A few weeks ago, I was at a routine doctor's appointment, and I had to get some labs done. I tend to be a little wary when my blood is drawn (which comes with being a phlebotomist, I suppose), but I'm always hopeful that things will go well, especially considering I have good veins. Despite my expectations, I was surprised by the number of mistakes and improper practices I ended up witnessing. I often see mistakes when having my blood drawn (some a big deal, some not), but this encounter ended up being one for the record books.

Let me first say that I really like this office. Everyone is very kind, patient, and professional - but their phlebotomy training is severely lacking. The phlebotomist led me down the hallway, chatting with me about my day. She was very friendly and seemed a really nice genuine person, but as soon as I sat down in the chair, the problems began. She asked me which arm I preferred; I told her my left arm was usually best, and then she applied the tourniquet, placed a foam ball in my hand, and told me to squeeze it repeatedly while she set up supplies. I held the foam ball in my hand but did not pump my fist. She noticed that but didn't say anything to me.

She put a glove on her right hand (only her right hand). She did a quick single swipe of the alcohol on my arm and then felt my vein with her gloved finger. At this point, I knew it was all going to be a train wreck, but it was also rather fascinating to watch. She grabbed a butterfly with her right hand and pulled my skin taut with her ungloved thumb and pointer finger (from above and below the site). Then she took the butterfly and inserted it at about an 80-degree angle, and let go of it. It stuck out of my arm like a lawn dart.

She began filling the tubes, and I struggled with the internal dilemma of saying something. Everything had been done wrong, but the biggest issue is that the tourniquet had been on for about a minute now, with several tubes still to go. I decided to ask her to take it off, to which she responded that she was almost done and would take it off soon. I knew that if I wanted my labs to have a chance to be accurate, it needed to come off now. I reached up and undid the tourniquet with my free hand - which is a really easy way to get your phlebotomist to hate you. I could see the annoyance on her face, and her attitude shifted from bubbly and friendly to irritated.

I apologized and quickly explained that leaving the tourniquet on for more than a minute could alter test results, but the damage was done. She silently finished filling the tubes up, removed the needle and dropped it onto her tray (without activating the safety), and then wrapped my arm with Coban. Then she (finally) activated the safety, inverted the tubes (hooray), and told me I could go and she would walk me out. There was one last serious issue, though. She had not identified me before the draw, and she had not labeled the tubes yet. I requested that she label the tubes in front of me before I left. She didn't say anything, but she applied the labels, and I double-checked that my info was correct on them. Her irritation had probably progressed to the contemplation of my murder at this point. I thanked her and let her walk me out; she said a clipped goodbye and left me at the front desk.

Unfortunately, we may never be friends, but at least my labs had a chance of having some accuracy - something that other patients would not have if this phlebotomist was the one drawing their blood. Typically I don't say anything while having my blood drawn. At least not unless there is a problem that could negatively affect me or my test results. I don't want to make them feel intimidated or nervous. Sometimes I'll say something after the draw if I think the phlebotomist may be open to a suggestion or tip. I usually find that they dismiss anything I say, which I understand. No one wants to hear a random stranger tell them how to do their job.

I have been on the other end as well, where someone tries to tell me I am doing something wrong, and I know how it feels. I don't blame anyone for being irritated at my requests. I blame the lack of phlebotomy regulations in my state. There is a lot of poor training, and unfortunately, I must say that I have never had my blood drawn entirely correct at any appointment since I became a phlebotomist myself and could recognize the problems. However, this recent appointment is one of the worst experiences I have ever had. I left frustrated, worried, and ended up with a hematoma from the crazy angle the needle was inserted at, along with it being unsecured and left to wobble around with every little movement.

So how do we fix issues like this? I know I am not alone in being dissatisfied with my experiences wherever I go as a patient. It's a really large issue and one that doesn't have a quick fix. In this situation, I reached out to the office and let them know about the problems I had seen. I told them that the phlebotomist was professional and very pleasant but that there were some technical issues that could be causing inaccuracies to tests and danger to patients. I told them who I was and that I would be happy to offer some training or resources for their staff, but I have not heard back from them regarding this issue. I don't have high hopes that they will take me up on my offer, but I will keep trying.

