Venepuncture
Aims of the day
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Understand the legislation, policy and practice used when obtaining a venous
blood sample
Be able to recognize the anatomy and physiology relevant to obtaining a
venous blood sample. From the ante-cubital fossa of adults and children over
12 years
Understand patient care while taking a venous blood sample.
Demonstrate an understanding of possible adverse effects and how to manage
them should they occur while taking a venous blood sample
Demonstrate and understanding of safe waste disposal.
Demonstrate an understanding of infection control especially hand hygiene.
Recognize the procedure, technique, materials and equipment for obtaining
venous blood samples.
Recognise how to report, record and document venous blood samples.
Safely perform venepuncture.
Accountability,
competence & consent
Lynne Powell RN. MSc. PgCEd
Objectives
 Discuss the health care support worker code of conduct
 Briefly define accountability, competence & consent
 Briefly identify the issues and your responsibilities
surrounding accountability, competence & consent
 Define consent
 Discuss the legal issues surrounding accountability,
competence & consent
Code of Conduct for
Healthcare Support
Workers in Wales (2011)
&
Code of Conduct for
Employers in Wales
(2011)
Codes of Conduct (2011)
Code of Conduct for Healthcare Support Workers in Wales
Code of Conduct for Employers in Wales
 The purpose of both codes is to ensure a high quality service
that focuses on the needs & experiences of individuals
 The basic principle is service user safety and public protection
7 Standards
As a health care support worker in Wales you must;
1.
Be accountable for your actions & omissions
2.
Promote and uphold privacy, dignity, rights and wellbeing of
service users
3.
Work in collaboration with colleagues and as part of a team
4.
Communicate in an open and effective way
5.
Respect a person’s right to confidentiality
6.
Improve quality of care by updating your knowledge, skills and
experience through personal & professional development
7.
Promote equality
What is accountability?
To be responsible
and
answerable for actions
Code of conduct for HCSWs in Wales 2011
Accountability
Nurse/HCSW
NMC Law
Employer Patient
Competence
Having the necessary ability,
knowledge or skill to do something
successfully
Code of conduct for HCSWs in Wales 2011
Competency Assessment Scale
1. I do not know the knowledge and skills required
2. I know the knowledge and skills required but I
don’t have them.
3. I know and I am developing the knowledge and
skills
4. I have the knowledge and skills, but I don’t use
them.
5. I have the knowledge and skills, and I use them
regularly
There are National standards to describe the performance
level expected of someone doing a particular task.
To find out more access
NHS Careers http://www.nhscareers.nhs.uk/explore-by-career/widerhealthcare-team/careers-in-the-wider-healthcare-team/clinical-supportstaff/phlebotomist/
RCN
http://www.rcn.org.uk/development/general_practice_nursing_career_framew
ork/the_gpn_career_framework/level_2__sample_competences_for_a_health_care_assistant
Skills for health
https://tools.skillsforhealth.org.uk/competence/show/html/code/CHS132/
Consent
Permission for something to
happen
or
agreement to do something
Consent
The voluntary and continuing permission of the
patient to receive a particular treatment based
on an adequate knowledge of the purpose,
nature and risk of the treatment, including the
likelihood of success and any available
alternatives
Informed consent

Informed consent is based on a clear appreciation and
understanding of the facts, implications and future consequences
of an action

Patients have the right to make decisions about their own health
and medical care

