Phlebotomy- It’s a

Risky Business
The Top 10 Safety Risks for Phlebotomists and Other Healthcare
Professionals

COURSE DESCRIPTION

This CE course will discuss (in no particular order) the major risks encountered on the
job by phlebotomists and other healthcare professionals. Some of the risks are unique
to phlebotomy, some to healthcare in general, and others can be found in all work
environments.

*Valid for P.A.C.E.® credit through 6/30/2022*

* ASCLS P.A.C.E.® is an approved continuing education agency by the California
Department of Health Laboratory Field Services, Accrediting Agency #0001.

*NCCT is approved as a provider of continuing education programs in the clinical

laboratory sciences by the ASCLS P.A.C.E.® Program, provider #122.

Rev 5
June 2020

COPYRIGHT
© 2020 National Center for Competency Testing
Reproduction or translation of any part of this work beyond that permitted by Sections 107 or 108 of the
1976 United States Copyright Act without the permission of the copyright owner is unlawful. No part of this
work may be reproduced or used in any form or by any means-graphic, electronic, or mechanical, including
photocopying, recording, taping, or information storage and retrieval systems without written permission of
the publisher.

1
 COURSE TITLE: Phlebotomy - It’s A Risky Business
Author: Lucia Johnson, M.A. Ed, MT(ASCP)SBB
Updated by: Tami Maffitt, MLS(ASCP)CM
National Center for Competency Testing
Number of Clock Hours Credit: 3.0
Course # 1220820
Level of Instruction: Intermediate
P.A.C.E. ® Approved: _X Yes _ No

OBJECTIVES
Upon completion of this continuing education course, the professional should be able to:
1. Identify activities and devices associated with sharps injuries in both the hospital
and non-hospital healthcare settings.
2. List ways to protect against sharps injuries.
3. Name the bloodborne pathogens of most concern for healthcare workers.
4. Identify documented infectious disease transmissions in healthcare and the
method of transmission for each.
5. Define and give examples of each of the links in the chain of infection.
6. Describe infectious disease transmission by contact (direct, indirect, contact),
vehicle, vector, and inhalation.
7. Identify how each link in the chain of infection can be broken.
8. Describe standard precautions and transmission-based precautions.
9. Describe work-related musculoskeletal disorders.
10. Identify exercises that may be helpful in preventing MSDs.
11. Identify risk factors for violence in hospitals and other healthcare settings.
12. List tips for healthcare professionals that alert them to the occurrence and
diffusion of violence.
13. Define slips, trips, and falls and list ways to prevent them.
14. Identify physical and health hazards and the potential effects of exposure to
each.
15. Identify components of hazardous materials labeling.
16. Identify information found in an SDS.
17. Identify patient injuries associated with blood specimen collection and ways to
minimize their occurrence.
18. List tips to deal with stress.
19. Identify risks associated with working non-standard shifts.
20. List recommendations to adjust and stay alert when working non-standard shifts.
21. List examples of workplace incivility.
22. Describe recommendations to reduce workplace incivility.

Disclaimer

The writers for NCCT continuing education courses attempt to provide factual information based on literature review
and current professional practice. However, NCCT does not guarantee that the information contained in the continuing
education courses is free from all errors and omissions.

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INTRODUCTION

Working in healthcare is rewarding. Those who do it report a satisfaction from helping

people who are recovering from surgery or dealing with an illness or disease.
Healthcare professions provide an opportunity to learn and grow from day to day
experiences.

The healthcare environment is however not without its problems. While all professions
have some sort of risk associated with them, working as a phlebotomist has its unique
risks.

This CE course will discuss (in no particular order) the major risks encountered by
phlebotomists on the job. Some of the risks are unique to phlebotomy, some to
healthcare in general, and others are found in all work environments.

- Sharps injuries
- Disease transmission
- Work-related musculoskeletal disorders
- Workplace violence
- Slips, trips, and falls
- Hazardous material
- Patient injury
- Stress/burnout
- Shift work
- Workplace incivility

RISK #1: SHARPS INJURIES

Sharps injuries can lead to serious and fatal infections. As many as 20 bloodborne
pathogens can be transmitted through a sharps injury including malaria, syphilis, and
herpes. Of most concern to healthcare workers in the United States are the
transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), and Human
Immunodeficiency Virus (HIV). These three viruses can cause potentially life-
threatening disease.

THE FACTS ABOUT SHARPS INJURIES

The National Institute for Occupational Safety and Health (NIOSH) which is part of the
Centers for Disease Control and Prevention (CDC), estimates there are 600,000 –
800,000 sharps injuries each year. About half of these injuries are not even reported.

Most sharps injuries are from hypodermic needles, blood collection needles, suture
needles, and needles used in intravenous catheter insertion. Sharps injuries can also
be caused by scalpels, fingerstick/heelstick lancets, and glass.

3
SHARPS INJURIES IN HOSPITAL AND NON-HOSPITAL FACILITIES

The Exposure Prevention Information Network (EPINet) collects data on sharps injuries
in both hospital and non-hospital (physician offices, long term care facilities, home
health, clinics, etc.) locations.

Figures 1 and 2 provide data from a 2017 EPINet survey conducted in hospitals. Figure
1 identifies activities associated with sharps injuries (in percentages) in the hospitals
surveyed in 2017.

Hospital Sharps Injuries

60%

50%

40%

30%

20%

10%

0%
During Use of Between steps of After use, before Disposal-related Other
Item a multi-step disposal
procedure

Figure 1

Over half of the injuries occur during the use of the sharp and 15% occurred after use
but before disposal. A small percentage occurred when a needle was recapped, a
practice that has been discouraged since the OSHA Bloodborne Pathogens Standard
was enacted in 1991.

Figure 2 on the following page identifies the type of device (in percentages) associated
with sharps injuries in hospitals in 2017.

4
 Types of Devices Associated with Sharps Injuries
in Hospitals
30%

25%

20%

15%

10%

5%

0%

Figure 2

Most hospital sharps injuries occur when using a syringe (for injection, venipuncture,
arterial blood gas collection, fine needle aspiration, etc.) and when using suture
needles.

The need to know when and how sharps injuries occur is important for two reasons.

1. Training can be provided to assure healthcare professionals are aware of high-

risk tasks and devices so they can be vigilant at these times.

2. New safe sharps products for high-risk tasks can be reviewed and implemented
as appropriate as a measure to reduce injuries.

PROTECTING AGAINST SHARPS INJURIES

Following are ways phlebotomists and other healthcare professionals can protect
themselves from sharps injuries.

 Plan for safe handling and disposal of sharps before using them.
 Receive training on the use of new safe sharps devices.
 Always use safe sharps devices per manufacturer’s directions.
 Assure sharps disposal containers are close to the procedure area.
 Assure sharps containers are at a height that allows users to see the top of the
container.
 Select sharps containers that are closable, puncture-resistant, and leakproof.
 Replace sharps disposal containers when ¾ full to avoid overfilling.
 Limit interruptions during procedures where sharps are used.
 Do not recap used needles.
 Promptly dispose of used sharps in the appropriate sharps disposal containers.
5
  Get assistance when performing procedures on patients that might be
uncooperative.
 Get the hepatitis B vaccine.

AFTER A SHARPS INJURY

Per the OSHA Bloodborne Pathogens Standard, employers must evaluate and treat
healthcare professionals in accordance with the most current post-exposure
assessment, prophylaxis, and treatment guidelines published by the CDC.

After a sharps injury, the following actions are recommended.

 Immediately wash the wound with soap and water. Do not apply pressure to the
wound. Allow it to bleed freely.
 Report the injury to a supervisor immediately after washing the wound.
 The employer will begin the process to assure proper medical assessment
occurs. This includes the following.
o Documentation of the exposure in detail.
o Identification of the source patient, who should be tested for HIV, HBV,
and HCV infections.
o Employee testing for HIV, HBV, and HCV status.
o Appropriate treatment per the current CDC guidelines.
 Receive monitoring and follow up of post-exposure treatment as indicated.

RISK #2: DISEASE TRANSMISSION

Phlebotomists and other healthcare professionals are at risk for occupational

transmission of a variety of diseases, primarily bloodborne pathogens and airborne
infections. Occupational transmission of disease is usually associated with violation of
one of the basic principles of infection control: handwashing, vaccination of healthcare
professionals, and/or timely placement of suspected or known infectious patients into
the appropriate type of isolation.

The following table identifies documented occupational infectious disease transmissions

to healthcare professionals.

