Readers Respond

Sept. 1, 2010

Phlebotomy in Japan
I recall my medical residency in dermatology in Japan. Phlebotomy was my first medical procedure. In Japan, it is regulated that phlebotomy should be performed by a doctor or nurse, and there are no allied health professionals who are permitted to perform venipuncture, such as phlebotomists. Practically, phlebotomy is performed by a nurse in many hospitals and clinics. However, in some university medical centers it is a job that is assigned to a doctor, especially a PGY-1 resident. Residents are drawing blood in wards and clinics, often without being supervised.

I remember that Monday mornings were a nightmare because there were a lot of routine blood draws in wards. Those were ordered by Fellows and faculties, and it was tough for residents to ask them to cancel or postpone their orders. Nurses were not encouraged to help residents with blood collection. Faculties were reluctant to become pinch-hitters, because if they failed, it might affect patients' trust, or just simply, phlebotomy was relegated to residents. I cannot tell you how many times I attempted, but I can tell you that I learned that even the simple technique can be difficult under certain circumstances.

From my experience, blood collection from patients with atopic dermatitis is quite difficult. Hyper-reactivity and abnormal vascular response to cold or trauma are characteristics of atopic dermatitis. Constriction of the blood vessels may occur when venipuncture is performed. Atopic dermatitis patients are very sensitive to pain. Lichenification (thickening of the skin) is often seen in the cubital fossa, and the skin is hard and not easily punctured. Thus, phlebotomists should bear in mind that several factors make difficult blood collection from atopic dermatitis patients.

—Eijun Itakura, MD, PhD
Department of Pathology
and Laboratory Medicine
David Geffen School of Medicine at UCLA
Los Angeles, CA

Editor's note:
We asked our resident phlebotomy expert, Dennis J. Ernst, to comment on Dr. Itakura's letter regarding the “Liability and the lab” column of May 2010, page 54.

Dr. Itakura provided MLO readers with a fresh perspective of phlebotomy in other lands. It is so easy to be provincial about such things, but his account demonstrates how vastly different blood-collection procedures are handled in healthcare systems outside the U.S. We thank him for the insight. His comments also serve to underscore what we have always thought about phlebotomy, i.e., that it is the most underestimated procedure in healthcare. It may look simple, but performing a venipuncture in a way that prevents injury to the patient, accidental needlesticks to the practitioner, and the test results from being altered in the process requires comprehensive training and a healthy respect for the impact poor training can have on patient care and employee safety.

While we have this opportunity, we would like to correct a comment in the same column — that “Any hard-and-fast rule about the number of permitted attempts is likely to be arbitrary.” The CLSI venipuncture standard puts the limit at two before seeking assistance from another person and is likely to constitute the standard of care. That is not to say one cannot make a third attempt if another qualified healthcare professional is not available, but one must be sought first. In her list of risks that must be managed when contemplating repeat venipunctures, Dr. Harty-Golder makes no mention of how deviating from the standards can create liability. To function apart from the standards, even unknowingly, opens a facility up to accusations that it operates beneath the standard of care. I have seen it happen. In my experience as an expert witness, a deviation from that very passage was at the core of more than one plaintiff's case.

—Dennis J. Ernst, MT(ASCP)
Center for Phlebotomy Education
Corydon, IN

CLR 2010-2011 needs a “fix”
We apologize to users of our newest Clinical Laboratory Reference guide who may have discovered an error on page 12 where the columns to the right of the opiate drugs Duragesic and Atiq should have been moved one column to the right: 0.2-1 ng/mL (C)(4) should be under the category Urine cut-off points for reporting positive or limit of quantitation. We also apologize to Robert Williams, PhD, D(ABCC), F(ACB), MT(ASCP), Quest Diagnostics, who worked so diligently to update this information for MLO readers. A corrected version of the “Cut-off and toxicity levels for drugs-of-abuse testing” is available as a PDF online at