2. Wash hands and put on gloves.

3. Outpatients must be called by name. They must be asked their birth date to confirm that name and date match the request form labels. Inpatients must have a DHMC name band on their arm or leg with name and medical record number (MRN) legible. NO ONE may be drawn without one. The name and MRN must match the requisition or labels.

4. Check patient preparation. Certain specimens may require fasting or other patient preparation. If special preparations were necessary, verify and note that the patient followed the instructions. Triglycerides, lipid profiles and glucose should be fasting, if ordered as such.

5. Select the appropriate tubes and needles for the specimens to be collected. Any tubes containing additives should be tapped to dislodge additives from the walls of the tube and the stopper.

6. Open the sterile needle package. Do not remove the needle cap. Screw the needle into the plastic holder and insert the tube into the holder. (If one is using a "winged" needle set, a Luer adapter will have to be used to attach the holder to the set ) Do not pierce the tube as this will result in a loss of vacuum pressure.

7. Establish specimen collection order. The following order should be used for vacutainer draws. (See venipuncture - using a syringe for syringe collection).

1. Sterile, clean, or blood culture tubes first
2. Non-additive tubes (red, SST or gold)
3. Citrate tubes (light blue)
4. Gel separator SST tube
5. Heparin tubes (green)
6. EDTA tubes (lavender)
7. Oxalate/fluoride tubes (gray)

8. Position and reassure the patient. Ask the patient which arm is best for drawing blood. The patient should be comfortably positioned with the sleeve rolled up and the arm extended and supported by the blood drawing chair or bed. It may be necessary to lower the side bed rails. (Remember to raise the rails when through). For an inpatient sitting in a chair, it may be useful to place a pillow or towel under the patient’s arm.

9. Apply the tourniquet 3 to 4 inches above the puncture site. It should be restrictive enough to be slightly uncomfortable for the patient. Tourniquet should not be on any longer than 1-2 minutes.

10. Ask the patient to make a loose fist. Any vigorous hand exercise like "pumping" must be avoided because it can affect test results.

11. Select a good venipuncture site. The larger, fuller median cubital veins are used most frequently (refer to Diagram 1). Wrist and hand veins are also acceptable for venipuncture. Lab personnel DO NOT draw from other sites such as legs, arteries, CVP lines, Hickman catheters, PICC lines, etc.

Factors to consider in site selection:

1. Extensive scarring or healed burn areas should be avoided.
2. Specimens should not be obtained from the arm on the same side as a mastectomy. Lymphostasis may occur.
3. Try to avoid areas of hematoma.
4. If an arm has an IV inserted, one may draw below it but NEVER above it. Phlebotomist never shut off IV's. If the IV is turned off by nursing staff, specimens can be obtained after a 10 minute wait.
5. Do not obtain specimens from an arm having a cannula, fistula, or vascular graft.
6. Never draw blood from a person that is being transfused with blood products until at least 10-15 minutes after transfusion has been completed.

1. Sharply tapping the inner elbow with the index and second finger may cause the vein to dilate.
2. Massaging the arm from the wrist to the elbow to force blood into the vein and cause it to distend.
3. Apply a warm, wet towel to the arm for 5 minutes to help the vein to dilate.
4. Have the patient dangle the arm for 5 minutes to distend the vein.
5. Always remember to check both arms.

12. Clean the puncture site. Use the alcohol wipe and make a smooth circular pass of the puncture site moving in an outward spiral from the zone of penetration. Allow the skin to dry before proceeding. Do not touch the puncture site after cleaning.

13. Perform the venipuncture:

1. Holding the needle/tube assembly in your dominant hand, remove the needle cap. Position the needle with the bevel up (your right hand is dominant if you are right handed).
2. Grasp the patient's arm just below the puncture site with your non- dominant hand and pull the skin tight with your thumb or index finger.
3. Align the needle/tube assembly with a 15 degree angle to the skin. Use a quick, but small thrust to penetrate the skin and enter the vein in one motion, if possible.
4. Holding the plastic tube holder's flange with the tube below the puncture site, push the tube onto the needle and puncture the stopper. Keep the tube at an upright angle to prevent tube additives from entering the patient. Blood should flow when the needle punctures the stopper. If it does not, then the needle is either too far in the vein or not in the vein. Backing the needle up a bit will work if the needle is too far in the vein. If it is not in the vein, repositions may work. If you feel that the needle is in the vein and the blood still does not flow, use another tube (probing is not recommended). A patient should not be stuck more than two times by the same phlebotomist.
5. After blood starts to flow, release the tourniquet and ask the patient to open his or her hand.
6. Constant forward pressure on the tube is necessary to keep the rubber boot from closing.
7. Remove the tube when blood flow stops. The rubber boot will close to prevent leakage. If multiple tubes are needed, they should be inserted in the order determined in step 7.
8. Each tube containing an additive should be gently inverted 5-8 times immediately after being removed from the patient to mix the specimen. TO AVOID HEMOLYSIS, DO NOT MIX VIGOROUSLY.
9. Repeat steps d, f, g and h for each tube to be collected.
10. Before removing the needle from the arm, gently push the last tube forward, causing the activation of the safety device inside the needle.

14. Remove the needle. A 2x2 inch gauze should be held just above the puncture site. Remove the needle quickly to minimize pain and immediately apply the gauze. Ask the patient to apply pressure to the gauze for at least 2 minutes. When the bleeding stops, apply a fresh bandage, or gauze and tape. The patient should be instructed not to remove it for at least 15 minutes.

15. Dispose of the needle and holder as one unit.