Revision 1

Issued:March 2010

Due For Review: 2012

Registered in Dublin. Registered number 469164.

Reg Office 4 whitethorn centre,

Kilcoole, Co. Wicklow.

The goal of these Guidelines is to provide accurate and up to date information for

phlebotomists in Irish hospitals and other facilities offering phlebotomy services.

Our aim is to ensure that every patient who presents for a blood test can do so with

the knowledge that they are being treated to the highest standards possible.

Clinical and Laboratory Standards Institute Documents.

(formerly NCCLS)

These guidelines are intended to guide and facilitate members of the PAI in caring for patients. While every

reasonable effort has been made to ensure the accuracy of these guidelines, the PAI can give no guarantee that the

information is free from error or omission. The guidelines do not indicate an exclusive course of action or serve as a

definitive mode of patient care. Variations, which take into account individual circumstances, clinical judgement and

patient choice, may also be appropriate. Phlebotomists are strongly recommended to confirm by way of independent

sources that the information contained within the guidelines is correct.

The PAI accepts no liability for any act or omission occurring in reliance on these guidelines or for any

consequences of any such act or omission.

The guidelines may be used for private education and research. However, if the user intends to employ the

guidelines for any other purpose, the user must first obtain consent from the PAI.

No part of the guidelines may be reproduced, stored in, or introduced into a retrieval system or transmitted in any

form without prior consent and acknowledgment of the PAI. The PAI retains copyright.

Tom Moloney Executive Officer AMLS

Brian Haskin Course Coordinator CIPH

Paul McGinn Barrister at Law

Niall O’Donnell

The Phlebotomist’s Association of Ireland was set up in 1995 by the members of

the Phlebotomy profession, to look at and address various issues of concern to the

profession and to meet the needs of phlebotomists throughout the country.

professional accreditation, and to regulate entry into the profession.

and to provide for accreditation for those already working in the profession,

provided that they satisfy a minimum requirement criterion.

exchange of information.

major Unions) in order to improve conditions, status and salary.

profession in its own right.

This Code of Practice is intended as a framework for each phlebotomist to ensure

high standards of conduct in his/her individual practice. It is intended for

practitioners working in hospitals, clinics or other environment. Any circumstances

which could have adverse consequences for the patient/practitioner or colleagues,

or which are not in accordance with safe standards of practice, should be made

known to the appropriate person or authority.

The person presenting for a phlebotomy procedure, regardless of health or status.

The person carrying out the phlebotomy procedure, whether a dedicated

phlebotomist or a nurse/phlebotomist.

of professional behaviour from its members and requires members to

conform to the National Guidelines for phlebotomy.

committed within the scope of their employment, the phlebotomist remains

accountable individually for his/her actions. He/she should therefore, comply

with the accepted standards of his/her profession. This standard is based on

conformity with a responsible body of opinion within the profession and is

outlined in National Guidelines. The trained and practiced phlebotomist

holds him/herself out as being proficient in a particular skill. The standard

expected is that he/she exercises the skill of a competent person exercising

that skill.

Guidelines, while taking account of local requirements in his/her employing

institution. Where these diverge, the phlebotomist should bring the National

Guidelines to the attention of the employer. All policies should be in writing.

safety and infection control guidelines laid down by his/her employing

authority.

assessed to be competent to carry out a particular procedure, before carrying

out that procedure. He/she should not carry out procedure that he/she has

not

been trained for or that he/she does not feel competent to perform.

applicable to his/her profession. The Phlebotomist should also be aware of

and consult local Ethics Guidelines.

the healthcare profession and behave in a professional manner at all times.

instructions or orders given, he/she should bring this to the attention of the

healthcare worker ordering the test or giving the instruction.

not rendered incompetent by reason of health to carry out duties. Where any

condition exists to impede proper standards of procedure, he/she should not

proceed with the task. Under no circumstances can the phlebotomist

practice while under the influence of alcohol or non-prescribed or nonapproved

drugs.

profession would consider inappropriate, dishonourable or disgraceful.

professional relationship will be regarded as professional misconduct.

condition or to inform him/her of the nature of the tests to be carried out or

the implications or results of any test that he/she may have had. However,

the phlebotomist should interact with the patient and can clarify the tests

ordered in order to help the patient to give informed consent and to promote

compliance with necessary instructions. Detailed queries should be

referred to the appropriate medical staff.

