Overview
Phlebotomy as the Backbone of the Laboratory
Usman Waheed, BS (MLT), MSc, MPhil Biochem,1* Muhammad Asim Ansari, BS (MLT), MSc Biochem,2
Hasan Abbas Zaheer, MBBS, FCPP, PhD1
ABSTRACT
In Pakistan, phlebotomy is the most underestimated procedure in
laboratory medicine, although it is a complex process requiring
knowledge and skill to perform. Most errors arise during this labor-
intensive, preanalytical phase. Lack of appropriate training can
result in improper specimen collection, which can lead to serious
complications, including misdiagnosis of the patient. In Pakistan,
The practice of modern medicine would be impractical
without the analysis performed in the clinical laboratory. In
Karachi, Pakistan, the first School of Medical Technology
was founded in 1961 at the National Health Laboratories
(now the National Institute of Health).1 Historically speaking,
phlebotomy—arguably the real face of any laboratory—has
been neglected. The effects of phlebotomy on specimen
quality are multifaceted; knowledge about these effects is
critical for preventing laboratory error and patient injury.2
However, practices vary among countries, institutions, and
individuals.3 A lack of training guidelines, standard operat-
ing procedures, and biosafety mechanisms may affect the
reliability of laboratory results derived from blood collection.
Keeping in mind the expression “the first impression is
the last impression” would direct us to think about the
neglected yet crucial phlebotomy department. The phle-
botomist is the ambassador of the laboratory. We have
noticed from patient feedback survey results that most
DOI: 10.1309/LMC7WIA8Z7VVBSTO
Abbreviations
EDTA, ethylenediaminetetraacetic acid; MRSA, methicillin-resistant
Staphylococcus aureus; TAT, turnaround time; MLT, Medical Laboratory
Technology; CME, continuing medical education; ISO, International
Standards Organization; HEC, Higher Education Commission
1
Safe Blood Transfusion Project, Islamabad, Pakistan, 2Department
of Pathology, Kulsum International Hospital, Islamabad, Pakistan
*To whom correspondence should be addressed:
E-mail: usman.waheed07@gmail.com
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no certification body or council exists for this discipline. Phlebotomists
must be properly trained and certified from an accredited organization.
Paramedical institutes need to introduce these processes as a
separate diploma or certificate course.
Keywords: blood collection, healthcare, pathology, MLT, Pakistan,
phlebotomy, laboratory
were predominantly concerned with the relative painless-
ness and pleasantness of the phlebotomy procedure rather
than factors such as speedy and accurate results or quality
control. Although we cannot promise the former, we can
focus on the latter. Regarding patient satisfaction, a strong
phlebotomy department could earn a favorable reputation
for the laboratory. The business plan (ie, cost and revenue
estimates), therefore, needs to focus on this key, often over-
looked, element to compete effectively in the health care
market.
Phlebotomy is about more than just the venipuncture tech-
nique. It also involves the interior design of the waiting room
and drawing stations, as well as the seating arrangement,
reading material, and decorations on the walls. Also of
concern are the dress code, language, and attitude of the
phlebotomy staff.
The patient needs to be comfortable during the procedure.
It is known colloquially in human psychology that negative
experiences linger longer in the mind than positive ones.
Therefore, a single negative phlebotomy experience on
the part of a patient can affect more than just the labora-
tory results. Common negative experiences reported by
patients includes the formation of a hematoma (ie, a local-
ized deposition of blood in the tissues), which could cause
a permanent compression nerve injury4; “double sticking,”
which happens when a phlebotomist is unable to puncture
a vein in the first attempt; pain at the site of venipuncture;
anxiety; and fainting. A study published by the Journal of
Family Practice5 reported the formation of a hematoma at
the venipuncture site in 12.3% of blood donors.
Overview
A review of the literature shows that only 13% of these er-
rors are analytical in nature,6-7 whereas 56% occur during
the preanalytical phase,8 the period between the time the
test is requested until sample analysis (ie, collection, pro-
cessing, and transportation). Preanalytical errors have fi-
nancial implications on laboratory budgets due to the costs
of repeated collection and retesting. Several preanalytical
errors can take place during the phlebotomy procedure,
namely, incorrect patient identification, improper tube se-
lection or labeling, unhygienic site preparation, delayed
tourniquet application, hemolysis, inadequate collection,
and erroneous order of tubes when drawing blood. The
sequence of drawing blood must start with blood-culture
vials, followed by sodium citrate tubes, serum (ie, gel)
tubes, and heparin, ethylenediaminetetraacetic acid (EDTA),
and oxalate/fluoride tubes.9 It is evident from these exam-
ples that this phase is complex and hard to manage.
Even the most sophisticated laboratory equipment can-
not guarantee accurate results from a specimen that has
been collected incorrectly. Phlebotomy will probably never
be fully automated and must be considered the backbone
of the analytical process because the probability of er-
rors is amplified when a manual procedure is brought into
play. For example, if a phlebotomist fails to use the correct
bar-code label on a specimen, it is reasonable that no one
could have spotted or anticipated this mistake. Phleboto-
mists must create an atmosphere of trust and confidence
with patients while drawing blood specimens in a skillful,
safe, and reliable manner. It is important that the profession
welcomes phlebotomists of both sexes, who must be dili-
gent, polite, and interactive, work well under pressure, and
communicate effectively. They must also act as the eyes
and ears of the other health care professionals, including
nurses and laboratory professionals.
