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Phlebotomy for Health Care Support Workers Lynne Powell RN. MSc. IP.

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Presentation on theme: "Phlebotomy for Health Care Support Workers Lynne Powell RN. MSc. IP."— Presentation transcript:

1 Phlebotomy for Health Care Support Workers Lynne Powell RN. MSc. IP

2 Aims of the day  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.

3 Accountability, competence & consent Lynne Powell RN.MSc. ip

4 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

5 Code of Conduct for Healthcare Support Workers in Wales (2011) & Code of Conduct for Employers in Wales (2011)

6 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 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

8  Answerability  Responsibility  Liability  To be held to account  Authority  Autonomy  Open  Transparency What is accountability?

9 Accountability To make a decision and be held responsible for the decision made Things to consider:- Are you working in the best interest of the patient? Do you have the knowledge and skills to perform the task? If not – don’t do it, you must be competent If you’re unsure ASK Ensure to keep up to date

10 Nurse/HCSW Employer Law Patient NMC Accountability

11 Competence Specific knowledge, skills, judgments and personal attributes required to practice safely

12 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 (WiPP /NHS UNIT 3 – Competence from a HCA’s perspective)

13 There are National standards to describe the performance level expected of someone doing a particular task. To find out more access  Working in Partnerships Programme (WiPP) – NHS.  Skills for Health (competencies for the healthcare workforce) (

14 Consent Permission for something to happen or agreement to do something

15 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

16 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

17 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 Lister v Romford Ice and Cold Storage Co[81]

18 The Legal System of the United Kingdom  The United Kingdom of Great Britain and Northern Ireland (UK) consists of four countries: England, Wales, Scotland and Northern Ireland. Some law applies throughout the whole of the UK; some applies in only one, two or three countries.  The four principal sources of UK law are legislation, common law, European Union law and the European Convention on Human Rights. There is no single series of documents that contains the whole of the law of the UK.  For practical purposes, the most significant distinction is between civil law and criminal law.  Civil law covers such areas as contracts, negligence, family matters, employment, probate and land law.  Criminal law, which is a branch of public law, defines the boundaries of acceptable conduct. A person who breaks the criminal law is regarded as having committed an offence against society as a whole.

19 How CRIMINAL LAW is enforced in England and Wales  A person who believes that a crime has been committed contacts the police, who conduct an investigation. If, after arresting and interviewing a person, the police believe that he or she committed the crime, that individual is charged. A report of the case is then sent to the Crown Prosecution Service (CPS).  If the CPS believes that the case has a reasonable prospect of success, and that it would be in the public interest to do so, it will start criminal proceedings against the suspect, who becomes the defendant in the case. In court, the CPS bears the burden of proving, beyond reasonable doubt, that the defendant committed the crime.

20 How CIVIL LAW is enforced in England and Wales  A person who believes that another individual or organisation has committed a civil wrong can complete a claim form and send it to the appropriate court.  The person who starts a civil case is called a claimant, and he or she has the burden of proving that, more probably than not, the other party (the defendant) committed a civil wrong. If the claimant is successful, the usual remedy is damages: a sum of money paid by the defendant to the claimant.

21 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

22 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

23 Personal Development Plan (PDPs) Up to date job description

24 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 

25 Infection control and safe waste disposal

26 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

27 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

28 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

29 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

30 Types of Hand Washing  Social  Hygienic (aseptic)  Surgical scrub

31 Social Hand Washing  Soap and Water  Reduces the numbers of transient micro- organisms upon hands.  Renders hands socially clean  Sufficient for most daily activities

32 Social Hand Hygiene with Alcohol Gel 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


34 Hand Drying Micro-organisms transfer most effectively from wet surfaces so always dry hands thoroughly with disposable paper towels.

35 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.

36 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

37 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


39 Waste disposal  Hazardous Waste Regulations 2005  Defined with the European Waste Catalogue (EWC)  Doesn’t include domestic waste  Regulated by the Environment Agency  Failure to comply can incur fixed penalty notices, fines and even terms of imprisonment  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.



42 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

43 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

44 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.

45 Pre-test checks and record keeping

46 Aim  Discuss anxiety  Identification  confidentiality  Record keeping

47 Anxiety Anxiety can be caused by: -  The undergoing investigations  Previous bad experience  ‘needle phobia’  General dislike of medical procedures

48 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.

49 Identification Implications of mis-identification  Unnecessary tests performed  Wrong procedure performed  Wrong results given  Wrong medication  HARM TO PATIENT

50 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

51 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)

52 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:  Held securely and confidentially  Obtained fairly and efficiently  Recorded accurately and reliably  Used effectively and ethically  Shared appropriately and lawfully

53 The Caldicott Report  Caldicott Report provides a number of principles & recommendations aimed at supporting the NHS in improving the way it handles identifiable information.  Access to patient information is granted on a strict need to know basis.  Staff have a responsibility to keep information confidential and ideally should have a confidentiality clause in their contract of employment.

54 The Human Rights Act 1998 Article 8 – The Right to Respect for Private and Family Life  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

55 Failure to comply with either the The Human Rights Act or The Data Protection Act could lead to litigation

56 Good record keeping  meets legal requirements.  protects staff in legal situations.  meets professional statutory requirements.  supports clinical audit.

57 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.

58 Record keeping  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.

59 Taking a blood sample

60 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




64 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.

65 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

66 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.

67 Action & observation  Insert the needle into the vein.  Once blood is flowing freely release tourniquet.  Fill each tube to its mark.  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.

68 Order of draw  Blue tubes  Red tubes  Yellow tubes  Purple tubes (EDTA)  Grey tubes

69 Factors affecting the sample  Wrong bottle used  Wrong order of draw (contamination)  Tourniquet too tight  Sample left overnight  Mislabeling  Bottles not filled

70 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

71 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 2-3 mins and raise arm.

72 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

73 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)

74 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

75 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).

76 Potential complications Remember  Most complications are preventable  Assess site thoroughly  Use correct insertion technique  Use appropriate use of tourniquet  Avoid blind plunging

77 Safety checklist  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.

78 All adverse incidents should be reported and an incident form filled in Finally

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