebotomists Work?

activity on the Student CD under Chapter 1 before you continue to the next section.

14 Chapter 1 Introduction to Phlebotomy

(CLSI), Healthcare Finance Administration (HCFA), and the Department

of Health and Human Services (DHHS). Additional information about the

role of regulatory agencies, certification, and accreditation is discussed in

Chapter 7, Practicing Phlebotomy.

Handwashing. Alcohol-based hand rub.

Figure 1-6




1. What was established to ensure the standards of laboratories?

2. What is the main accrediting agency for hospitals?

Answer the questions above and complete the Regulatory Agencies activity on

the Student CD under Chapter 1 before you continue to the next section.

1-6 Safety and Infection Control

Safety and infection control are two very important elements for protecting

both you and the patient when you are providing any aspect of phlebotomy.

The Centers for Disease Control and Prevention has set standards

that prevent nosocomial infections (infections acquired in a hospital or other

Chapter 1 Introduction to Phlebotomy 15

TABLE 1-4 Hand Hygiene Procedure Related to Phlebotomy

Recommended Practices

• Wash your hands with soap and water whenever they are visibly contaminated with

blood or other body fluids.

• If hands are not visibly contaminated, an alcohol-based hand rub can be used.

Indications for Hand Hygiene

• Before and after putting on gloves

• Between patient contacts; between different procedures on same patient

• After touching blood, body fluids, secretions, excretions, and contaminated objects

• After handling specimen containers or tubes

• After restroom visits, eating, combing hair, handling money, and any other time your

hands get contaminated

Basic Steps for Handwashing

• Remove all rings and jewelry.

• Turn on water and adjust temperature to warm.

• Wet hands liberally without leaning your body against sink area.

• Apply soap and work up a good lather.

• Use circular motions while applying friction, being sure to interlace

fingers to clean between them for 2 minutes at the start of your work

day, 10–15 seconds in between patients, and 1–2 minutes when hands are

really soiled.

• Rinse each hand, allowing water to run from wrist toward fingertips, keeping fingers

pointing downward. Contamination under fingernails should be removed with a tool

designed for that purpose, such as an orange stick.

• Repeat above steps if hands are very soiled.

• Dry hands thoroughly with paper towels and discard them into waste


• Turn off water with a clean, dry paper towel, if indicated. *

• Clean area using dry paper towels only if indicated. *

Basic Steps for Alcohol-Based Hand Cleanser

• Make sure there is no visible dirt or contamination.

• Apply ½ to 1 teaspoon of alcohol cleanser to one hand. Check the

manufacturer’s directions for proper amount.

• Rub your hands together vigorously, making sure all surfaces are


• Continue rubbing until your hands are dry.

* Many facilities have sensors that turn water on automatically when the hands are lowered to the

faucet. Other facilities have a knee or foot device that is used to turn the water on.

medical setting). Nosocomial infections are responsible for about 20,000

deaths in the United States per year. Approximately 10% of American hospital

patients (about two million every year) acquire a clinically significant

nosocomial infection. Phlebotomists come in contact with many patients

throughout the day, which makes performing correct hand hygiene critical

(see Figure 1-6 and Table 1-4).

16 Chapter 1 Introduction to Phlebotomy

Nosocomial infections are prevented by hand hygiene and other precautions

that break any of the links in the chain of infection . The chain of infection

is six steps (links) that must take place for an infection to occur. The six links

are the infectious agent, reservoir, portal of exit, mode of transmission, portal of

entry, and susceptible host. Transmission of an infection can occur at any one

of these six links in the chain of infection. Likewise, if the chain is broken at

any of the links, an infection will not develop (see Figure 1-7 and Table 1-5 ).