MICROORGANISM DISEASE DESCRIPTION METHOD OF

TRANSMISSION
Adenovirus Most often causes respiratory illness, can also Respiratory droplets
cause fever, diarrhea, pink eye (conjunctivitis),
bladder infection (cystitis), or rash illness
Bordetella pertussis Whooping cough, a serious upper respiratory Respiratory droplets
illness
Clostridium difficile Infection of the colon that most often occurs in Indirect contact (oral-fecal)
individuals who have been using antibiotics
long-term; most common infection acquired by
patients while they are in the hospital
Creutzfeldt Jakob Rare, degenerative, and fatal brain disorder Bloodborne
Disease (CJD)

6
MICROORGANISM DISEASE DESCRIPTION METHOD OF
TRANSMISSION
Cryptosporidium Diarrheal illness Indirect contact (oral-
fecal)
Cytomegalovirus (CMV) Common virus; most infected Bloodborne
people have no signs or
symptoms; serious disease can
occur in people with a weakened
immune system and in babies
infected in utero
Ebola Hemorrhagic fever Direct and indirect
contact, respiratory
droplets
Helicobacter pylori Bacteria that causes gastritis and Indirect contact (oral-
gastric ulcers fecal)
Hepatitis A Virus (HAV) Self-limiting hepatitis, a liver Indirect contact (oral-
infection; usually no long term fecal)
effects
Hepatitis B Virus (HBV) Causes hepatitis, a liver infection; Bloodborne
many people infected have self-
limiting disease; for others serious
liver disease can occur
Hepatitis C Virus (HCV) Causes hepatitis, a liver infection; Bloodborne
many people infected have self-
limiting disease; for others serious
liver disease can occur
Herpes Simplex Virus (HSV) Oral and genital skin ulcers Direct contact
Human Immunodeficiency Virus Causes decrease in cells that Bloodborne
(HIV) provide immune function; can lead
to the development of Acquired
Immunodeficiency Syndrome
(AIDS)
Influenza A Virus Influenza (“flu”), respiratory illness; Respiratory droplets
Influenza B Virus can cause serious illness in the
very young and very old
Measles Virus (rubeola) Measles, usually a mild respiratory Airborne
illness with a rash
Mumps Virus Mumps, usually a mild illness with Respiratory droplets
swelling of the salivary glands
Mycobacterium tuberculosis Causes tuberculosis, a serious Airborne
lung infection that may spread to
other organs
Parvovirus B19 Fifth Disease, rash Respiratory droplets
Respiratory Syncytial Virus (RSV) Respiratory illness, can be severe Respiratory droplets
in newborns and the elderly
Rubella Virus “German” measles, usually mild Respiratory droplets
with fever and rash; infection in a
pregnant woman causes serious
birth defects
Salmonellosis Diarrheal disease caused by Indirect contact (oral-
several species of Salmonella fecal)
bacteria
Sarcoptes scabiei Scabies (skin mites); intensive Direct contact
itching
SARS-CoV Causes SARS (no new cases Respiratory droplet
since 2004)
SARS-CoV-2 Causes COVID-19 Respiratory droplet

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 MICROORGANISM DISEASE DESCRIPTION METHOD OF
TRANSMISSION
Shigellosis Diarrheal disease caused by Indirect contact (oral-
several species of Shigella fecal)
bacteria
Varicella Zoster Virus Causes chickenpox as an initial Airborne
(VZV) infection, and shingles when virus
is reactivated later in life

Phlebotomists and other healthcare professionals must know and practice infection
control recommendations with every patient to protect themselves from occupationally
acquired infections.

THE CHAIN OF INFECTION

Infectious diseases are spread through a series of steps known as the chain of
infection.

6 1
SUSCEPTIBLE INFECTIOUS
HOST AGENT

5
2
PORTAL OF
RESERVOIR
ENTRY

4
METHOD/ 3
MODE OF PORTAL OF EXIT
TRANSMISSION

For an infection to occur and spread, each of the six links of the chain must take place.
Removing any link in the chain will stop the cycle. Therefore, identifying and instituting
appropriate actions at different steps in the cycle will halt the spread of the infection.

1. Infectious Agent
Infectious agents can be bacteria, viruses, parasites, fungi, rickettsia, or prions.
 Bacteria - examples of disease: gonorrhea, tuberculosis, strep throat.
 Viruses - examples of disease: influenza, measles, hepatitis B.
 Parasites – examples of disease: malaria, pinworm, lice.
 Fungi (molds and yeasts) - examples of disease: vaginal yeast infections,
ringworm, histoplasmosis.
 Rickettsia - examples of disease: Rocky Mountain Spotted Fever, typhus,
scrub typhus.
 Prions - example of disease: Creutzfeld-Jakob Disease.

8
2. Reservoir
A reservoir is a place for microorganisms to live. Reservoirs can be animals,
insects, food, water, humans, objects, the air we breathe, etc. If a human, animal,
or insect serves as the reservoir, they often do not have any symptoms of the
disease.

3. Portal of Exit
For disease to be transmitted there must be a way for it to leave the reservoir. This
is known as the portal of exit. For example, some infectious bacteria may leave the
human body in the feces.

4. Method/Mode of Infection
Infectious diseases are spread by contact, droplet, vehicle, vector, and inhalation
(airborne). Some infectious diseases are spread by more than one route.

Transmission by Contact: Contact transmission is the most common mode of

disease transmission. There are three ways infectious diseases can be spread by
contact: direct, indirect, and droplet.

 Direct contact
o Some microorganisms are transferred from one individual to another
by close or intimate contact such as kissing, or transmission via
healthcare professionals touching a patient’s infected area with
ungloved hands.
o Example: staph/strep infections, scabies, herpes.

 Indirect contact
o Some microorganisms are transferred from one individual to another
when the healthy individual comes in contact with items from the
infected individual such as eating utensils, Kleenex, contaminated
clothing, bed linens, contaminated sharps (needles and instrument
probes), and splashes of blood, serum, plasma, body fluids to the
eyes, mouth, or nose. This includes bloodborne pathogens.
o Includes transfer of microorganisms through needle sticks and sharps
injuries; includes transfer of microorganisms via contaminated patient
care devices, shared toys, contaminated personal protective
equipment, and inadequately cleaned instruments.
o Examples: hepatitis B, hepatitis C, HIV, influenza, staph/strep
infections.

Transmission by Droplet

Microorganisms are present in respiratory droplets generated when an infected

individual coughs, sneezes, or talks. The healthy individual becomes infected when
these droplets come in contact with nose, mouth, or eyes.

 Requires close contact (typically within 3 feet); droplets are greater than (>) 5
microns in size.

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  Examples: Ebola, Bordetella pertussis (whooping cough), influenza, group A
strep, Rhinovirus, Neisseria meningitides, coronaviruses.

Transmission by Inhalation (Airborne)

Infectious droplets are generated by infected individuals when they cough, sneeze,
spit, laugh, or talk. Microorganisms are present in the droplets. The droplets, called
droplet nuclei, are less than (<) 5 microns in size, and can remain suspended in air,
be widely dispersed by air currents, and remain in air over a long distance. Infection
is transmitted when a healthy individual inhales the droplets.

 Close patient contact is not necessary.

 Examples of infections spread by inhalation include rubeola (measles),
Varicella Zoster virus (chickenpox/shingles), and Mycobacterium tuberculosis.

Diseases Spread by Droplets – Size is Important!

The difference between airborne and droplet transmission of infection is the size of the droplet that
contains the infectious microorganism.
Airborne Droplet
Infectious droplets are < 5 microns* Infectious droplets are > 5 microns*

Droplets are lifted up into the air and float with Droplets fall to the ground or surfaces
the air currents as a mist

Droplets can travel more than 30 feet Droplets travel only about 3 feet and no more
than six feet

Droplets can stay in the air for minutes Droplets stay in the air for less than a minute

Infection to a susceptible person can occur if Infection occurs through close contact with the
the mist is inhaled; close contact is NOT patient when he/she creates droplets when
necessary due to the distance the droplets can coughing, sneezing, talking, or during
travel procedures such as CPR, intubation, etc.

Infection to a susceptible person occurs when

the droplets come in contact with his/her
mucosal surfaces (eyes, nose, lips, mouth)

How does this affect healthcare professionals? This little variation in size makes all the difference in
protecting healthcare professionals from acquiring an infection from a patient.

 When working with a patient that has a disease spread by airborne transmission, a N95 (or higher)
respiratory mask. This mask is designed to prevent droplets < 5 microns from reaching the mouth. A
regular surgical mask will NOT protect healthcare professionals from infections transmitted via the
airborne route.

 When working with a patient that has a disease spread by droplet transmission, a regular surgical
mask is sufficient to protect healthcare professionals. The droplets are too large to go through the
mask. However, as droplets may cause infection if they reach the mucosal surfaces of the eyes, it
may be necessary for healthcare professionals to wear goggles or a face shield as protection. This
may depend on the procedure being performed on the patient.