Sampling. He/she should ensure the Local Ethics Committee has given

approval and follow approved protocol.

of information about a patient.

on the understanding of confidentiality.

any privileged information disclosed to the phlebotomist in his/her

professional capacity should be regarded as confidential. Professional

judgment should be exercised in sharing this information with professional

colleagues.

treatment in a variety of condition. Confidentiality is of the utmost

importance.

directly concerned with patient care.

electronic processing of information to breach patient privacy.

should be considered. Request forms should be treated as confidential

documents. All material with personal details or information on a patient

should be shredded before discarding.

person. Therefore consent should be obtained prior to carrying out any

treatment or procedure.

(i.e. be of adult years and be of sound mind). The doctor ordering the test

should inform him/her as to the nature and purpose of the test. The

phlebotomist should then explain the procedure and gain the patient’s

consent. Consent may be expressed or implied.

refusal should be respected and documented. The nursing/medical staff

should be informed according to the employer’s policy.

prior to venepuncture procedure.

Given that the law respects the right of a patient even with reduced mental

capacity to refuse treatment, a phlebotomist should attempt to gain the

consent of such a patient to venepuncture, either by verbal consent or

implied consent. If the patient is unable to give consent, the phlebotomist

should consult the referring doctor or nurse. Under Irish law, the next of kin

cannot consent on behalf of such a patient but can only advise the treating

doctor or nurse about what may be in the patient’s best interests. It is then up

to the treating doctor or nurse to decide whether to prescribe venepuncture

on the basis of the patient’s best interests.

When a blood test has been ordered by a medical doctor for an unconscious

patient, a phlebotomist may presume that the consent has been given or that

the venepuncture has been deemed medically necessary in the patient’s best

interests. If, however, the patient has some level of consciousness, the

procedure of venepuncture should be explained to the patient.

under general consent for treatment, in accordance with the directions of the

ordering doctor.

and continuing education by co-operating in the training of phlebotomy

students.

trainees and ensure that any tasks delegated to them are appropriate to their

skill, experience and competency.

advances that affect their profession. It is the personal responsibility of each

practitioner to maintain his/her level of competency in practice to remain

updated.

adopt this code of Practice and will adhere to the National Guidelines in

Phlebotomy.

certification of phlebotomists. This will provide for a measurable standard

and certification for all practicing phlebotomists. It is envisaged that this or

equivalent will be the minimum requirement for new phlebotomy employees

in all healthcare facilities in the future.

systems and needs to be familiar with the properties of those used locally.

workplace is governed by the Safety, Health and Welfare at Work Act 2005.

The healthcare facility should have a Safety Statement available in the

workplace. Each phlebotomist should be familiar with the elements of the

Safety Statement which govern his/her practice. It is the responsibility of the

phlebotomist to read the Safety Statement. Each employing facility should

have a regularly updated policy on infection control which should be easily

available and understood by the phlebotomist. The policy should deal with

blood spillage, reporting of incidents and accidents as well as the

management of high risk patients. It should also include advice, counselling

and follow up services. Management should have a sharps policy. Hepatitis

B vaccination should be available for all at risk healthcare workers. Standard

precautions should always be observed when dealing with blood and bodily

fluids.

legislation. The phlebotomist should recognize that there is a potential risk

associated with the phlebotomy procedure. He/she should take all reasonable

precautions to protect against such risk. The phlebotomist has a duty of care

for his/her own safety at work and also that of co-workers, patients and any

persons who may be affected by his/her acts or omissions while at work.

such an extent as will enable his/her employer/other person to comply with

the relevant statutory provisions.

use by him/her alone or in common with others in the manner intended in

order to secure his/her safety, health and welfare while at work.

supervisor, without unreasonable delay, any defect in equipment, place of

work or system of work that might endanger safety, health or welfare, of

which he/she becomes aware.

Blood analysis is an important part of the diagnosis and treatment of the patient and great care

should be taken in ensuring that a suitable specimen is obtained.

It is of the utmost importance that the patient receives a quality service.

The need for accuracy in all aspects of identification, procedure, labelling and handling cannot

be over emphasised.

Venepuncture is the most commonly performed invasive procedure for patients in hospital and

outpatient clinics. Blood collection has become one of the major diagnostic tools available.