TABLE 1-5 Chain of Infection

Link Description How the Phlebotomist Can Break

the Links

Infectious agent Pathogen, or disease-producing


• Perform hand hygiene

• Wear gloves when obtaining and

handling any specimens

• Dispose of contaminated materials


• Use of personal protective equipment

when required, including mask, gown,

gloves, eye protection

• Perform aseptic technique when


• Follow isolation precautions when


Reservoir Site where the organism grows and multiplies

Portal of exit The exit port for the pathogen to the host in

the human includes skin, respiratory tract,

and gastrointestinal tract

Mode of transmission How the pathogen travels; most commonly

by contact, droplet, or airborne

Portal of entry Entry point for pathogen such as break in

skin or respiratory system

Susceptible host Person at risk for developing an infection

from the pathogen




Portal of


Mode of


Portal of




Figure 1-7 If one of the links in the chain

of infection is broken, infection can be


Chapter 1 Introduction to Phlebotomy 17

Contact transmission is the most frequent source of nosocomial infections

and can be by either direct or indirect contact. Direct contact requires

a physical transfer of pathogens from reservoir to susceptible host (person

to person) by something as simple as a touch.

Indirect contact occurs when a contaminated item, such as a soiled

dressing, is handled prior to contact with a susceptible host (person to contaminated

item to person). Indirect contact most often occurs when health

care workers fail to wash their hands and change gloves between patients.

Methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium

difficile (C-diff) enteritis are examples of infections spread by contact


Droplet transmission is a form of contact transmission, but the method

of transfer is much different. This form occurs when droplets from an infected

person are propelled short distances to the susceptible host through the nasal

mucosa, mouth, or conjunctiva. Examples of infections spread by droplet

transmission are influenza, mumps, and rubella. Droplets are propelled by

coughing, sneezing, breathing, or talking. The droplets are not suspended

in the air as they are with airborne transmission.

In airborne transmission, small particles carry the pathogens. These particles

can be widely dispersed by air currents before being inhaled by a host.

Legionnaires’ disease, varicella, and tuberculosis are examples of infections

spread by airborne transmission.

Vehicle-borne transmission occurs when a host comes in contact

with a contaminated item such as food, linen, or equipment. To prevent

this mode of transmission, soiled linen and equipment must be cleaned

or disposed of properly. Vector-borne transmission requires an animal or

insect as an agent to spread disease, such as the mosquito that carries the

West Nile virus.

Preventing Infections

To help prevent nosocomial infections, the CDC in 1994 implemented two

levels of precautions. The first level is Standard Precautions (formerly

Universal Precautions). These precautions combine hand hygiene and the

wearing of gloves when health care workers are exposed to blood and body

fluids, nonintact skin, or mucous membranes. Standard Precautions include

the major features of Universal Precautions, but they apply when workers

are exposed to nonintact skin, mucous membranes, and blood and all body

fluids, secretions, and excretions except sweat regardless of whether blood

is visible. (Universal Precautions apply to blood and any other body fluids

only if they contain visible blood.) The use of Standard Precautions reduces

the risk of transmission of microorganisms from both recognized and unrecognized

sources of infection. (See Appendix A: Standard Precautions.) In

addition, the CDC advises that health care workers should not wear artificial

nails because they are more likely to harbor gram-negative pathogens on

their fingertips than workers with natural nails, both before and after handwashing.

Natural nails should be no longer than one-fourth inch.

The CDC’s second level of precautions is isolation precautions that are

based on how the infectious agent is transmitted. These isolation precautions


_ Airborne precautions that require special air handling, ventilation, and

additional respiratory protection (HEPA or N95 respirators)

18 Chapter 1 Introduction to Phlebotomy

_ Droplet precautions that require mucous membrane protection (goggles

and masks)

_ Contact precautions that require gloves and gowns during direct

skin-to-skin contact or contact with contaminated linen, equipment,

and so on

You should follow Standard Precautions with every patient when performing

phlebotomy. Isolation precautions are used less often and only

with patients who have specific infections. When isolation precautions are

mandated for a patient receiving phlebotomy, you will be required to follow

the specific guidelines for the type of precautions implemented (see

Appendix B: Transmission-Based Precautions).