*Please note that current research is controversial regarding droplet size as other factors may play into
the transmission of infection by droplets. However, current standards use 5 microns as the deciding
factor between airborne and droplet transmission. When there may be doubt about the type of personal
protective equipment to be worn, infection control professionals will err on the side of safety and require
the use of a N95 (or higher) respiratory mask.
10
Transmission by Vehicle
The infection is transmitted by contaminated food, water, drugs, and more. Examples
include food contaminated with E. coli 0157, salmonella, or hepatitis A.

Transmission by Vector
The infection is transmitted by the bite of an insect, animal, or arthropod. Examples
include West Nile virus (mosquito), malaria (mosquito), and Lyme disease (tick).

5. Portal of Entry
Microorganisms must have a means of entering a new reservoir or host. They can
enter through breaks in the skin, through the mucous membranes, through the
digestive tract, through an insect bite, through the respiratory tract, etc.

6. Susceptible Host
If the host’s immune mechanisms are strong, it may be able to stop the infection.
However, factors such as age, genetics, nutritional status, disease state, and overall
health, can make a person significantly more susceptible to a microorganism.

BREAKING THE CHAIN OF INFECTION

Methods used to break the chain of infection are shown in the table below.

LINK INTERVENTION
Infectious Agent  Early recognition of signs/symptoms of infectious diseases so appropriate
Transmission-Based Precautions can be implemented
 Accurate and rapid identification of microorganisms
Reservoir  Employee health exams and screening
 Environmental sanitization including floors, walls, exam tables, and beds
 Disinfection/sterilization of equipment and instruments
 Standard Precautions
 Medical asepsis
 Proper hygiene
 Clean gowns, linens, and towels
 Clean wound dressings
Portal of Exit  Appropriate hand hygiene
 Use of personal protective equipment
 Clean dressings over wounds
 Medical asepsis
 Control of excretions/secretions
 Covering the mouth and nose when coughing/sneezing
 Proper trash and waste disposal
 Standard Precautions
Method/Mode of  Appropriate hand hygiene
Transmission  Standard Precautions
 Rooms with air flow control
 Safe food handling
 Transmission-Based precautions
 Sterilization of equipment and supplies
 Medical and surgical asepsis
 Use of personal protective equipment
 Proper disposal of contaminated objects
Portal of Entry  Aseptic technique
 Sterile technique or surgical asepsis
 Medical sepsis

11
  Catheter care
 Wound care
 Proper disposal of needles/sharps
 Maintaining skin integrity
 Standard Precautions
Susceptible Host  Treatment of disease
 Recognition of patients at risk
 Immunization
 Exercise
 Proper nutrition

INFECTION CONTROL PRECAUTIONS

To minimize the spread of infection in healthcare settings, two types of infection control
precautions are used: Standard Precautions and Transmission-Based Precautions.

Standard Precautions

Standard Precautions are used for the care of all patients in all healthcare settings.
These are basic precautions used to limit healthcare professionals contact with all
secretions or body fluids, skin lesions, mucous membranes, blood, or body fluids.

Following is the list of Standard Precautions.

 Hand Hygiene: Clean hands with soap and water or an alcohol-based hand rub
to prevent transmission of microorganisms to others
o Soap and water handwashing must be performed in the following
situations as alcohol-based hand rubs are inadequate to prevent
transmission of infections:
 when hands are visibly dirty, contaminated, or soiled
 after using the restroom
 before eating or preparing food

o Perform hand hygiene before and after

 patient contact
 after contact with objects or surfaces in the patient’s immediate
vicinity
 after removing gloves

 Personal Protective Equipment

o Face mask/face shield/eye protection (goggles)
 Worn if contact with blood or body fluids may occur, especially
during suctioning and intubation
 Masks must be worn for insertion of catheters or injection of
material into spinal or epidural spaces via lumbar puncture
procedures (e.g., myelogram, spinal or epidural anesthesia)

o Gloves
 Worn if contact with blood, body fluids, mucous membranes, non-
intact skin, or contaminated items in the patient environment may
occur
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 o Gown
 Worn if contact with blood or body fluids may occur

 Safe Sharps Practices

o Do not recap, bend, break, or hand-manipulate used needles
o Use safety features when available
o Place used sharps in a puncture-resistant container

 Respiratory Hygiene/Cough Etiquette (for both patients and healthcare

professionals)
o Maintain a distance of at least 3 feet or wear a surgical mask
o Cover mouth/nose when coughing/sneezing
o Use tissues and promptly dispose of them in trash
o Perform hand hygiene after soiling hands with respiratory secretions

TRANSMISSION-BASED PRECAUTIONS

Transmission-based precautions are initiated as soon as a patient is suspected to be

infected. It is not necessary to wait for confirmation of an infection. These precautions
are used in addition to Standard Precautions. Transmission-Based precautions are
used to protect all people who enter the patient’s room from the patient’s known or
suspected infectious disease. There are three types of Transmission-Based
precautions: Contact Precautions, Droplet Precautions, and Airborne Precautions.

Contact Precautions

Patients are placed in Contact Precautions isolation when they have a known or
suspected infection that can be spread through direct or indirect contact with skin,
mucous membranes, feces, vomit, urine, wound drainage, or other body fluids.
Examples of these types of infections include herpes simplex, hepatitis A, MRSA, and
salmonellosis.

Gloves and gowns are worn when handling the patient, body fluids, or items from the
patient room. A surgical mask and eyewear should be worn if there is a potential for
exposure to body fluids.

Droplet Precautions

Patients are placed in Droplet Precautions when they have a known or suspected
infection that is transmitted by droplets formed when the patient coughs, sneezes, or
talks. Droplets formed when the patient coughs, sneezes, or talks can travel
approximately three feet. Examples of these types of infections include influenza,
whooping cough, and rubella.

Regular surgical masks are worn to prevent inhalation of droplets. Gloves and gowns
must be worn if being exposed to blood or body fluids.

13
Airborne Precautions

Patients are placed in Airborne Precautions when they have a known or suspected
infection where very small infectious particles can be carried on air currents and dust
particles. Examples of these types of infection include tuberculosis, measles, and
chickenpox.

The isolation room must have special ventilation with a negative air pressure.
Individuals entering the patient room must wear a high efficiency particular air (HEPA)
N95 or higher respiratory mask that has been properly fit. Gowns and gloves must be
worn if coming into direct contact with the patient.

ANOTHER TYPE OF ISOLATION - PROTECTIVE ENVIRONMENT

Patients who have received bone marrow or stem cell transplants are placed in a type
of isolation called Protective Environment. These patients are severely
immunocompromised and during the first 100 days post-transplant (usually) they are at
great risk of getting an infection from the environment and/or an individual entering their
room. The patients must stay in the room except for procedures that cannot be
performed in the room. They must wear a N95 respiratory mask when leaving the room
for any reason.

The room must have HEPA filters for incoming air. The air flow and air pressure must
meet specific guidelines to assure it is as free as possible of infectious materials.

Specific requirements exist for daily cleansing of the room and furnishings. No flowers,
fresh or dried, or potted plants are allowed in the Protective Environment room.

Use of gown, gloves, mask by healthcare professionals and visitors according to

Standard Precautions are recommended. If the patient has an infectious disease then
the appropriate Transmission-based Precautions are also implemented.

RISK #3: WORK-RELATED MUSCULOSKELETAL DISORDERS

When the physical requirements of the job and the physical abilities of the employees
do not meet, the result can be musculoskeletal disorders (MSD). MSD are also called
cumulative trauma disorders (CTD) and repetitive motion injuries (RMI). These
disorders result when muscles, joints, tendons, and nerves are overused resulting in
pain.

MUSCULOSKELETAL DISORDERS

MSD can be grouped into four types – tendon, nerve, neurovascular, and lower back.