Balance of risks and benefits of treatment

Consent must be voluntary

Failure to obtain consent can be viewed as assault

Implied consent
Capacity to consent
•
•
•
•
Mental capacity Act (2005)
Over 16yrs
Presumption of capacity S1(2)
If patient has capacity – bound by decision
however irrationa
• Record advice given
• Get patient to sign – record any refusal to do so
• countersignatory
Code of Conduct for Employers in Wales
(2011)
•
Employers have to provide mentoring, supervision, monitoring and
assessment for the HCSW
•
HCWS should have a named mentor
Employers must:
1.
Employ suitable individuals who understand their roles, accountability &
responsibilities
2.
Ensure HCSW are able to meet the requirements of the Code of Conduct
(2011)
3.
Provide education and training
4.
Promote the HCSW Code of Conduct
Employers
 Employers are legally responsible for the actions you carry
out during the course of your employment. This is known as
vicarious liability, and your employer will have insurance for
this purpose. Vicarious liability is not optional and employers
cannot choose to opt in or out. (RCN)
 Vicarious Liability – (English Law) imposes a strict liability on
employers for the wrongdoing of their employees while
conducting their duties
Lister v Romford Ice and Cold Storage Co[81] created a controversial principle at
common law that entitled an employer to recover the indemnity from the employee
Negligence
The law of negligence
 This allows a civil action to be taken to financially
compensate the person who has suffered unwarranted
harm, or damage at the hands of another.
Negligence has been defined as :
 The omission to do something which any reasonable
man would do, or to do something which a reasonable
man would not do
For a case of negligence to be proved by the
claimant, three elements must be satisfied.
 The defendant owed a duty of care to the
claimant
 There was a breach of that duty of care
 Harm occurred as a direct result of that
breach in duty of care
Material Contribution – Bailey v. Ministry of Defence (2008) ‘but for’
Duty of Care
 All healthcare professionals treating a patient
owe a duty of care to them
 The test of when that duty is breached is a
peer test. The law will judge your practice
against that of a responsible body of
practitioners with your qualification
(Bolam v Friern Management Committee [1957])
Sources of breach of duty
 Incorrect act
 An omission
 A consent issue
 Record-keeping
Examples of breach of duty
 MMR given instead of Hib
 Excessive pain following flu vacc
 Pt given follow up treatment for only 1 month rather
than a year (breach of duty - record keeping)
 Long term steroids for atopic eczema led to glaucoma
 Script for atropine given to wrong patient-glaucoma
Personal Development Plan
(PDPs)
Up to date job description
Personal development plans
 Helps identify own training and development needs
 Demonstrates personal development and career progression
 Can be used as a tool for annual performance
review/appraisal
 Assists employers and managers to identify areas that need
improvement in the practice
 http://www.wales.nhs.uk/sites3/home.cfm?orgid=739
Infection control and safe
waste disposal
Infection control
Taking blood is the most common
intervention that breaches the
circulatory system. Therefore
compliance with policies and
procedures is important to prevent
infection
Phlebotomy for Health
Care Support Workers
Lynne Powell RN. MSc. IP
Why hand washing is so
important?
Good hand hygiene is one of the single most
effective measures for preventing the spread of
infection
 Our hands move germs from one place to another
 By hand washing, we remove transient micro-
organisms acquired by recent contact with infected
patients, or with the environment
 Hand washing protects both patients, and staff
What Lives on our hands?
 Transient flora – acquired by contact these
micro-organisms survive on the skin for less
than 25 hours and can be removed by hand
washing.
 Resident flora – part of our normal skin flora
these micro-organisms survive and multiply on
the skin, they rarely cause infections (other than
skin infections) except when introduced into the
body through invasive procedures
When to decontaminate hands.
Every healthcare worker should conduct a risk
assessment to determine when to decontaminate
 Before contact with a patient
 After completing tasks where hands may have become
contaminated with micro-organisms
 When hands are visibly dirty or soiled
 Between different types of cleaning procedures
Types of Hand Washing
 Social
 Hygienic (aseptic)
 Surgical scrub
Social Hand Washing
 Soap and Water
 Reduces the numbers of transient micro-
organisms upon hands.
 Renders hands socially clean
 Sufficient for most daily activities
Social Hand Hygiene with Alcohol Gel
•
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Visibly Clean Hands
Utilise approx 3 mls
Allow hands to dry prior to patient contact.
NOT in cases of D&V
Hands must be dry prior to patient contact
Hand Drying
Micro-organisms transfer most
effectively from wet surfaces so
always dry hands thoroughly
with disposable paper towels.
Skin Care
Frequent hand washing can cause long term
changes in the skin.
• Always put soap onto wet hands.
• Apply hand cream regularly to protect skin
• Report any skin irritation/ abnormality to
occupational health advisor.
Other Measures
• Wear Short Sleeves
• Do not wear wrist watches
• No jewellery to hands or wrists other than wedding
band
• Short Nails
• No False nails/ Nail Extensions
• Moisturise Hands
Protective clothing
 It is appropriate for practitioners to wear non-sterile
disposable gloves and disposable apron
 Wearing gloves does not protect against needle-stick injury
but will protect against splashing or spillage