The process of blood collection is an invasive procedure, and whenever

blood or body fluid from one person comes in contact with another person,

there is a major risk of exposure to bloodborne pathogens such as human

immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B

virus (HBV). OSHA requires that health care facilities provide annual training

on preventing exposure to bloodborne pathogens as well as the necessary

personal protective equipment (PPE) for employee use, such as gloves,

gowns, masks, and protective eyewear. (OSHA is the federal body charged

with preventing or minimizing employee exposure to bloodborne pathogens,

as outlined in the Occupational Exposure to Bloodborne Pathogens

Standard.) See Figure 1-8 and Table 1-6 for more information about personal

protective equipment and its applications.

In general when using PPE you should:

_ Don before contact with the patient, generally before entering the room

_ Use carefully—don’t spread contamination

_ Remove and discard carefully, either at the doorway or immediately

outside patient room; remove respirator outside room

_ Immediately perform hand hygiene

Figure 1-8 Removing gloves properly.

(a) Grasp the outside edge near

the wrist. Peel away from the hand,

turning the glove inside out. Hold the

glove in opposite gloved hand.

(b) Hold the contaminated glove in

the gloved hand while removing the

second glove.

(c) Slide the ungloved fi nger under the

wrist of the remaining glove. Peel off

from inside, creating a bag for both

gloves, and then discard.

Chapter 1 Introduction to Phlebotomy 19

TABLE 1-6 Personal Protective Equipment

Type When Used Rules for Use

Gloves For hand contact with

blood, mucous membranes,

other potentially infectious

materials, or when nonintact

skin is anticipated,

when performing vascular

access procedures, or when

handling contaminated

items or surfaces

• Does not replace handwashing

• Perform hand hygiene before applying and after removing gloves

• When removing gloves do not touch the outside (contaminated) area

of the gloves (see Figure 1-8 )

• Keep gloved hands away from the face

• Avoid touching or adjusting other PPE

• Remove if torn and perform hand hygiene before putting on new


• Limit surfaces and items touched

• Extend gloves over isolation gown cuffs

Gown During procedures and

patient care activities when

contact of clothing/exposed

skin with blood/body fluids,

secretions, or excretions is


• To put on gown

• Opening is in the back

• Secure at neck and waist

• To remove gown

• Unfasten ties

• Peel gown away from neck and shoulder—do not touch outside

• Turn contaminated outside toward the inside

• Fold or roll into a bundle

• Discard

Mask During patient care

activities likely to generate

splashes or sprays of blood,

body fluids, secretions, or


• Must fully cover nose and mouth

• Respirator masks such as N95, N99, and N100 must be used for

airborne precautions

• To put on mask

• Place over nose, mouth, and chin

• Fit flexible nosepiece over nose bridge

• Secure on head with ties or elastic

• Adjust to fit

• To remove mask

• Untie the bottom, then top tie

• Remove from face—do not touch the outside

• Discard



During patient care

activities likely to generate

splashes or sprays of blood,

body fluids, secretions, or


• Goggles should fit snugly over and around the eyes

• Personal glasses are not an acceptable substitute

• Can use a face shield that protects face, nose, mouth, and eyes

• Face shield should cover forehead, extend below chin, and wrap

around side of face

• Position goggles over eyes and secure to the head using the

earpieces or headband

• Position face shield over face and secure on brow with headband

• Remove goggles or face shield

• Grasp ear or head pieces with ungloved hands

• Lift away from face—do not touch outside

• Place in designated receptacle for reprocessing or disposal

20 Chapter 1 Introduction to Phlebotomy

Needlestick Injuries

The National Institute for Occupational Safety and Health (NIOSH) estimates

that between 600,000 and 800,000 needlestick injuries occur

annually, exposing health care workers to bloodborne pathogens. A

needlestick has both financial and emotional consequences. Follow-up

for a high-risk exposure is approximately $500 to $1000 per needlestick

even if no infection develops. However, the emotional impact and health

consequences can be severe and can continue for a long time, especially

if the exposure is to HIV. Needlestick injuries are preventable with proper

education, safer equipment, and elimination of the need for needles

whenever possible.

Through the recommendation of NIOSH and the efforts of OSHA,

the Needlestick Safety and Prevention Act was passed into law in 2001.