TENDON DISORDERS
Tendonitis
 Inflammation of a tendon
 Usually occurs in hand, wrist, arm, shoulder
14
 TENDON DISORDERS - continued
Tenosynovitis
 Inflammation of the sheath that surrounds a tendon
 Usually occurs in hand, wrist, arm, shoulder
DeQuervain’s Disease
 Narrowing of the sheath that surrounds a tendon
 Occurs in wrist and thumb
Trigger finger
 Finger that jerks/snaps as a result of a locked tendon; end segments of the fingers end up being
flexed while the middle segments are straight
 Fingers and hand
Ganglionic cyst
 Tendon sheath swells up with synovial fluid
 Most commonly occurs in wrist
Epicondylitis
 Unsheathed tendons in elbows and shoulders become inflamed and radiate pain
 Occurs in elbows and shoulders
Rotator Cuff Syndrome
 Inflammation of the tendons in the rotator cuff of the shoulder resulting in pain
 Occurs in shoulders

NERVE DISORDERS
Carpal Tunnel Syndrome
 Compression of the nerve on the thumb side of the wrist resulting in weakness, pain, burning,
tingling, and numbness; reduced grip strength
 Affects hands (palm to area below the ring finger, the thumb and the index, middle, and ring finger)
Guynon Tunnel Syndrome
 Compression of the nerve on the “little” finger side of the hand resulting in weakness, pain, burning,
tingling, and numbness
 Affects little finger
Cubital Tunnel Syndrome
 Compression of the nerve below the notch on the inside of the elbow resulting in tingling,
numbness, or pain radiating into the ring or little finger
 Affects ring and little fingers

NEUROVASCULAR DISORDERS
Thoracic Outlet Syndrome
 Compression of the nerves and blood vessels between the collar bone and the first and second
ribs resulting in numbness of the arms; also limits muscle activities
 Occurs in shoulders and arms

LOW BACK DISORDERS

Low Back Disorders
 Lower back pain resulting from problems with muscles, intervertebral discs, and nerves next to
the spine resulting in pain
 Affects the lower back

Phlebotomists are at risk for MSD as in the performance of their work duties they

 perform repetitive tasks such as reaching for venipuncture supplies and twisting
with fingers to open venipuncture needles;
 frequently bend, reach, or stretch; and
 use awkward postures.

15
ERGONOMICS

Ergonomics is the science of designing the workplace to accommodate the worker for
the purposes of avoiding physical injuries resulting from work-related tasks. Employers
should proactively evaluate the ergonomics in their workplace. However, most
evaluations do not take place until an employee has reported an injury.

Some ergonomic techniques for phlebotomy include the following.

 Design phlebotomy draw areas to avoid reaching across the body to reach
needed supplies.
 Use adjustable height phlebotomy chairs for outpatients. These chairs can be
adjusted to assure minimal bending while performing phlebotomy and easy
access to phlebotomy supplies at the appropriate height.
 Place anti-fatigue mats in front of outpatient phlebotomy chairs to minimize
issues that can arise from standing in place for prolonged periods of time.
 For inpatients, use phlebotomy carts instead of trays. Pushing a phlebotomy cart
is easier on the hands and wrists than carrying a phlebotomy tray with or without
a handle.
 Raise inpatient beds to perform phlebotomy to minimize bending. Remember to
lower the bed before leaving the patient’s room.

Exercises performed throughout the day may help in preventing injuries. Phlebotomists
can benefit from performing the following exercises throughout the day.

 Head rotations to relieve neck tension

o Drop the head forward and rotate it in a circle to the left three times.
o Repeat the motion to the right.
o Perform this exercise slowly and avoid bending head backwards.

 Stretching exercises to reduce the chance of carpal tunnel syndrome

o Tightly clench hands and release. Fan out fingers.
o Repeat five times.
o Rest forearm on the edge of the table.
o Grasp the fingers of one hand and gently bend back wrist for five seconds.
o Repeat with the other forearm.

 Elbow presses to reduce the tension between your shoulder blades

o Fold arms at shoulder height in front of you and then push elbows back.
o Hold for a few seconds, repeat as necessary.

 Leg pulls to help stretch out your lower back and upper leg muscles
o From a sitting position, grasp the knee or shin of one leg and slowly pull it
toward chest.
o Hold for the count of three and then release.
o Repeat the movement on the other leg.

 Shoulder rolls to loosen tight neck and upper arm muscles

o Roll shoulders in a wide circular motion to the front.
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 o Repeat several times.
o Then perform the same movement to the back.

 Body bend to stretch out the lower back

o From a sitting position, slowly bend upper body down toward knees.
o Hold for a count of three then slowly raise upper body.
o Repeat several times.

 Deep breathing to promote breathing from the diaphragm—the key to relaxation

o On the count of one, inhale.
o Hold breath for counts of two and three.
o Count to four and exhale.
o Repeat several times.

Phlebotomists should assure they attend ergonomic training programs, report/offer

suggestions when unsafe working conditions are identified, and promptly report any
signs and symptoms of MSD or injuries.

RISK #4: WORKPLACE VIOLENCE

According to a report published by NIOSH in 2009, healthcare professionals are more
than three times as likely as workers in other industries to be injured on the job by acts
of violence. NIOSH defines workplace violence as any physical assault, threatening
behavior or verbal abuse occurring in the workplace. The violent acts occur during
interactions with patients, family, visitors, coworkers and supervisors.

In hospitals, it is patients and their family members who most frequently become violent.
These individuals often feel frustrated, helpless, and out of control. Violent acts may
occur anywhere in the hospital but are most frequent in psychiatric wards, emergency
rooms, geriatric units, and waiting rooms.

Common risk factors for violence in healthcare facilities include the following.

 Working with volatile people especially if they are under the influence of drugs or
alcohol, have a history of violence, or have certain psychological illnesses
 Working when understaffed, especially during meal times and visiting hours
 Transporting patients
 Long waits for service
 Overcrowded, uncomfortable waiting rooms
 Working alone
 Poor environmental design such as dark hallways
 Inadequate security
 Lack of staff training in preventing and managing potentially volatile
patients/family members
 Drug and alcohol abuse
 Unrestricted movement throughout the facility

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Violent acts include minor physical injuries, serious physical injuries, psychological
trauma, temporary and permanent disability, and death. Acts of violence have negative
outcomes in the workplace as a whole including low morale, increased stress, increased
turnover, and reduced trust of management.

Healthcare employers have the responsibility to prevent violence in the workplace and
should develop a program that includes management commitment, employee
participation, hazard identification, training, and reporting of violent acts. Whenever an
employee is threatened or assaulted, counseling services must be made available.

Tips for healthcare professionals follow.

Watch for signals that may be associated with impending violence

 Verbally expressed frustration and anger
 Threatening gestures
 Signs of drug or alcohol abuse
 Presence of a weapon

Maintain a behavior that helps diffuse anger

 Acknowledge the person’s feelings (“I know you are frustrated”)
 Remain calm with a caring attitude
 Avoid matching threats or giving orders
 Avoid behavior that could be interpreted as aggressive (speaking loudly, moving
rapidly, getting too close)

Be alert
 Evaluate the potential for violence with each and every patient/family member
encounter
 If you suspect a potentially violent patient/family member, do not isolate yourself
 Always keep an open path for exiting the room; i.e., do not let a potentially violent
person stand between you and the door

If a situation becomes violent

 Remove yourself from the situation if possible
 Call for help
 Report the incident to management

RISK #5: SLIPS, TRIPS, AND FALLS

When considering workplace falls, most people immediately think of falls from a height.
Yet according to the U.S. Bureau of Labor Statistics (BLS), the majority of fall-related
injuries (65%) occur as a result of falls from same-level walking surfaces. From a 2009
report, BLS reported a 90% higher rate of slips, trips, and falls (STF) from the same
level in hospitals than for all other private industries combined. STF as a whole are the
second most common cause of lost-workday injuries in hospitals.

Work-related STF can result in disabling injuries that prevent a healthcare professional
from the ability to perform his/her job, resulting in:

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  lost workdays,
 reduced productivity,
 worker compensation claims, and
 reduced ability to care for patients.

The most common injuries resulting from STF from the same level in hospitals include
back injuries, strains and sprains, contusions, abrasions, and fractures. Falls from the
same level can be categorized into three general groups.

Slip and Fall: Slips are primarily caused by a slippery surface and are compounded by
wearing the wrong footwear. Common causes of slips are:

 wet or oily surfaces,

 occasional spills,
 weather hazards,
 loose, unanchored rugs or mats, or
 flooring or other walking surfaces that do not have a consistent degree of traction
in all areas.

Trip and Fall: Trips occur when the front foot strikes an object and is suddenly
stopped. The upper body is then thrown forward, and a fall occurs. Common causes of
trips are:

 obstructed view,
 poor lighting,
 cluttered walkways,
 wrinkled carpeting,
 uncovered cables/cords,
 open cabinet bottom drawers, and
 uneven walking surfaces (steps, thresholds).

Step and Fall: Another type of fall is the “step and fall”. The first type of step and fall
occurs when the front foot lands on a surface lower than expected, such as when
unexpectedly stepping off a curb in the dark. In this type of fall, the person normally
falls forward. The second type of step and fall occurs when one steps forward or down,
and either the inside or outside of the foot lands on an object higher than the other side.
The ankle turns, and one tends to fall forward and sideways.

