Student Name (PRINT) ________________________________________
:
1.
To assist development of proper collection technique using a Butterfly/Winged Infusion Set.
2.
To reduce accidental needle sticks involving Butterfly/Winged Infusion Set equipment.
3.
To improve patient satisfaction, specimen quality and procedure outcome.
.
Before the student performs venipuncture blood draws using Butterfly/Winged Infusion equipment, the following conditions must be met.
1.
Student has successfully completed a minimum of 5 successful venipuncture vacuum draws under the supervision of the clinical mentor.
2.
Student has observed a minimum of two (2) butterfly draws performed by a clinical mentor.
1.
The first five ‘butterfly’ venipunctures performed by a student MUST be under direct supervision of the clinical mentor.
2.
The mentor will observe that each item on the attached checklist has been performed in an acceptable manner. If the student makes any errors during the draw it cannot be counted as one of the five successfully observed draws.
3.
At the end of each draw, the mentor appropriately documents that each skill was performed correctly by filling in the attached checklist and signs and dates this signature page.
Each individual who supervises the blood collection must sign and date the collection observed.
Signature Date
1 st
draw supervised by:
2 nd
draw supervised by:
3 rd draw supervised by:
4 th
draw supervised by:
5 th
draw supervised by:
1

Student Name (PRINT) ________________________________________
Revised 11/21/13
Place a “  ” in the column to indicate the skill was performed successfully.
1.
Successful completion of routine pre-venipuncture procedures including :
1) Reviews test request form.
2) Introduces themselves to the patient, stating they are an ACC Phlebotomy student, and asking patient’s permission to draw their blood.
3) Identifies patient according to facility’s protocol.
4) Reviews patient blood drawing history and explains procedure as appropriate.
5) Sanitizes or washes hands and applies gloves.
2.
Applies tourniquet and evaluates the anticubital area of each arm independently - in search of a suitable vein that would allow use of traditional venipuncture equipment. Removes tourniquet within 1 minute or as soon as vein evaluation is complete.
3.
Based on proper evaluation of patient’s veins, unique patient attributes and the test(s) ordered, the student selects the appropriate site and equipment for venipuncture.
Use the letters below to indicate the site and equipment used for each butterfly draw
KEY A) back of hand using butterfly and syringe
B) lower arm using butterfly and syringe
C) anticubital area using butterfly and syringe
D) anticubital area using butterfly and vacuum collection system
4.
Properly cleanses site and allows to air dry.
5.
“Breathes” syringe and attaches to butterfly; has safety transfer device available (Or NA).
6.
Reapplies tourniquet; asks patient to clench fist as appropriate.
1 2 3 4 5
7.
With bevel up, bends wings of butterfly over the top of the needle and carefully removes cap
8.
Securely anchors vein below the intended venipuncture site, maintaining aseptic technique.
9.
Inserts needle swiftly and quickly into the vein using proper angle; looks for flash of blood.
10.
Anchors butterfly needle according to manufactures directions and facility policy.
11.
Carefully pulls back on syringe and collects blood sample (or NA).
12.
Collects correct volume of blood into vacuum tubes using the correct order of the draw, using a discard tube if necessary (or NA).
13.
Releases tourniquet at the appropriate time.
14.
Removes last tube from tube holder (or NA).
15.
Places gauze or biowipe over needle, quickly removes the needle and IMMEDIATELY activates safety device according to manufacturer’s instructions.
16.
Immediately applies pressure to venipuncture site, and then asks patient to take over.
17.
Removes syringe from butterfly tubing; discards butterfly needle and tubing appropriately .
18.
Attaches syringe to safety transfer device and fills tubes in the correct order of the draw.
19.
Discards syringe and safety transfer device appropriately.
20.
Performs routine post-venipuncture procedure including :
1) Mixes additive tubes gently.
2) Correctly labels tubes at the chair or bedside.
3) Inspects puncture site to make sure bleeding has stopped. Applies appropriate bandage.
4) Discards all used materials appropriately in sharps, biohazard trash or regular trash.
5) Thanks patient.
6) Disinfects work area according to facility protocol.
7) Removes gloves and sanitizes or washes hands.
2