The intent of the law and the implementation regulation is to mandate the

use of safety devices that reduce needlestick injuries in the clinical setting.

The introduction of needleless equipment and protected needles has

significantly reduced the risk of needlestick injuries. All devices selected

for phlebotomy should be equipped with needlestick prevention features.

These devices will be discussed in more detail in Chapter 3, Equipment for

Specimen Collection.

Isolation Precaution Equipment

Follow the guidelines for isolation precautions when entering a patient’s

room. If you are not certain what personal protective equipment (PPE) to

wear, such as gowns, gloves, or mask, consult with the licensed practitioner

caring for the patient, such as a nurse. Never take a tray of phlebotomy

equipment into an isolation room. Take only the equipment needed for the

particular draw. If you need additional equipment, you must remove all

PPE before leaving the room, collect the needed supplies, then don new

PPE before re-entering the room. Only the equipment to be used should be

taken in, and only the tubes and the phlebotomist should leave the room.

Any unused equipment or supplies must be left in the room.

_ Apply in correct sequence; gown, mask or respirator, goggles or face

shield, then gloves

_ Remove in correct sequence; gloves, face shield or goggles, gown, then

mask or respirator

Employees at increased risk of exposure are to receive, free of charge,

the HBV (hepatitis B virus) vaccination. Each health care facility is also

required to have an occupational exposure plan, which is a protocol to be

followed in the event an employee is exposed to bloodborne pathogens. The

ultimate objective is to protect patients, peers, and oneself from coming in

contact with potentially harmful materials such as contaminated needles

and syringes. Proper disposal of venipuncture equipment greatly decreases

the incidence of accidental needlestick injuries and exposure.

Chapter 1 Introduction to Phlebotomy 21

1-7 HIPAA, Ethics, and Law

In 1996, the Health Insurance Portability and Accountability Act (HIPAA)

was established in response to information that was being transferred electronically

for medical transactions. In 2003, a federal law was passed that

establishes a national standard for electronic health care transactions and

protects the privacy and confidentiality of patient information. Among other

provisions, HIPAA states that information about a patient must not be discussed

with individuals other than the patient unless the patient has given

written or verbal permission for you to do so. A patient’s information cannot

be shared among health care professionals unless it is for the patient’s treatment.

The following is a list of other guidelines from HIPAA that could apply

to the care of patients during phlebotomy.

_ Close patients’ room doors when caring for them or discussing their


_ Do not talk about patients in public places.

_ Turn computer screens that contain patient information so passersby

cannot see the information.

_ Log off computers when you are done.

_ Do not walk away from patient medical records; close them when leaving.

Following a code of ethics is a principal part of being a phlebotomist.

Ethics consists of a set of written rules, procedures, or guidelines that examines

values, actions, and choices to help determine right from wrong. It

is also a moral philosophy that varies by individual, religion, social status,

or heritage. Acting morally toward others requires putting yourself in their

place. If you were a patient requiring blood tests to rule out a disease or other

condition, how would you want to be treated?

There may be instances when the patient or family member will ask the

phlebotomist why the blood is being drawn, or what the results of previous




1. Name three things you can do to prevent infection.

2. In what order should you apply and remove PPE?

Answer the questions above and complete the Safety and Infection Control activity

on the Student CD under Chapter 1 before you continue to the next section.

22 Chapter 1 Introduction to Phlebotomy

blood tests were. It is the responsibility of the physician to discuss this information

with the patient, not that of the phlebotomist. In such cases, the

phlebotomist might respond by saying, “You will need to ask your physician

about these tests or results. I am not allowed to discuss them with you.” All

information concerning the care of patients is strictly confidential and is not

to be discussed. Inpatient settings may require the phlebotomist to travel

throughout the facility to collect specimens, from the patient’s bedside to other

departments such as the emergency room. Information obtained, no matter

how small, must remain confidential to protect the patient and the facility.