Preventing Slips, Trips, and Falls

1. Wear the right shoes for the job.

 Slip resistant footwear is the answer to preventing slips and trips.
 High heels, taps on heels, shoes with leather or other hard, smooth surface
soles lead to trips and slips.
2. Install non-skid strips or floor coatings in work areas that are likely to be slippery.
Mats or abrasive-filled paint-on coating can also reduce the risk of falling.

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 3. Assure extension cords and/or cables are not trip hazards. Whenever possible,
route them around an area instead of crossing an area.
4. Do not overload when carrying items; the healthcare professional should take
what can be carried comfortably, and should assure he/she can see over it.
5. Make sure that floor rugs/“scatter” rugs are attached to the floor with adhesive
strips.
6. Avoid bending while seated in a chair with wheels.
7. Report torn or loose carpeting right away.
8. Turn on the lights before entering a room. Report burned out light bulbs right
away.
9. Keep cabinet drawers closed when not in use.
10. If a wet or slippery surface must be walked upon, the healthcare professional
should slow down, take small steps, and keep a hand free for balance.
11. Take time and pay attention to the walkway.
12. Practice good housekeeping.
 Clean up spills immediately.
 Use “WET FLOOR” signs when needed.
 Secure mats, rugs, and carpets with tacking or tape.
 Remove obstacles from walkways.
 Keep clutter to a minimum.
 Keep working areas and walkways well lit.

RISK #6: HAZARDOUS MATERIALS

Many hazardous substances are used daily in healthcare. Some substances harm you
right away. Others may cause health problems that show up years later. When
hazardous substances are present in the workplace, OSHA requires employers to have
a written Hazard Communication program.

Health effects of hazardous substances: The following table summarizes the types
of health effects that can result from exposure to hazardous materials.

ACUTE HEALTH EFFECTS These happen right away. Some substances may cause
immediate coughing and a sudden burning feeling in the throat
upon exposure.
CHRONIC HEALTH EFFECTS These occur over time. Cancer or reproductive problems may only
occur after years of exposure.
TARGET ORGAN EFFECTS Health hazards could cause damage to the lungs, kidneys, liver, or
other body organs.
SYSTEMIC EFFECTS Exposure to hazardous materials may harm the central nervous,
respiratory, cardiovascular, or other body systems.

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Hazardous materials can enter the body by one of three ways: inhalation (breathing in
fumes), ingestion (getting the material into the mouth), or eye/skin/mucous membranes
(splashes or fumes that come into contact with the eye and/or skin).

Common hazardous materials found in laboratories and doctor offices include hydrogen
peroxide, glutaraldehyde, ammonia, chlorine, isocyanates (orthopedic casting materials)
and formaldehyde.

OSHA requires that employees who work with hazardous substances be trained on the
following.

 General information on types of hazards, potential health effects, exposure

routes, chemical inventories, safe work practices, and spill procedures
 Reading and understanding of labels on hazardous substances
 Information included in Safety Data Sheets (SDS)

Chemical inventories: Each laboratory must keep a chemical inventory that is

updated on an annual basis. The chemical inventory includes the following.

 Chemical name
 Catalog number (from the manufacturer)
 Quantity
 Hazard class and hazard severity
 Expiration date
 Storage location

Working safely with hazardous materials: Following are general guidelines for
working with hazardous materials.

 Know what chemicals are present in the work area.

 Handle all chemicals with caution.
 Store and transport chemicals safely. Check containers for leakage and missing,
torn, or illegible labels.
 Learn emergency procedures. Don’t wait for a crisis!
o Know what to do in the event of a spill.
o Know how to obtain an SDS.
o Wear the right personal protective equipment (PPE).
o Don’t misuse PPE. Gloves, glasses, and masks cannot fully protect if they are
damaged, the wrong size, or not designed for the hazardous substance in
use.

General spill instructions: Spills of hazardous materials are handled differently than
spills of blood or body fluids. Most laboratories use spill “pillows” to soak up the
hazardous material and yellow bags for disposal. However, this may vary from
laboratory to laboratory so facility-specific procedures should be reviewed and followed.

Potential and/or known reproductive toxins or carcinogens have special handling

procedures. Disposal of hazardous materials varies by type. Some can be flushed

21
down the drain, some can be recycled, and some must be picked up and disposed by a
licensed contractor.

Hazard Classification and Hazard Communication Standard (HCS)

Per OSHA, “OSHA's Hazard Communication Standard (HCS) is designed to protect

against chemical-source injuries and illnesses by ensuring that employers and workers
are provided with sufficient information to anticipate, recognize, evaluate, and control
chemical hazards and take appropriate protective measures.”

Laboratories have additional requirements and these can be found in OSHA’s

Occupational Exposure to Hazardous Chemicals in the Laboratory standard.

The purpose of the Hazard Communication Standard (HCS) is to ensure that the
hazards of all chemicals produced or imported are classified and that information on the
hazardous chemicals is transmitted to employers and workers. Chemical manufacturers
and importers are required to perform hazard classifications on the chemicals they
produce or import. Under the HCS, an employer that manufactures, processes,
formulates, blends, mixes, repackages, or otherwise changes the composition of a
hazardous chemical is considered a "chemical manufacturer."

Under the HCS, any chemical that is classified as a physical hazard, a health hazard, a
simple asphyxiant, combustible dust, pyrophoric gas, or hazard not otherwise classified
is considered a hazardous chemical.

PHYSICAL HAZARDS HEALTH HAZARDS

 Can harm quickly Can irritate, cause illness, or injure the body
 May cause fires or explosions, become unstable,
or react with other substances
Effects of physical hazards: Effects of health hazards:
 Explosive;  Acute toxicity (any route of exposure);
 Flammable (gases, aerosols, liquids, or solids);  Skin corrosion or irritation;
 Oxidizer (liquid, solid or gas);  Serious eye damage or eye irritation;
 Self-reactive;  Respiratory or skin sensitization;
 Pyrophoric (liquid or solid);  Germ cell mutagenicity;
 Self-heating;  Carcinogenicity;
 Organic peroxide;  Reproductive toxicity;
 Corrosive to metal;  Specific target organ toxicity(single or repeated
 Gas under pressure; exposure);
 In contact with water emits flammable gas.  Aspiration hazard.

Per HCS, the effects of each hazard are further broken into specific classifications that
are assigned a hazard category (often a number 1-4).

SAFETY DATA SHEETS (SDS)

There are many styles of Safety Data Sheets (SDS) but all must contain the same
details about hazardous substances. Each lab must either maintain a hard copy of the
SDS for each hazardous material in the chemical inventory or contract with a company
that can immediately provide a SDS on demand. Chemical manufacturers, distributors,
or importers are required by the Occupational Safety and Health Administration (OSHA)

22
to provide an SDS for any potentially hazardous chemical substance. The following
information is found in a SDS, regardless of the manufacturer.

SECTION INFORMATION CONTAINED IN SECTION

Introduction to the Hazardous Material
Section 1: Identification Tells the name of the substance, recommended uses, and who
made/imported it.
Section 2: Hazard(s) Identifies the hazards and the appropriate warning information
Identification associated with those hazards.
Section 3: Identifies the ingredient(s).
Composition/Information on
Ingredients
What to Do in an Emergency
Section 4: First Aid Measures Tells what to do if you are exposed to the substance.

Section 5: Fire Fighting Tells what to use to put out a fire caused by the hazardous substance
Measures
Section 6: Accidental Release Tells how to respond to spills, leaks, or releases, and how to clean
Measures them up.
How to Prevent Exposure & Accidents
Section 7: Handling & Storage Covers safe work practices for the substance.
Section 8: Exposure  Covers ways to reduce hazards and the correct PPE to use.
Controls/Personal Protection  Exposure controls show the greatest concentration of a chemical
an individual may be exposed to safely.
Section 9: Physical & Provides more technical data about the substance such as
Chemical Properties appearance and odor.
Section 10: Stability & Tells stability of the substance, and how it may react to other
Reactivity substances or conditions, like heat.
Other Useful Information
Section 11: Toxicological Based on test data, describes harmful effects that can occur if
Information overexposure to the substance occurs.
Section 12: Ecological Info Tells how a spill or release may affect plants, animals, and the
environment.
Section 13: Disposal Advises the proper way to dispose of hazardous waste.
Consideration
Section 14: Transport Provides basic shipping guidelines.
Information
Section 15: Regulatory Refers user to applicable federal, state, and international laws.
Information
Section 16: Other Information Contains any other information needed work safely with, store,
transport, dispose, etc. of the substance.

