Dear Center for Phlebotomy Education: Since I’m subscribed to the newsletters and bought the Lab Draw book, I’ve been up to date with the changes in using the wrist area in the CLSI standard. I’ve had no problems following this change in most of my patients. However, last week a patient came in whose wrist is her best spot. We’ve never found anything in her antecubital, and she won't allow us to use her hands because of a previous bad experience. The last time she came in I told her I would no longer be able to use her wrist because it is against the standards. She gave me a VERY difficult time.

So I got her to let me draw from her antecubital, and was only successful because of the tips I've gotten from Phlebotomy Today, (prewarming her antecubital and using an alcohol prep pad to point to the vein), and she was singing my praises. However, she's going to push for a wrist draw every time. Throughout the draw, she tried to convince me that she would not sue me or tell on me and that I should draw from her wrist. She said she did her own research and did not find anything about the wrist being unacceptable. She’s from Europe and feels that the change in the standards has to do with Americans being litigious, not necessarily what’s in the best interests of the patient. I tried reassuring her that I’ve used many patients’ hand veins without problems. 

My lab director doesn’t feel as strongly as me about the wrist. He feels the AC is worse than the wrist when it comes to a nerve injury. He supports my right to choose, but also the patient's right to say what’s done to her body. What should we do?

Our response: 

First of all, I sincerely appreciate your patient's concerns. She had a bad experience with hand veins. But she could have a bad experience with wrist veins soon if the site continues to be used. I think it's important for you to obtain the standard and show her the passage. The passage also needs to be reflected in your facilities procedure, which you can also show her. 

The passage was not inserted into the standards because the US is so litigious, but to protect patients from injuries. If there is no injury, there is no litigation. That's why there are standards, not to prevent lawsuits, but to prevent injuries. In the standards, my committee cites no fewer than 8 references supporting the passage against wrist veins.

Even though she insists she won't sue, you can't take the risk. People change their minds after they're injured. I can't agree with your manager, though, who said "people have a right about what happens to their bodies." With that logic, if the patient requested a puncture to the jugular vein, is it okay to draw there? Of course not. 

When patients challenge your choice of where to draw them, they are asking you to violate the standard of care. No patient has that right. If your facility allows this as a matter of policy, sooner or later a professional victim will show up, demand you draw from an unacceptable site or in an unacceptable way, and slap you with a lawsuit that is indefensible. Consider drug addicts. They're savvy and have a habit to finance. They know where the best sources of revenue are. Don't think some won't research what the standard says, get someone to deviate from it (like your manager),, fake an injury and cash in. Stranger things have happened.

This is not her right versus your right. She doesn't have the right to choose the site, especially when her choice violates the standards. Nor does your manager. You've done a magnificent job managing the customer service aspect of this without alienating the patient. I think your only path forward here is to continue resisting the wrist, show her documentation as to why it can't be considered, and draw from the AC, even if that means drawing from the basilic. It's not against the standards when there are no other AC veins. At the end of the day, the patient can choose to go somewhere else for her lab draws or allow you to draw from her hands. I think you should bring your risk manager into this discussion. He/she will certainly advise against allowing patients to dictate standards deviations. 

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