Obtaining a Blood Specimen

With few exceptions, phlebotomists will be required to obtain blood

specimens when ordered by the primary practitioner regardless of the

patient diagnosis. Patients with infectious diseases such as tuberculosis,

hepatitis, and AIDS deserve to have their blood drawn just as other

patients would. Some health care personnel attempt to avoid such

patients. This is considered discrimination and may result in disciplinary

actions and/or legal liability. All patients, regardless of condition, should

be treated with respect and dignity. Certain exceptions could occur when

a phlebotomist may not be required to draw a specimen, such as when a

patient is receiving radiation treatment and the phlebotomist is pregnant,

or when an irate patient infected with hepatitis or AIDS does not have the

phlebotomist’s safety at hand.

Consent is an important legal aspect of phlebotomy. Prior to performing

any blood collection procedure, the phlebotomist must explain to the patient

in nonmedical terms what he or she can expect to happen during the procedure.

Patients generally sign a consent form for treatment during the initial

in-take before entering the hospital or before being treated by a physician

in his or her office. Consents take a variety of forms, for example, written

agreements, spoken words, implicit actions, or making an appointment for a

test. It is important to provide quality patient education and to make sure the

patient understands what he or she is agreeing to. Because the phlebotomist

will also be instrumental in collecting urine specimens for chain of custody,

it is essential to discuss expressed consent whereby the patient not only has

to be informed of the procedure and its process, but he or she must also sign a

consent form agreeing to have the procedure done. Other procedures that may

require written consent would be drug and alcohol screens and HIV testing.

The issue of patient rights is not new, and it has been clearly defined

since 1975 by the American Hospital Association in a document called the

Patient’s Bill of Rights. In addition to the right to refuse care, patients have

the right to be treated with respect, to have all records and information classified

as confidential, to be informed about the purpose and expected results

of treatments, and to have access to their medical records.

On occasion, family members can serve to calm the patient prior to procedures,

but there are times when the visitors may interfere with the blood

collection process. If there are too many visitors or if they appear to make the

patient anxious, politely request that they leave the room for a few minutes.

It is rare that visitors will resent such a request when asked politely.

Chapter 1 Introduction to Phlebotomy 23

Phlebotomists may also be confronted with issues involving team members.

Serving as a member of a team is a challenge because all the “players”

affect the outcome. The team concept implies working together to achieve

common goals. Phlebotomists will work closely with other phlebotomists,

physicians, nurses, and other health care members. The ultimate goal is to

provide quality care to consumers accessing your health care facility.

All blood specimen tubes must be properly labeled at the patient’s bedside.

If you find specimen tubes without a label, bring this to the attention of

other team members. Do not label specimens that you did not collect. If you

label a specimen as requested by a team member, you become accountable for

the accuracy of that specimen. Unless you saw your team member obtain the

specimen, you cannot be sure that the blood specimen belongs to that patient.

Just imagine the potential implications of placing the wrong patient label on a

specimen. A patient with a potential abnormal test result may not receive the

needed treatment, and a patient not needing that treatment may receive it. Both

of these situations could lead to disciplinary actions and compromise patient

safety, so never label specimens for which you did not assume responsibility.


Consent must always be very clear. If a patient just puts out his or her arm,

but does not bother to stop watching TV or otherwise acknowledge the

phlebotomist, this is considered implied consent. If the patient doesn’t speak

English, but notices the tray and automatically puts his or her arm out, that

too is considered implied consent. Only if confl icting information is present,

or if the patient doesn’t understand English and seems confused about what

you are there for, must the phlebotomist be very careful to verify the true

intent of the patient. Confl icting consent has resulted in several lawsuits. If a

minor child or mentally incompetent patient is to have blood drawn, and the

parent or guardian is not present, the written consent for treatment the parent

signed on admission is considered adequate. There are three instances where

a patient can NOT refuse to consent. These are in the case of a minor or a

patient under the age of 18, a patient with mental incapacitation, or a patient

who has been ordered by law to have his or her blood drawn.

Patient Refusal

The phlebotomist may encounter a patient who refuses to have blood drawn.