Labels

Per OSHA,

“Under the current Hazard Communication Standard (HCS), the label preparer must
provide the identity of the chemical, and the appropriate hazard warnings. This may be
done in a variety of ways, and the method to convey the information is left to the
preparer. Under the revised HCS, once the hazard classification is completed, the
standard specifies what information is to be provided for each hazard class and
category. Labels will require the following elements:

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 Pictogram: a symbol plus other graphic elements, such as a border, background
pattern, or color that is intended to convey specific information about the hazards
of a chemical. Each pictogram consists of a different symbol on a white
background within a red square frame set on a point (i.e. a red diamond). There
are nine pictograms under the GHS. However, only eight pictograms are required
under the HCS.

Signal words: a single word used to indicate the relative level of severity of
hazard and alert the reader to a potential hazard on the label. The signal words
used are "danger" and "warning." "Danger" is used for the more severe hazards,
while "warning" is used for less severe hazards.

Hazard Statement: a statement assigned to a hazard class and category that

describes the nature of the hazard(s) of a chemical, including, where appropriate,
the degree of hazard.

Precautionary Statement: a phrase that describes recommended measures to

be taken to minimize or prevent adverse effects resulting from exposure to a
hazardous chemical, or improper storage or handling of a hazardous chemical.”

Each time a hazardous material is used, the individual should assure the labels are:

 not worn, torn, or damaged;

 not covered up with another label, and
 present on all containers including secondary containers that do not have a
manufacturer’s label.

Globally Harmonized System (GHS)

SDSs are part of the Globally Harmonized System for Hazard Communication (GHS).
The GHS sets internationally agreed-to standards for hazard testing, warning
pictograms, and more. The manufacturing, transport, and use of hazardous materials
are part of the worldwide economy. As such, there is a need for universally accepted
definitions of health, physical, and environmental hazards, as well as specifying what
information should be included on labels of hazardous chemicals and in safety data
sheets. In 2003, the United Nations (UN) adopted the Globally Harmonized System of
Classification and Labeling of Chemicals (GHS). The GHS includes criteria for the
classification of health, physical and environmental hazards, as well as specifying what
information should be included on labels of hazardous chemicals as well as safety data
sheets. The United States was actively involved in the development of the GHS. The
GHS itself is not a regulation or standard. The GHS document is referred to as “The
Purple Book” and is updated by the United Nations every two years.

Implementation of GHS varies from country to country. In 2012, OSHA announced that
the Hazard Communication Standard (HCS) had been updated to align with the GHS. In
the United States, employees were required to be trained on the GHS including new
labeling and Safety Data Sheets (SDS) by 12/1/2013. By 6/1/2016, employers were
required to be in full compliance with revised HCS.

24
There are nine pictograms under the GHS to convey the health, physical and
environmental hazards. The Hazard Communication Standard (HCS) requires eight of
these pictograms, the exception being the environmental pictogram (as environmental
hazards are not within OSHA's jurisdiction). The hazard pictograms and their
corresponding hazards are shown below.

RISK #7: PATIENT INJURY

“It’s just a simple blood test.” “I just need to draw some blood.”

These two phrases are said a thousand times every day across the United States. In
truth, there is nothing simple about a phlebotomy procedure. To quote Dennis Ernst,
MT(ASCP), director of the Center for Phlebotomy Education in Indiana. “I refer to
phlebotomy as the most underestimated procedure in health care.” While it is estimated
that at least 1 billion venipunctures are performed each year in the United States, the
number that cause injury to patients is very small. However, when these injuries do
occur, they may be serious, life-altering, and even result in death. These injuries may
result in lawsuits against the healthcare facility, the phlebotomy supervisor, and the
phlebotomist. These lawsuits are generally ruled in favor of the injured patient.

25
Serious errors that result in patient injury can occur in any part of the phlebotomy
procedure. It is important that phlebotomists be aware of the risks involved in
phlebotomy and how to minimize them. It is vital that individuals performing
venipuncture procedures be correctly trained and follow the facility’s policies and
procedures. This is the best way for the phlebotomist to avoid legal action.

Following are the most common aspects of phlebotomy that lead to patient injury. For
all areas discussed, there are documented cases of lawsuits against the phlebotomist or
other healthcare provider for the injury incurred by the patient.

Communication with Patient

The phlebotomist’s very first contact with the patient is important. The phlebotomist
must identify him/herself and explain that he/she is there to collect a blood specimen.
This is the process of obtaining permission from the patient to perform the procedure.
Per the American Hospital Association Patient Bill of Rights, the patient has a right to
refuse any procedure. If the phlebotomist does not listen to the patient and ignores a
verbal or even a non-verbal refusal, he/she can be considered guilty of assault if the
procedure is performed. Once the phlebotomist proceeds and touches the patient to
perform the procedure, this can be considered battery, even if no harm comes to the
patient.

The same is true if the phlebotomist attempts to collect blood specimens from a
sleeping patient. Patients must always be awakened before a phlebotomy procedure is
performed.

If a patient is unconscious, a healthcare professional may perform whatever procedures

are reasonably necessary in the circumstances. If the patient’s spouse, legal guardian,
or individual who has healthcare power of attorney are present, they can be asked. If
no one is present, it can be assumed that the doctor has made the decision that the lab
work is needed and consent is then presumed.

Patient Identification

If a patient is not positively identified and blood is collected and labeled with incorrect
information, the laboratory test results from that specimen will not represent the status
of the intended patient. Serious consequences may arise if the patient is treated based
on the lab results. For example, underdosing or overdosing of medications such as
insulin and Coumadin® could be given to a patient, causing serious consequences.
The worst-case scenario is a patient dying because of an incompatible blood
transfusion.

Each patient should be identified with two unique identifiers. These identifiers include
patient first/last name, medical record number, birth date, Social Security number,
address, or unique number generated by a computer system. The patient should only
have blood drawn if the two unique identifiers match exactly. See the CLSI GP33
Accuracy in Patient and Specimen Identification standard.

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Selection of Venipuncture / Skin Puncture Location

1. In the antecubital area, the veins used for venipuncture lie in close proximity to
various nerves and arteries. Failure to select the most appropriate site for
venipuncture can result in nerve damage and/or puncture of an artery.

Permanent disability due to nerve damage may result if a nerve is punctured or

nicked during a venipuncture procedure. Several nerves lay among the muscles,
veins, and arteries of the arm. The nerves include the axillary, radial, median, ulnar,
and basilic. The median nerve is the nerve most likely to be punctured or nicked
during a venipuncture in the antecubital space. When this occurs, the patient will
exhibit severe pains in the arm. Numbness or tingling in the hand or arm may also
occur. The venipuncture should immediately be discontinued and direct pressure
applied to the site until bleeding has stopped. A supervisor should be notified about
the incident so the proper documentation is made and the patient is evaluated by a
physician.

If the venipuncture continues when the patient experiences the severe pain
associated with nerve puncture/nick, permanent nerve damage may occur. Life-long
disability may occur.

In the antecubital area, veins should be selected for venipuncture in the following
order.

 1st – Median cubital, often called the median vein

o Generally prominent and well-anchored
o Few nerves lie closely to this vein
 2 – Cephalic vein
nd

o Generally well-anchored
o May lie close to the surface requiring a very low angle of needle
insertion
 3 – Basilic vein
rd

o Should only be used for venipuncture when no other veins are

available
o May not be well anchored and can “roll”
o Median nerve lies closely to this vein and can be punctured or nicked
during use of this vein

Following are graphics demonstrating the two most common anatomic arrangements of
these veins in the antecubital fossa – H and M arrangements.

27
 NCCT Graphic

2. Venipuncture should not be performed on an arm where the patient has had a
mastectomy or lumpectomy with lymph nodes removed from the axillary (underarm)
area. Venipuncture, as well as other procedures such as injections, can lead to
infection which in turn can cause an inflammatory response. The inflammatory
response can result in the development of lymphedema, or worsening of existing
lymphedema symptoms. Lymphedema is fluid buildup in the tissues resulting in
painful swelling of the arm. As a result of other diseases and treatments,
lymphedema can also occur in the legs.

3. Veins in the ankle and foot should not be used for venipuncture without approval of
the physician. Poor circulation in the lower extremities due to age, diabetes, and
other disorders can lead to the development of blood clots and/or wounds that will
not heal, leading to infection, necrosis, and possible amputation.

Selection and Use of Equipment

Venipuncture equipment is not “one size fits all.” The type of equipment selected for
blood specimen collection depends on the vein or skin site selected, age of the patient,
and more. Use of the most appropriate equipment can assure the phlebotomist
minimizes the amount of needle movement, thus ensuring that nerves, arteries, and
other physical structures are not punctured.