Bioethical aspects should also be covered by phleboto-
mists, who must clearly describe all the procedural steps
and potential hazards to the patient or client. They should
communicate with the patient about the tests to be per-
formed on his or her specimen. Formal (written or verbal)
consent pertaining to all the procedures should be obtained
before venipuncture. Fairness and sincerity are closely
linked to the ethical aspect of phlebotomy.10 In case of mal-
practice, the phlebotomist faces an ethical decision; report-
ing actions that may constitute malpractice could result in
disciplinary action taken against him or her.
The techniques used for phlebotomy include venipunc-
ture, capillary (ie, skin) puncture, and arterial puncture.
Venipuncture, the most frequently performed procedure,
e70 Lab Medicine  Winter 2013  |  Volume 44, Number 1 www.labmedicine.com
involves the collection of blood from the veins (mostly medial)
for the purpose of diagnostic tests and blood donation. The
capillary puncture technique is useful in initial blood typing,
point-of-care testing, and in newborns, for whom this tech-
nique is preferred due to its low risk of injury.11 The arterial
puncture technique collects blood from the arteries to test
for arterial blood gases. Of importance, capillary puncture
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results have the same oxygen concentration as arterial punc-
ture results2; however, because the specimen volume and the
possibility of contamination with skin microbial flora are small,
this collection method is not suitable for blood gas testing. All
these techniques are best performed if the patient displays
strong involvement in the procedure and cooperation with
the phlebotomist. It is also crucial that phlebotomists practice
proper hand hygiene, wear personal protective equipment
such as gloves, decontaminate the skin before puncture,
and use a disinfected tourniquet. The contamination rate of
tourniquets with methicillin-resistant Staphylococcus aureus
(MRSA) has been reported to be 25% due to lack of proper
hand hygiene by phlebotomists.12
Professional and effective phlebotomy contributes to the
efficiency and reputation of any laboratory. The lowest pos-
sible turnaround time (TAT) for analysis is the key to suc-
cess for any laboratory. Trained phlebotomists can perform
their tasks efficiently; this, in turn, lowers TAT.
It is almost certain that the procedure of phlebotomy will
always be performed manually; therefore, it is crucial to
educate and to train staff involved with specimen collection
and handling, to help them avoid errors. For the same rea-
son, staff members that have already been trained should
follow the standard operating procedures and policies of
their laboratory. Proper training of personnel who perform
phlebotomy procedures remains crucial as institutions look
to improve patient care and to decrease collection errors
while keeping an eye on the bottom line. Many developed
countries offer professional diplomas and/or bachelors-
degree programs in phlebotomy.13 These certificates and
degrees probably cover all theoretical and practical aspects
of the subject. Unfortunately, in Pakistan, such academic
programs do not exist, to our knowledge; training institutes
for phlebotomy are insufficient. The common perception
is that anyone can draw a blood specimen after just a few
hours of basic training. This misconception has neglected
the field of phlebotomy as an independent subject. As a
result, we have self-trained individuals performing phle-
botomy rather than qualified phlebotomists.
Medical Laboratory Technology (MLT) diplomas and de-
grees offered across Pakistan have no credit-hour courses

or practical activities on the subject of phlebotomy.14 Thus,
one can easily evaluate how we focus and concentrate on
this vital laboratory procedure. Our phlebotomists in the
field do not understand the logic and philosophy behind
this science and so cannot consult with the patient in a
professional manner. An entire course or part of a course
should be incorporated into the syllabus of every MLT di-
ploma and degree program; paramedical schools should
also initiate an independent diploma or certificate course in
phlebotomy.
The standards of the profession of phlebotomy should be
raised; this will require planning to develop long-term train-
ing programs and refresher courses. Short courses (as part
of continuing medical education [CME])15 taken periodically
by all phlebotomists working in medical laboratories (in-
cluding blood banks) would increase the efficiency of these
employees and upgrade their knowledge based on the
latest advancements in the field. These courses could be
conducted as interactive training workshops to help bring
about continual improvement in the workplace. Motivational
visits to International Standards Organization (ISO)–certi-
fied/accredited laboratories should also be offered to the
student-professionals. To make this activity productive,
these training plans should be offered through public and
private institutions. Such courses should also give aca-
demic grades, to accommodate the likely preferences of
personnel in the institutional hierarchy. These training plans
should be offered through the Medical Laboratory Institutes
in close collaboration with the private sector, as a type of
public/private partnership, to equip trainees with informa-
tion on the latest developments and to make them aware of
the current market needs.
Identifying the categories and modules of long-term edu-
cation required for phlebotomy professionals in Pakistan
should be performed in close collaboration with the Higher
Education Commission (HEC), which has a well-defined
process for curriculum revision and is authorized through
Pakistani law.16 The objective should be to design a cur-
riculum that caters to the needs of Pakistani medical labo-
ratories (public and private sectors). The Higher Education
Commission and the Medical Laboratory Institutes should
establish a dedicated task force that would be responsible
for developing standardized and uniform curriculum at a
level equivalent to that of international medical colleges and
universities. All these reforms in the education and training
of phlebotomists would bring consistency in operations,
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Overview
update knowledge among health care professionals, and
impart appropriate skills.
The role of phlebotomy in health care should not be un-
derestimated. As an invasive procedure, it presents many
opportunities for error and harm to the patient. For policy-
and decision-makers, it is important to devise strategies to
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manage the risks involved. This involves the availability of a
trained workforce, hygienic environments, and a monitoring
and evaluation system that can document adverse events
and developments.
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