In such instances, it is best to remind the patient that the physician ordered

the tests to assist with evaluating the patient’s condition. If this explanation

fails and the patient still refuses to have his or her blood drawn, politely

leave the room and be sure to document a detailed account of the patient

interaction. It is also helpful in hospital settings to tell the patient’s nurse so

the physician can be notifi ed as soon as possible.

As a phlebotomist it is important to protect yourself against harm from

blood and body fluid exposure as well as legal issues. If you feel as though

there are policies and procedures that will place your safety in jeopardy, you

must first alert your supervisor. If there is no resolution, take it to the next

24 Chapter 1 Introduction to Phlebotomy

Chapter Summary _ Phlebotomy has evolved from the use of leeches for blood collection to

modern-day certified phlebotomists.

_ Phlebotomists are responsible for the collection, processing, and transportation

of blood specimens.

_ Professionalism includes such things as a positive attitude and appearance

plus keeping up with current information in the field. Public image

starts with the first impression and is expressed in your behavior and

methods of communication. Communication and customer service are

necessary to maintain your public image and confidence and cooperation

from your supervisor, patients, and co-workers.

_ Phlebotomists can be employed at hospitals, rehabilitation centers, nursing

homes, clinics, physicians’ offices, ambulatory care centers, blood

banks, and reference laboratories.

_ The regulating agencies for phlebotomy include CLSI, JCAHO, HCFA,


_ Infection control and safety practices include hand hygiene, gloving,

Standard Precautions, and isolation precautions.

_ HIPAA provides protection of health care information. Ethics consists of a

set of rules, procedures, or guidelines that helps determine right from wrong.

The law includes following your scope of practice, policies, and procedures

at your facility and obtaining consent for phlebotomy procedures.




1. Name three ways you can follow HIPAA guidelines as a phlebotomist.

2. What should you say to a patient who asks you for the results of a

blood test?

Answer the questions above and complete the HIPAA, Ethics, and Law activity

on the Student CD under Chapter 1 before you continue to the next section.

person in charge until your situation has been resolved. Phlebotomists may

also purchase liability insurance through several insurance carriers who

provide low-cost coverage to health care workers. Be sure to check with

your employer to see if they carry liability coverage on you; if so, then there

would be no need to purchase liability insurance.


Chapter Review

Multiple Choice

Choose the best answer for each question.

1. The term phlebotomy comes from Greek words that translate to mean:

a. Draw blood

b. Cut a vein

c. Drain blood

d. Dermal cut

2. Phlebotomy may be used to help treat which of the following medical conditions?

a. Polycythemia

b. Diabetes

c. Hypertension

d. Anemia

3. The main duty of a phlebotomist is to:

a. Interpret laboratory values

b. Evaluate blood specimens

c. Process blood specimens

d. Collect blood specimens

4. If a phlebotomist failed to properly identify a patient and blood was drawn on the wrong patient,

this would be considered an act of:

a. Malpractice

b. Assault and battery

c. Negligence

d. Consent

5. CLIA classifies laboratories based on:

a. Number of employees

b. Size of the laboratory

c. Number of tests performed

d. Complexity of tests performed

6. Which of the following is the current CDC guideline for infection control?

a. Universal Precautions

b. Standard Precautions

c. Body Substance Isolation

d. Waived Precautions

26 Chapter 1 Introduction to Phlebotomy

7. A phlebotomist must obtain before he or she draws a patient’s blood.

a. a license

b. hepatitis B vaccination

c. certification

d. consent

8. If your hands are visibly soiled, you can:

a. Use an alcohol-based hand rub

b. Perform handwashing

c. Wear gloves

d. Perform phlebotomy

9. Customer service would least likely include the following:

a. Flexibility

b. Professionalism

c. Common courtesy

d. Complexity

10. Which of the following is the most frequent source of nosocomial infections?

a. Direct or indirect contact

b. HIV

c. Airborne particles

d. Droplet particles

Fill in the Blanks

Write the word(s) or statement needed to answer the following questions.