In order to carry out blood collection safely the phlebotomist should have a basic knowledge of

the following:

Many patients fear the prospect of undergoing phlebotomy. The phlebotomist can, with skill and

experience, minimise the discomfort and reassure the patient.

Accurate identification of the patient is essential.

All data is checked with the request form. Where any detail is incorrect

nursing/medical staff should correct it prior to procedure.

All data is checked with the request form or G.P. letter. Where any detail is

incorrect or unspecific the phlebotomist may need to contact G.P. to verify request

prior to procedure.

Name, D.O.B. and M.R.N. on request form should be checked with wrist- band.

Carer, relative or nursing staff should verify details.

All equipment to be used in the collection of the sample should be prepared in advance.

This includes:

All equipment should have expiry dates and sterility seals checked before usage.

venepuncture.

circulation. The pulse should be palpable below the level of the tourniquet.

required to find a suitable vein the tourniquet may be released and reapplied.

and allowed to dry, then tourniquet re-tightened to proceed with venepuncture.

sufficient blood is obtained, the tourniquet may be reapplied lightly.

These are used where transmission based precautions are required.

For example; elasticised strap with Velcro fastening or Latex strip.

amputation and fistula.

When the patient has been correctly identified:

wrist extended.

decontamination of the site.

discomfort.

patient’s arm with the bevel of the needle facing upwards and in line with blood flow

direction.

is inadequate tourniquet may be lightly reapplied.

vacuum is exhausted and blood flow ceases.

or 23g blood collection set may also be used.

causing pain and trauma to the patient.

8 times (or in accordance of manufacturers instructions) avoiding vigorous shaking of the

tube.

vein.

needle is fully removed.

possible.

requirements.

discouraged as it can lead to bruising.

waste bin.

waste bin.

waste bins, in room.

been engaged fully, before placing in a sharps container. Never separate needle from holder.

When labelling a general sample, the following information is required:

The full forename should be used. An initial for the first name is not sufficient. Blood sample

tubes should be labelled in the presence of the patient. The patient’s wristband should be checked

prior to sampling.

The labelling requirements for a pre-transfusion sample are:

The following information is required:

It is essential that this information is provided on the sample, otherwise the relevant laboratory

will not process the sample.

Where a minor mistake occurs, correction may be acceptable.

All corrections should be initialled.

responsibility of the phlebotomist to ensure that all samples are correctly identified and labelled

or scanned.

There are a number of factors that may render the sample unsuitable for testing or which may

interfere with accuracy of results. These are known as pre-analytical variables. They can occur at

any time from phlebotomy procedure to the testing of the sample.

Immediately following blood collection, all tubes should be inverted 5 to 10 times or as per

manufacturer’s instructions, at approximately 180°. For a complete inversion, the air bubble

should move from the top to the bottom of the tube. Inverting the tubes will lead to adequate

mixing of the blood and the tube additives and give more accurate results.

When taking blood, the tubes should be filled in a specific sequence in order to reduce the risk of

the additives in the bottles contaminating each other and falsifying the results of the test. The

recommended order is as follows:

Each evacuated specimen bottle contains a pre-measured amount of vacuum. This allows the

tubes to fill a definite point, marked on the bottle with use of an arrow or dot. Suction tubes

should be filled to the mark.

While it may be possible to test blood at a level below this line, the results will not be as

accurate.

For this reason, the sample may be unsuitable for testing.

Where a butterfly system is used for coagulation sampling, the tubing should be primed with a

non additive discard tube or a citrate tube. This ensures adequate fill in sample tube.

Haemolysis, the process by which the red blood cells disintegrate and release their pigment,

occurs normally at the end of the life cycle of the cell. This effect is undesirable when testing the

blood, as it renders the sample unsuitable. Haemolysis usually occurs for the following reasons:

Strict adherence to protocols will reduce risk of haemolysis.

If the patient requiring blood collection is receiving IV therapy in one arm, the other arm, if

possible, should be used.

If this is not possible due to medical reasons, or the patient is receiving bilateral IV therapy, then

one of the IV therapies should be stopped for 5 minutes prior to sampling. This allows natural

blood levels to recover and gives a more accurate result.Where I.V.potassium or anticoagulation

therapy is progress at access site, I.V. should be stopped for 10 minutes prior to

sampling. Nursing staff should be contacted to stop I.V. and to restart it following procedure.