This is a problem that won't be addressed until there are standard state and national regulations put in place. There needs to be more attention on the practice of phlebotomy and how much of an impact it can have on patient lives. It's a critical skill necessary for nearly everyone at some point, so how is it so ignored? These issues have bothered me (and many of you as well) for years. Luckily, I am in a better position to help bring phlebotomy practices to where they need to be, but it will take all of our voices calling for change before anything will happen. I hope we can all work together to help accomplish this someday, and make healthcare safer for everyone.

Butterfly overuse

I also find it interesting that she reached for a butterfly right away when you said you have good veins. She should have been able to use a straight needle. Butterflies are costly, so maybe you need to take the save money approach with this place and offer your services as money-saving and best practice.

Jen Kryzyanowski, 02/01/2022 09:11:13

Awesome testimonial

Wow, Shan! You did exactly what I would have done... and have done. Only my letters to managers always got a reply. Perhaps one is still forthcoming. On the other hand, maybe incompetence is top down. Sadly, there are plenty of managers in our industry striving for mediocrity and falling short.

Dennis Ernst, 02/01/2022 09:16:16

Confidence shaken

Great article! We have all been there. With years of phlebotomy experience and supervisory experience, it has become very evident that 99% of the average phlebotomists hate being criticized. In my opinion, good phlebotomy incorporates a lot of personal confidence (not to be confused with over-confidence). As soon as that confidence is shaken at any point of an encounter- whether it be patient criticism, personal criticism, or some other uncontrollable external factor- the entire experience can turn downhill as it did with you during this scenario. I agree with you about poor training practices and lack of regulation when it comes to the profession. I also think that leadership needs to do a better job of constantly monitoring performance according to the standards and best practices. At least where I'm at, we focus so much time on training and onboarding and getting our "new hires" up to speed. However it's often the seasoned vets that have somehow incorporated an inappropriate practice into their behavior over the years and these are oftentimes the most challenging areas to correct. Constant education and retraining are necessary to ensure the standards are being met.

Steve D, 02/01/2022 09:18:46

Oh no, not again!!

Great story, one I hear far too often! Every semester as my students get their pre-clinical blood work done, I ask them to share their experience with the class and have them identify any incorrect things that the phlebotomist did when drawing their blood. It is very scary what we hear and your experience highlights all kinds of pre-analytical errors.

Rita Kealy, 02/01/2022 09:26:35

Addressing issues

I agree there are issues to be addressed! But until phlebs are compensated adequately, we cannot expect advanced training or the highest standards. It baffles me that those of us responsible for collecting samples that directly affect patient health plans are not held in higher esteem.

Emily, 02/01/2022 09:27:11

Unfortunately phlebotomist have bad experiences when getting their blood drawn

I participated in a COVID study which involved getting your blood taken every few months. They knew I was a phlebotomist which made the girl nervous. I had to correct her once because she almost did wipe with alcohol before I stopped her. Then, she missed. She took the needle out and didn't cap it and left it on the gauze and prepared to poke me again- using the same needle! I was shocked! I told her no way you can't do that. Her reply was that we do that all the time! I explained that that is never an acceptable practice. I should have reported the incident to the clinical coordinator but let time pass before it was too late. There were other errors - but I've had to do the same types of things you had to do. Ugh. Now, I just let me co-workers that I trust draw my blood!

Martha, 02/01/2022 11:29:01

Phlebotomist - retired

I have advocated to my state legislators to require a phlebotomy license. This is not even close to some nightmare stories I've heard or witnessed.

Mark, 02/01/2022 11:31:49

What, therefore, should we do?

I wonder which of the following actions you feel we should take:

1. threatening or insinuating legal action could be taken as adherence to CLSI standards is mandatory.

2. Letters/phone calls to management on a case-by-case basis as a customer of care.

3. Organized effort in each state to enact laws which require certification and licensure standards with required documentation of competence by CLSI standards annually with licensure revocation for demonstrated incompetence.

There are pluses and minuses for each of these approaches including feasibility, and costs.

Is there a different recommended approach?