1. Lancets used for newborn heel punctures must not exceed 2.0 mm in length. The
calcaneus (heel bone) may be no more than 2.0 mm beneath the plantar heel skin
surface and no more than half this distance at the posterior curvature of the heel.
Puncturing deeper than this on the plantar surface of the heel can risk puncture of
the bone, leading to potential infection and bone damage. Puncture of any length
should be avoided on the posterior curvature of the heel.

2. Successful venipuncture of veins that lie close to the surface (such as those on the
hands),veins that are small or fragile due to patient age (pediatric or geriatric), or
28
 treatments such as chemotherapy may require use of a winged infusion set, more
commonly called a butterfly. Insertion of a butterfly needle is at a lower angle and
the device can be manipulated easier than the adapter and safety needle unit used
for routine venipuncture, thus increasing the chance of successful specimen
collection.

3. When a phlebotomist needs to control the amount of force by which blood is

removed from a vein in order to avoid its collapse, a syringe and safety needle can
be used. The phlebotomist can control the removal of blood from the vein by
controlling the speed at which the syringe plunger is pulled.

4. Once a tourniquet is applied, it should be released if the phlebotomist requires more

than one minute to find a vein, cleanse and let the alcohol dry, and access the vein.
If these steps require more than one minute to complete, the tourniquet must be
released and then reapplied after a couple of minutes (to allow hemoconcentration
to disperse). Not only can prolonged tourniquet application affect the accuracy of
laboratory test results due to hemoconcentration, it can cause irreversible tissue or
nerve damage.

Angle of Needle Insertion

The venipuncture needle should enter the skin at an angle of less than 30°. Increasing
the angle of insertion increases the chance of the needle going through the vein and
puncturing or nicking a nerve or artery.

As discussed previously, damaging a nerve can lead to life-long disability. Puncture or

laceration of an artery can lead to unseen bleeding into the venipuncture area. The
accumulation of blood can cause severe pain and a compression nerve injury.

If the patient is taking anticoagulant drugs or is on aspirin therapy, blood can

accumulate in the subcutaneous spaces of the arm. This can result in a serious
complication called compartment syndrome, which may irreversibly damage nerves,
arteries, and muscles. Infiltration may also result in complex regional pain syndrome
(CPRS), which is a long-term neurologic disorder resulting from tissue damage.

Probing

When blood is not immediately obtained upon venipuncture, the needle can be
repositioned very slightly. If the needle has advanced too far, it can be gently pulled
out; if the needle has not advanced far enough, it can be gently pushed in. The needle
can be slightly rotated as the bevel of the needle may be up against the vein wall,
preventing blood from entering the needle. If slight movements are not successful, the
needle should be withdrawn and a new venipuncture performed.

These movements are very minute. Probing of any sort should be avoided as this is a
common cause of nerve and/or artery puncture or laceration.

29
Post-Puncture Care

As soon as the needle is removed, pressure should be placed on the puncture site. If
the patient is capable, they can firmly hold pressure on the site with a gauze square
using fingers from the hand opposite to the venipuncture arm. The patient should never
bend their arm as a method of applying pressure to the site. This practice does not
place pressure appropriately on the venipuncture site.

If the patient is not capable of holding pressure on the venipuncture site, the
phlebotomist must do so. Pressure should be applied until bleeding has ceased. The
phlebotomist should carefully observe the site for at least 10 seconds to confirm
bleeding from the site has ceased. The phlebotomist must also confirm that blood is not
seeping from the vein and pooling under the skin around the venipuncture site. It is
possible that the actual puncture site can cease bleeding but the puncture of the vein is
still oozing.

Bandages should not be placed over a venipuncture site until bleeding has ceased. If a
patient continues to bleed from the venipuncture site and/or blood is pooling under the
skin, the phlebotomist should raise the patient’s arm above their head, and firmly place
pressure on the venipuncture site. If the patient still continues to bleed, the patient’s
nurse should be notified and notation made in the patient’s laboratory and medical
record.

As previously discussed, accumulation of blood in the subcutaneous spaces of the arm

can result in severe pain, compartment syndrome, and/or complex regional pain
syndrome (CPRS).

Fainting/Syncope

Fainting, also called syncope, is the most adverse reaction to venipuncture. Of most
concern is the patient falling to the floor which can result in a sprain, strain, fracture, or
head injury. Phlebotomist should be prepared to watch for signs on fainting and react
according to facility policy.

Phlebotomy should only be performed on patients lying in bed or seated in a chair with
two arm rests, such as a phlebotomy chair. A patient lying in bed rarely faints and
falling is not an issue. If drawing from a patient seated in a chair, the phlebotomist
should place himself/herself directly in front of the patient, thus serving as a barrier if the
patient begins to fall out of the chair.

Signs that a patient might faint include sweating, pallor, dilated pupils, and shaking.
The patient may state they are feeling light-headed and is seeing “spots in front of my
eyes”. At this time, the phlebotomist should call for assistance.

If a patient feels faint, the phlebotomy procedure should be discontinued (tourniquet

removed, needle withdrawn, safety feature activation, needle discarded, pressure
applied). If the patient is seated upright, the patient’s should either lower their head
between their knees or the phlebotomist should recline the chair if that feature is
available. Tight clothing should be loosened. If the patient is not reclined and loses
consciousness, the phlebotomist should try to ease the patient to the floor. The
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phlebotomist should keep the patient in a recumbent position until recovered. A wet
towel applied to the patient’s forehead and a glass of juice or water can help the patient
feel better. The patient’s nurse should be notified of the occurrence and notations made
in the patient’s laboratory and medical record.

Specimen Labeling

Tubes of blood should be labeled at the patient’s bedside or outpatient setting area
immediately following the phlebotomy procedure and before leaving the patient’s side.
If this procedural step is not followed, the specimen may be mislabeled and the
laboratory test results will not represent the status of the intended patient. As previously
discussed, serious consequences may arise if the patient is treated based on the lab
results. For example, underdosing or overdosing of medications such as insulin and
Coumadin® could be given to a patient, causing serious consequences. The worst-
case scenario is a patient dying because of an incompatible blood transfusion.

Tubes should not be prelabeled as they can be mistakenly picked up and used for
another patient. Unlabeled tubes arriving in the laboratory, even if patient labels are
rubber banded around the tubes or placed in a transport bag with the tubes, must be
rejected, discarded, and new specimens collected. See the CLSI GP33 Accuracy in
Patient and Specimen Identification standard.

Confidential Information

In healthcare, confidentiality is maintaining the privacy of medical information about

patients. Information regarding a patient’s test results, treatment, or condition is to be
discussed only with those professionals responsible for the medical care of that
individual. Unauthorized release of information concerning an individual can lead to a
claim of breach of confidentiality or invasion of privacy.

As an example, a phlebotomist noticed a neighbor’s name on the surgery schedule at

the hospital where she worked. The phlebotomist mentioned this to another neighbor,
and this neighbor came to the hospital to visit the neighbor who had surgery. The
neighbor had wanted only family members to know of the surgery and contacted a
lawyer to sue for violation of Health Insurance Portability and Accountability Act (HIPAA)
privacy laws.

RISK #8: STRESS / BURNOUT

Phlebotomists deal with stressful situations daily – patients are never really pleased to
see them, a patient may be a “hard stick”, STAT specimens are never collected quick
enough (per nursing staff) or brought to the lab fast enough (per lab staff), and so on.

Stress negatively affects the body by increasing heart rate, elevating blood pressure,
and increasing respiratory rate. Prolonged stress leads to headaches, sleep
disturbances, stomach/colon problems, poor concentration, depression, and eventually
professional burnout. Burnout often ends with the individual leaving his/her profession.

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Following are tips to help deal with stress.

 Exercise: Exercise forces deep breathing which helps muscles relax. While at
work, a phlebotomist can do a few minutes of shoulder shrugs and head rolls
along with deep cleansing breaths to help bring physiologic calm back to the
body.

 Take breaks: A phlebotomist can take a 5 minute break and do something

unrelated to work to help deal with stress. Going outside of the lab (or other work
environment) and taking a walk or flipping through a magazine can help deal with
stress. Even breathing fresh air for a few minutes can be helpful.

 Use humor to lighten the stressful day. Following a particularly stressful day, a
phlebotomist should watch a 30 minute comedy show on TV instead of the
evening news or crime solver drama.

 During stressful times, a phlebotomist should try to eat a balanced diet and get
enough sleep. Making time to do enjoyable activities is also helpful.

 If unable to handle stress, a phlebotomist should take advantage of programs

offered at work such as employee assistance programs. Programs such as
these provide short-term counseling to assist employees through difficult times.