Improper usage of the tourniquet may lead to the falsification of the results of the test. If the

tourniquet is placed too tightly on the arm, or remains in situ for too long a period of time, then

haemo-concentration or haemolysis may occur.

If the overall technique of the phlebotomist is poor, then one or more of the previously

mentioned factors may be associated with the unsuitability of a sample.

Where special instructions, e.g. time of day, fasting, post prandial, posture, or specified interval

following antibiotic or drug levels, are not adhered to, results may be inaccurate.

In addition to standard precautions which should be applied to all patients, transmission based

precautions are used for patients suspected or known to be colonised or infected with

transmissible micro-organisms.

The patient is colonised or infected with a communicable disease, and needs to be isolated from

other patients in order to reduce the risk of the infection spreading. e.g. Chicken Pox, Bacterial

Meningitis, MRSA, Tuberculosis etc.

The patient has a weak or suppressed immune system, and is highly susceptible to infection. This

patient needs to be protected from any infection that staff or other patients may be carrying.

Phlebotomist should be familiar with Infection Control Manual.

swabs, gauze balls, strip of tape disinfectant wipes, disposable tourniquet or and double

sheet disposable towel.. (Patient dedicated tourniquet may be left in room)

please ensure they are worn as directed.

A haematoma is a collection of blood under the skin. This can be painful and can potentially

cause nerve damage. If a haematoma begins to form while blood is being withdrawn, needle

should be removed immediately and pressure maintained over the site.

Incident form should be completed and medical / nursing staff informed.

Inadequate cleansing or poor technique can lead to infection.

Inappropriate sites or excessive probing may lead to nerve damage. Patient may complain of

severe pain. Procedure should be stopped immediately. If pain persists, incident form should be

completed and medical / nursing staff informed.

While some discomfort is to be expected, the needle should be removed immediately if the

patient complains of excessive or severe pain. If pain continues, medical/nursing staff should be

informed and an incident form completed.

Failure to properly identify the vein by lack of pulse and by collapse on removal of tourniquet

can result in inadvertent arterial puncture.

Where this occurs pressure should be maintained on the site for at least 5 minutes.

Nursing / medical staff should be informed and an incident form completed.

Should the patient complain of weakness or suffer a syncope, the phlebotomist should

immediately withdraw and dispose of the needle. If appropriate, sips of water can be given and

patient should be reassured.

Phlebotomy chair should be fully reclined or patient lowered to supine position.

Phlebotomist stays with patient until he/she recovers.

If Syncope occurs, incident form should be completed and medical/nursing staff informed.

A sharps/inoculation injury occurs when a clinically unclean or contaminated , or potentially

unclean or contaminated sharp e.g. needle, specimen bottle, vial etc penetrates the skin, and

exposes the recipient to risk of blood/body fluid borne diseases.

A splash injury occurs when blood/body fluid comes in contact with the skin or mucous

membranes i.e. eyes or mouth, and exposes the recipient to risk of disease.

Despite all precautions, sharps/splash and inoculation injuries do occur. Prevention of these is far

more desirable than treating one. Use of safety devices for blood collection reduces the risk of

sharps injury. Sharps Containers are effective methods of disposal of sharp clinical waste

material, as they are perforation proof. However they are not leak proof, and so, should exposed

blood products be placed in them, the risk of splash injury is increased.

The Infection Control Manual should contain the policy on treating a sharps injury. Action packs

should be available.

Phlebotomists should ensure that they are familiar with procedure for dealing with sharps injury

in their workplace.

To minimise the risk of a sharp/splash injury associated with phlebotomy procedure, the

following rules apply.

removing needle from vein.

a sharps box.

and use appropriately to clean the hazardous material.

has a wiping action and will reduce the amount of blood inoculated.

All sharp injuries should be reported to the head of department. A risk management occurrence

form should be completed, and other necessary paper work also. Early treatment is vital and so

every phlebotomist should familiarise themselves with the action packs, and especially the firstaid

instructions they contain.

Spill kit should be available in all phlebotomy areas.

Care should always be taken when handling blood specimens. All specimens are potentially

infectious.

Standard precautions should always be used.

This is the hospital management’s written policy for safeguarding and maintaining health and

safety standards. It specifies the manner, organisation and resources provided for that purpose.

It is the responsibility of each member of staff to read and become familiar with the safety

statement.

A copy of the Safety Statement should be available to all Phlebotomists.