How many times should a phlebotomist try to draw blood?

Q How many
venipuncture attempts are permitted on a single patient? Is there a rule
that limits the number of attempts that can and should be made?

A The real issue in
venipuncture is not “how many attempts” but “when to stop.” Knowing when
to stop or defer a venipuncture requires assessing the patient and the
clinical situation, and evaluating whether the initial attempt has
already produced a complication. The purpose of policies to limit
multiple attempts at drawing blood is not to set a fixed number of
attempts but to preclude multiple attempts when it would potentially be
injurious to the patient.

From a risk-management standpoint, guidance for phlebotomists should
reflect the reasonable legal and clinical concerns, and clearly
establish and appropriately enforce the policy. Because of the potential
for complications, an assessment of the possible adverse outcomes is
needed in drafting a useful and reasonable policy.

Minor complications of venipuncture are local and relatively common — up
to 15% in some studies, most of which consider minor complications as
bruising, hematoma, or transient pain. Such problems are more common in
women, most notably bruising, which occurs about five times as often in
women as it does in men. Minor complications, by definition, resolve
completely and without medical intervention, though they may be
temporarily bothersome. Serious complications can be local or systemic,
are much less common — generally less than 3% overall — and include
diaphoresis, syncope, seizure, and temporary arrhythmias. Patient injury
from these reactions generally occurs secondarily, for example, when
syncope induces a fall that results in a scalp laceration.

Nerve injury can occur as a result of direct trauma or because of
compression as a result of hematoma. To determine the rate of such
injuries is difficult, but they, too, are relatively uncommon. Injuries
of this type can result in permanent damage and have even been
associated with the development of reflex sympathetic dystrophy, a
painful and often progressive condition that affects skin, nerves,
muscles, and even bones and joints.

The first avoidance of a repeat attempt is when the patient objects;
refusal is an absolute contraindication to an additional attempt until
and unless permission is given again. Proceeding in the face of a
patient’s objection could raise issues of battery, as could proceeding
in the face of a serious request to stop once the attempt is underway.
The use of topical anesthetics can reduce the incidental pain from
phlebotomy, resulting in more relaxed and cooperative patients
(especially children) and fewer objections.

When patients show evidence of direct nerve trauma (shock-like pains,
burning pain, pins and needles, especially when it involves the distal
arm and fingertips), the attempt should be stopped immediately; there
should not be a second attempt in the same site. Similarly, if the first
attempt has resulted in significant local bleeding which could result in
nerve compression, the procedure should be halted. In either case,
further attempts to draw blood should be deferred until the patient is
evaluated for the complication that has already occurred, if for no
other reason than to get baseline documentation of his status.

Recognition of patient conditions and clinical circumstances that
increase the risk of complication is also a basis for restricting the
number of attempts. Patients with bleeding disorders or those on
anticoagulants present an increased risk for localized bleeding.
Although additional attempts may be warranted, care should be exercised
not to exhaust available sites; appropriate post-phlebotomy care should
be instituted to limit bruising in sites where multiple attempts were

Any hard-and-fast rule about the number of permitted attempts is likely
to be arbitrary; not more than two venipuncture attempts is the most
common standard. In general, most patients do not require a second
attempt. The average number of attempts in one study of 500 samples
drawn reported 1.25 attempts per successful draw. A second attempt — if
necessary, at a second site — in the absence of potential complicating
factors is generally medically reasonable. Keep in mind that any such
limit is a maximum; depending on the patient and other circumstances, it
may be both reasonable and prudent not to make more than one attempt. If
a patient is agreeable to two or more attempts, documenting informed
consent is wise.

More important than a specific number of permitted attempts are good
training, oversight, and reporting to help phlebotomists perform within
their skills and their patients’ needs. Making sure an experienced
phlebotomist is always available to assist or relieve a less-experienced
colleague will help ensure that second attempts are productive. Tracking
complications can identify phlebotomists whose higher-than-average
complication rates may indicate a need for additional training. A
post-phlebotomy questionnaire also can provide helpful information by
assessing patient satisfaction in situations where no complication is
reported but some less-than-optimal result occurs.

Barbara Harty-Golder is a pathologist-attorney consultant in Chattanooga, TN. She maintains a law practice with a special interest in medical law. She writes and lectures extensively on healthcare law, risk management, and human resource management.

Published: May, 2010