Marianne T. Downes, 02/01/2022 12:34:14

Lupus and Phlebotomy

I have been a phlebotomist for about 30 years, and I have lupus. My joints are extremely tender, especially my antecubital fossa area. I have blood taken every 3 months and every time I have an issue with the tourniquet being on to tight and to long. It hurts so bad I almost get into tears! I have ask that they do not tie it so tight and it seams like they just re-tie it tighter! I too, have taken the tourniquet off or try and loosen it up. I really get very frustrated and dread going to get my labs even taken.

Kathy Harris CPT, 02/01/2022 12:39:19

Bad management

Shanise, only when those training or coaching phlebotomists concentrate on consistency and good habits, will this start to get better. Management in most of these facilities only want the job done, not necessarily done right. The phlebotomy trainers MUST teach new phlebotomists to create good habits and practices up with consistency. In this profession, phlebotomists mostly work alone, with little to no supervision. This leaves phlebotomists open to create their own version of what to do when released on their own. Instead of utilizing good habits formed by initial training, that a lot of times never even get brought up by those training them. We as trainers fail these phlebotomist, along with every patient they victimize, by not teaching them to create good habits initially and to be consistent with those habits. This is a tuff row to hoe for those who train new phlebotomists, with lots of weeds, and management being one of those weeds sometimes.

Jonathan Dobler, 02/01/2022 13:22:41

Great article

Thanks Shan for sharing this experience. I too have had many similar experiences, and have spoken up up during the blood draws as well as written emails to the pathology group trainers. In most cases I have found that people don't want any feedback that isn't positive, but how do we encourage change without being able to critique our own practice?

I am a phlebotomy trainer in Australia and really value the technical information and support I get from the Centre for Phlebotomy Education and CLSI. I'm particularly thankful because we don't have anything like this in Australia - no standards, no central body of authority, no certification of phlebotomists. We do have a TAFE system (in between high school and university level education often associated with trades training) where they offer a Certificate in Pathology Collection, but this is not a mandatory requirement for phlebotomists working in Australia.

I personally attended a cannulation course a few weeks ago (which included basic phlebotomy training as part of the 1/2 day package!) and was astounded that some of what was being taught (by a Registered Nurse) was inaccurate and had potential to cause harm to the patient and the blood sample. This just reinforced to me, the need for standardised training for all people who work in this field.

Roxanne Maher, 02/01/2022 17:17:05

Similar Experiences

I have been a phlebotomy instructor for over a dozen years and have had similar experiences to what you're describing. Even worse is when I witness collection errors at the clinical sites where my students are completing their rotations. Often, when I present my observations to the lab managers they either deny that their phlebotomists do anything wrong or simply dismiss my concerns. They know the CLSI guidelines just like I do but they do not enforce them and will tell my students things like "in the 'real' world, what your teacher said doesn't apply" which isn't true - when I worked "in the real world" i followed ALL the guidelines the same way I teach it!!

Until and unless there is legislation in every state, this problem will persist.

Kristie Fuller, 02/01/2022 18:22:17

Training

I enjoyed this article. I seriously have an issue with blood being drawn with no identifying. That is the most important part. It was also years before someone explained about the tourniquet staying on too long and how it alters the results. Training long ago said to keep the tourniquet on to keep the blood flow. So, I agree updates and revamping phlebotomy techniques can help a great deal for new and old phlebotomists.

Nicole Taylor, 02/03/2022 09:45:32

I have never understood the lack of training needed for phlebotomists given the vital role we play in the patients medical treatment with an estimation of more than 70% of a physicians decisions being based on information derived from the laboratory test results. Physicians rely on accurate laboratory test results for proper disease diagnosis and guided treatments. Any errors during the laboratory testing process can affect patient care, including delay in reporting, unnecessary redraws, misdiagnosis, and improper treatment. And not to mention at times these errors may even be fatal (e.g., acute hemolytic reaction after incompatible blood transfusion caused by an error in patient identification). I believe the lack of training leads to more of these errors in the preanalytical phase. It may not be possible to eliminate all pre-analytical errors but with the right standards, education, training and proper quality control measures we can prevent a good portion of them. But how or where do we even start to get more standardized education requirements for phlebotomists and more compensation?

Jennifer , 02/03/2022 19:22:20