 Always ask about latex allergy if gloves are worn – use latex
free gloves
Waste disposal
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Hazardous Waste Regulations 2005
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Defined with the European Waste Catalogue (EWC)
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Doesn’t include domestic waste
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Regulated by the Environment Agency
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Failure to comply can incur fixed penalty notices, fines and even
terms of imprisonment
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Duty of care applies to everyone in the management chain; from
the person who produces it to the person who finally disposes of, or
recovers it.
Use and disposal of sharps
 needle-stick injuries lead to increased exposure to blood-
borne viruses. This can cause pain and anxiety. Sharps
injuries can be prevented by careful adherence to good
practice.
 Needles should never be re-sheathed
 All sharps should be disposed of at point of use
Needle Stick Injuries
 Bleed the site and wash under running water
 Inform the patient
 Take the patient’s full details and contact number
 Report the incident and give patient’s details to Clinical
Governance lead for risk assessment.
 Incident report
Environment
 Check that the area where venepuncture is to be carried out
is clean and tidy.
 Ensure that all equipment is easily accessible, sterile where
necessary, intact and in-date.
 Ensure good lighting.
 Tourniquets can be a source of infection.
Blood spillage Kits
Preparation; Pre-test
checks and record keeping
Aim
 Discuss preparation
 Discuss anxiety
 Identification
 confidentiality
 Record keeping
Anxiety
Anxiety can be caused by:  The undergoing investigations
 Previous bad experience
 ‘needle phobia’
 General dislike of medical procedures
Reducing anxiety
 Talk to the patient (check identity).
 Ask if they’ve had blood taken before.
 Do they know what the blood test is for?
 Explain how to obtain the results.
 Distraction can be useful (cough technique; creams).
 Be honest with the patient – regarding pain.
 Talk the patient through the procedure.
Identification
Implications of mis-identification
 Unnecessary tests performed
 Wrong procedure performed
 Wrong results given
 Wrong medication
 HARM TO PATIENT
Patient Identification
 Full name
 Date of birth
 Address
 NHS number
All these are used to identify a patient – remember if this
information is lying about others can identify the individual and
confidentiality may be breached
Confidentiality
 You have a duty to protect the patient’s information.
 It is generally accepted that information provided by patients
is given in confidence.
 The Data Protection Act (1998)
 Caldicott Report
 The Human Rights Act (1998)
Data protection Act (1998)
In March 2000, the Data Protection Act 1998 became law and applies
to all organisations. It covers computer and manual records across all
departments where patient information may be collected and used.
The principles in the Act state that information must be:
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Held securely and confidentially
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Obtained fairly and efficiently
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Recorded accurately and reliably
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Used effectively and ethically
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Shared appropriately and lawfully
The Caldicott Report
Caldicott Report provides a number of principles &
recommendations aimed at supporting the NHS in improving the
way it handles identifiable information. There are 6 Caldicott
principles;
 Justify the purpose(s) of using confidential information
 Only use it when absolutely necessary
 Use the minimum that is required
 Access should be on a strict need-to-know basis
 Everyone must understand his or her responsibilities
 Understand and comply with the law
The Human Rights Act 1998
Article 8 – The Right to Respect for Private and
Family Life
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The right to respect for private life
The right to respect for family life
The right to respect for one’s home
The right to respect for correspondence
The Act can be used only against a public body therefore
the NHS are subject to the Act
Failure to comply with either
the
The Human Rights Act
or
The Data Protection Act
could lead to litigation
Record keeping
4. Communicate in an open and
effective way
4. Document and maintain clear and accurate
record of your care and report any changes or
concerns in the condition of individuals
immediately to a senior member of staff
Good record keeping
 meets legal requirements.
 protects staff in legal situations.
 meets professional statutory
requirements.
 supports clinical audit.
Good record keeping helps to protect the
welfare of patients by promoting:
 High standards of clinical care.
 Continuity of care.
 Better communication and dissemination of information
between members of the inter-professional health care
team.
 An accurate account of treatment and care planning and
delivery.
 The ability to detect problems, such as changes in the
patient’s condition, at an early stage.
Record keeping
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ENSURE YOU HAVE THE CORRECT PATIENT
Remember the patient’s record is a legal document.
Remember patients have the right to access their medical records.
Record information as soon as it is obtained to minimise the chance
of mistakes.
Involve the patient in the compilation of their records.
Enter recordings into the correct Read codes.
Record the facts.
Avoid abbreviations as they can be confusing
Avoid duplication.
Useful information