11. List two negative verbal and nonverbal communication skills that must be avoided.

Verbal Nonverbal

12. List three settings in which a phlebotomist may gain employment.

13. What term describes tests that are performed at the patient’s bedside?

True or False

Write T or F on the line provided to indicate whether you think each statement is true or false. Correct

the false statements to make them true.

14. Entry into phlebotomy programs usually requires a high school diploma or its equivalent.

Chapter 1 Introduction to Phlebotomy 27

What Should You Do? Critical Thinking Application

Use your critical thinking skills to respond to the following situations.

26. A phlebotomist has been asked to obtain a blood specimen from a hospitalized patient. The

phlebotomist enters the patient’s room and gives the appropriate greeting, only to discover that

the patient speaks only Spanish, a language the phlebotomist is unfamiliar with. Should the

phlebotomist proceed with the blood collection? What are the phlebotomist’s next steps? Give

information to support your answer such as legal/ethical implications and also consider the

patient’s rights.

15. Phlebotomists are the only health care personnel allowed to collect blood specimens.

16. Venipuncture requires the use of a skin puncture device to remove a small amount of

capillary blood.

17. Blood specimens assist in the diagnosing and monitoring of patients.

18. All specimens require proper collection, handling, labeling, and transporting.

19. A HEPA mask is used for airborne precautions.

20. Dermal puncture is used for larger blood samples.


Match each agency, legislature, or committee abbreviation with the correct description by writing the

appropriate letter in the space provided.


22. CLIA

23. CDC

24. CLSI

25. OSHA

a. Federal agency responsible for monitoring and reporting diseases.

b. Nonprofit organization that sets standards for phlebotomy training


c. Federal body responsible for preventing or minimizing work-related


d. Main accrediting agency for hospitals.

e. Legislation responsible for regulating all laboratories and phlebotomists.

28 Chapter 1 Introduction to Phlebotomy

27. While explaining the purpose of a visit to a patient, the phlebotomist notices five visitors

entering the room. The patient greets the visitors pleasantly, and one of the visitors asks the

phlebotomist what blood tests have been ordered. How should the phlebotomist handle this

situation and why?

28. The phlebotomist is scheduled to obtain a blood specimen from a patient in a patient’s home.

The phlebotomist enters the home and makes the appropriate greetings. The patient is very

agitated and states, ‘‘I’m just sick and tired of you people drawing my blood. It’s not helping

me to get any better, so get out! I refuse to be a pincushion for you medical jerks!” What would

be a good response for the phlebotomist to make? How should the phlebotomist handle this


29. A phlebotomist employed at the outpatient clinic of a large acute-care hospital begins her shift

to find the waiting room full of patients. Two of the scheduled phlebotomists have called in

sick, and it will be at least 20 minutes before any additional phlebotomists can arrive. The

phlebotomist begins to call patients back and listens while each patient voices his or her

frustration, saying only what is required to collect the specimen and letting the patients leave.

Did the phlebotomist make any error? What could he or she have done differently?

30. You notice a co-worker carrying a tray of phlebotomy equipment out of the room of a patient

who is in airborne precautions. What should you do?

Get Connected Internet Activity

Visit the McGraw-Hill Higher Education Online Learning Center Phlebotomy for Healthcare

Personnel Website at to complete the following activities.

The History of Bloodletting To find out more about the history of bloodletting and the equipment

used, search the Internet and find at least one image to share with the class:

Chapter 1 Introduction to Phlebotomy 29

UCLA Biomedical Library has graphics of bloodletting devices and historical data

Museum of Questionable Medical Devices by Graham Ford presents an overview of ancient

bloodletting practices

Phlebotomy Regulating Agencies To find out more about phlebotomy, visit any of these sites:

American Society for Clinical Pathology

American Society of Phlebotomy Technicians

National Credentialing Agency

National Phlebotomy Association

American Medical Technologis

Centers for Disease Control and Prevention

Occupational Safety and Health Administration

Joint Commission on Accreditation of Healthcare Organizations

College of American Pathologists

National Healthcareer Association

National Center for Competency Testing

Research one site and determine its mission and relationship to the practice of phlebotomy. Share

your findings with your class.

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