WHO guidelines on drawing blood: best practices in phlebotomy

Code of conduct for healthcare support workers in Wales

Code of Conduct for Employers in Wales

Data protection Act (1998)

The Caldicott Report

Hazardous Waste Regulations 2005
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Look at health board guidelines
The clotting process
Taking a blood sample
Aims
 Describe the anatomy of the ante-cubital fossa
 Discuss the appropriate choice of vein
 Preparing the patient for taking blood
 Idendtify the order of draw
 Factors affecting venepuncture
 Discuss adverse effects and how to manage them
All arteries carry blood away from the heart
All veins carry blood to the heart
Most arteries carry oxygenated blood
Most veins carry de-oxygenated blood
•
Veins have vavles that prevent blood from flowing in the wrong direction
•
Veins are wider than arteries
•
Contraction of body muscles helps the blood flow through the veins
•
Arteries have more elastic tissue and a thick muscular layer to cope with the high pressure
of blood flow caused by the heart beat
•
Capillaries transport blood from the
arterioles to venules.
•
They are microscopic vessels which are
in most of our organs.
•
They are one cell thick so they allow
exchange of gas (O2;CO2); salts and
water to occur between the capillaries
and surrounding tissue.
Choice of vein
 The vein should be easily accessible.
 Choose a vein that can accommodate repeated blood
samples.
 Choose sites that are less sensitive.
 Do not choose veins that are adjacent to an infected area.
 CVA/mastectomy – do not use affected arm.
 The tourniquet may cause pain if joints are inflamed through
rheumatoid arthritis.
Improving access to veins
•
•
•
•
The application of a tourniquet promotes venous distension. The
tourniquet should be tight enough to impede venous return but not restrict
arterial flow. The tourniquet should be placed approx 7-8 cm above the
intended venepuncture site. Placing the tourniquet over a sleeve or paper
towel may be more comfortable for the patient to prevent pinching of the
skin. The tourniquet should not be left on for more than one minute as it
may cause haemoconcentration or pooling of the blood, leading to
inaccurate results. The tourniquet should be released as soon as the
vein has been successfully accessed.
Opening and closing of the fist encourages muscles to force blood into
the veins however this action may affect certain blood results e.g.
potassium
Blood supply can be increased by lowering the arm below the heart level
Venodilation and venous filling can be encouraged with warm
compressions either of clothing or heat packs covered in towels. This
procedure can only be used once prior to any venepuncture procedure.
Pathology forms
biochemistry
haematology
•
Renal
•
LFT
•
FBC
•
Glucose
•
PV
•
Lipids
•
TFT
•
Bone
•
B12/folate
•
ferritin
Preparation
1.
Wash hands
2.
Assemble the equipment - maintain sterility
3.
Identify the patient
4.
Identify the tests required on the form
5.
Allow the patient time to ask questions & express concerns
6.
Site patient – comfortable position arm extended &
supported
Action & observation
•
Determine the patient’s preferred site.
•
Ensure patient’s skin is clean.
•
Apply tourniquet (quick release) to upper arm approximately
3-4 ins above puncture site.
•
Apply enough pressure to stop venous flow but not arterial
flow – check pulse.
•
Observe and palpate selected vein (do not over palpate).
•
Instruct the patient to hold still.
Action & observation

Insert the needle into the vein.
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Once blood is flowing freely release tourniquet.
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Fill each tube to its mark.
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Invert the tube 8-10 times (do not shake)

Place cotton wool over site.

Remove needle.

Apply pressure to site.

Dispose of needle appropriately.

Check site and apply dressing, ensure patient comfort.

Complete labels on sample bottles.
Order of draw
 Blue tubes
 Red tubes
 Yellow tubes
 Purple tubes (EDTA)
 Grey tubes
Factors affecting the sample
 Wrong bottle used
 Wrong order of draw (contamination)
 Tourniquet too tight
 Sample left overnight
 Mislabeling
 Bottles not filled
Potential complications
Excessive bleeding
 Drug therapy (e.g. aspirin; clopidogrel; warfarin; heparin)
 Disease process (liver disease; hemophilia; von Willebrand
disease; deficiency of vitamin k.)
 Prevention – ASK; don’t overuse tourniquet; may need
clotting therapy before venepuncture
Potential complications
Haematoma – collection of blood leaked from the vein at
the puncture site. Causes
 Overshooting the vein
 Inadequate pressure applied after procedure
 Failure to release the tourniquet before removing the needle
 If haematoma occurs during the procedure, remove tube,
release tourniquet, remove needle, apply firm pressure for 23 mins and raise arm.
Potential complications
Bruising caused by blood seeping into the tissue. May occur in
patients that bleed easily. Drugs(e.g. aspirin)
Preventable by

Using suitable veins

Correct angle and insertion technique.

Do not apply excessive pressure during procedure, with tourniquet.

Use skin traction during insertion.

Apply adequate pressure after procedure
Potential complications
Arterial puncture – leads to bright red blood pulsating into
the tube. Preventable by thorough assessment of site and
correct insertion technique.
Management: Remove needle, apply digital pressure for 5 mins then pressure
bandage for 5 mins. Do not reapply tourniquet to that arm for
24 hrs. seek medical help. Needs to be reported (pt records and
incident reporting)
Potential complications
Excessive pain – caused by frequent use of vein, poor technique
(blind plunging where a nerve or valve is touched), anxiety, fear or low
pain threshold.

Ensure patient is comfortable, arm supported

Avoid sites of known nerves (lower part of cephalic vein, near
wrist),

Consider local anaesthetic cream

Distraction – ask pt to concentrate on breathing

If possible nerve damage – seek help from Dr. or nurse
Potential complications
Fainting
 Some patients may feel weak and become dizzy or faint.
Patients have no control over this condition.
 Call for help.
 Ask the patient to put their head between their knees.
 If they feel no better help them to the floor – lie them flat -
ensure a safe environment.
 Get help (phone).
Potential complications
Remember
 Most complications are preventable
 Assess site thoroughly
 Use correct insertion technique
 Use appropriate use of tourniquet
 Avoid blind plunging
Safety checklist
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Do you have the right person?
Is the patient comfortable and easily accessible?
Are you comfortable?
Is there a history of fainting?
Is equipment ready and accessible (e.g. sharps bin)?
Is your work area clean and tidy?
Do you have adequate lighting?
Ensure you have the correct patient
Enquire about allergies (e.g. latex; plasters)
Use quick release tourniquet.
Do not re-sheath used needles.
Finally
All adverse incidents should be
reported and an incident form
filled in
Any
questions?