RISK #9: SHIFT WORK

NIOSH estimates that approximately 15.5 million people in the United States work a
non-standard shift, which is defined as a shift that is outside the normal daylight hours.
To the shift worker, it generally means extra pay, more free time during daylight hours,
and a solution to daycare issues. However, many individuals who work non-standard
shifts experience sleep disorders, depression, higher rates of certain diseases, and
increased absenteeism. Several studies have identified that shift workers in healthcare
also are at a greater risk for work-related injuries and for making errors that result in
patient injury.

Shift work disrupts the circadian rhythm, the body’s 24-hour rhythmic activity cycle. It
helps the body’s internal cycle keep in time with the external day-night cycle. Circadian
rhythm differs some from person to person, perhaps explaining “night owls” and “early
birds”, and why some individuals have no problems working non-standard shifts.
Circadian rhythm is responsible for setting the cycle of hormone secretions from the
endocrine system and thus affects organ function and metabolism. This is thought to be
a factor in shift workers having higher rates of cardiovascular disease, diabetes, thyroid
disorders, gastrointestinal disorders, and more.

The following are recommendations for individuals who work non-standard shifts to
make it easier to adjust, stay healthy, and alert.

 Keep your sleep schedule consistent during both work and non-work days.

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  Assure the sleeping area is dark and free of distractions that could remind one of
the time of day, such as a clock. Use room-darkening shades, turn off the
phone, and wear earplugs.
 Schedule a 20-30 minute naptime if your facility allows.
 Avoid caffeine 3-6 hours before the scheduled bedtime.
 Maintain a healthy diet avoiding excess fats, sugars, and calories.
 Participate in aerobic exercise before going to work.
 If needed, speak with a physician about medication to assist with going to sleep
and/or staying asleep.

RISK #10: WORKPLACE INCIVILITY

In their book The Cost of Bad Behavior, Christine Pearson and Christine Porath define
incivility as “the exchange of seemingly inconsequential inconsiderate words and deeds
that violate conventional norms or workplace conduct.”

A recent report found that six out of ten respondents believe lack of courtesy is getting
worse in the workplace and 41% admitted they are sometimes part of the problem. The
official term for this lack of courtesy is workplace incivility and it encompasses behavior
from rudeness to emotional abuse to violence.

According to Pearson and Porath, incivility is more widespread than realized and it has
destructive effects. Their research found that 96% of individuals have experienced
incivility at work and 48% claim they were treated uncivilly at work at least once a week.

Following are both minor and serious examples of incivility in the workplace.

 Taking someone else’s food or beverage from a shared refrigerator without

permission
 Purposely not greeting or acknowledging someone in the work area
 Taking the last cup of coffee without making more
 Playing music loudly enough for coworkers to hear
 Arriving late to a meeting
 Checking email or texting during a meeting
 Using profanity
 Ignoring or interrupting a coworker
 Rude or obnoxious behavior in the workplace
 Not giving credit publically to a coworker on a shared project
 Answering phone calls during a meeting
 Withholding important information
 Sabotaging a project or damaging a coworkers reputation
 Badgering or back stabbing a coworker
 Losing one’s temper or yelling in the workplace
 Assaulting a coworker

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Incivility does not happen just between coworkers. About 25% of customers/clients
surveyed state they encounter increasing amounts of incivility in their interactions with
businesses in both their personal and professional lives.

Workplace incivility has a negative effect on the efficiency and productivity of an

organization. The workplace becomes a hostile environment and employees stress
levels increase. Employees become less motivated, put in less effort, produce lower
quality work, make more errors, and even suffer burnout. Ultimately, these employees
will leave the employer.

Pearson and Porath state that in an uncivil work environment, employees no longer feel
psychologically safe. “They will quit asking for help, talking about errors and informing
one another about potential or actual problems.”

Incivility in the healthcare environment increases the risk of medical errors, which adds
another level of seriousness to the problem. Healthcare in and of itself is stressful as
there is little or no room for error in the care and treatment of patients.

To combat incivility in the workplace, management must assure there is awareness of

incivility and its impact on the organization, set workplace standards of acceptable and
unacceptable behavior, provide training, and encourage communication and feedback
for an open and friendly workplace.

Following are recommendations for all to follow to reduce incivility in the workplace.

 Assess your own behavior to assure you are not adding to the problem.
 Treat others with respect and kindness, which can become contagious.
 Report incidences of workplace incivility before situations worsen.
 Be sensitive to how others perceive your actions or words.
 Take the “high road” and do not return rudeness with more rudeness. Speak
with the offending coworker in private or in the presence of a manager for the
purposes of improving the situation.
 Remember that you do not need to be friends with each coworker. You just need
to maintain a respectful and professional relationship.

CONCLUSION

Working as a phlebotomist is rewarding and it can be risky business. This CE course

has discussed ten risks associated with working as a phlebotomist. These risks include
sharps injuries, disease transmission, musculoskeletal disorders, workplace violence,
slips/trips/falls, hazardous materials, patient injuries, stress/burnout, shift work, and
workplace incivility. Also discussed were ways to avoid injuries to self and patients, and
methods to deal with day-to-day workplace issues.

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REFERENCES
ACS Chemistry for Life. Safety Data Sheets. www.acs.org Accessed 25 June 2020.

Blueprint for blue-penciling phlebotomy errors. CAP Today; http://www.cap.org/apps/cap.portal;

downloaded 10/24/2012

Causes of Needlestick Injury to Healthcare Workers; http://www.bd.com/us/safety/facts.asp; downloaded

10/6/2012

Diseases and Organisms in Healthcare Settings; Centers for Disease Control and Prevention;
http://www.cdc.gov/hai;organisms/organisms.html; downloaded 10/6/2012

International Safety Center. EPINet Report for Needlestick and Sharp Object Injuries, 2017. EPINet
Accessed 9 June 2020.

Minimizing Chemical Hazards in Healthcare; http://www.healthcaredesignmagazine.com; downloaded

10/6/2012

MSDS Online. GHS 101. US Adoption (HazCom 2012). 2019. www.msdsonline.com. Accessed 9 June
2020.

Needlestick Prevention Guide; American Nurses Association;

http://www.nursingworld.org/Mobile/Nursing-Factsheets/safe-needles-save-lives.html;
Downloaded 10/14/2012

Night Owls Only; www.advanceweb.com/MLP; downloaded 6/19/2008

Occupationally Acquired Infections in Health Care Workers Part I; Sepkowitz, K.; Annals of Internal
Medicine. 1996;125:826-834. Downloaded from http://annals.org; 10/19/2012

Occupationally Acquired Infections in Health Care Workers Part II; Sepkowitz, K.; Annals of Internal
Medicine. 1996;125:917-928. Downloaded from http://annals.org; 10/19/2012

Occupational Safety and Health Administration (OSHA). A Guide to the Globally Harmonized System of
Classification and Labeling of Chemicals (GHS). www.osha.gov. Accessed 9 June 2020.

Occupational Safety and Health Administration (OSHA). Hazardous Communication: Safety Data Sheets.
www.osha.gov Accessed 25 June 2020.

Occupational Safety and Health Administration (OSHA). Hazardous Communication: Questions and
Answers. www.osha.gov Accessed 25 June 2020.

Occupational Safety and Health Administration (OSHA). Hazard Communication Hazard Classification
Guidance for Manufacturers, Importers, and Employers www.osha.gov Accessed 26 June 2020.

Phlebotomy Meets the Law; Advance for Administrators of the Laboratory; http://laboratory-
manager.advancedweb/com/Article/Phlebotomy-Meets-the-Law.aspx;
Downloaded 10/24/2012

Preventing Phlebotomy Errors-Potential for Harming Your Patients; Ogden-Grable and Gill. Lab
Medicine. Volume 36 Number 7; July 2005

Sharps Injuries; Centers for Disease Control and Prevention;

http://www.cdc.gov/niosh/stopsticks/sharpsinjuries.html; downloaded 10/17/2012

Shiftwork Safety Measures; http://www.hcpro.com/HOM-65347-3506/Shiftwork-safety-measures-for-

laboratories.html; downloaded 12/12/2006

35
Stop Workplace Incivility: http://worldwit.org;ThinkingAloud/Guests/stop-workplace-incivility; downloaded
10/6/2012

Stress Management for Healthcare Providers;

http://www.bepreparedcalifornia.ca.gov/Partners/HealthcareProviders; downloaded 10/6/2012

Stress Management Tips for Healthcare Workers; http://career-advice.monster.com; downloaded

10/27/2012

The Late Shift; http://laboratorian.advanceweb.com/common/EdiorialSearch;

Downloaded 2/9/2006

Violence in Hospitals a Growing Problem; http://workplaceviolencenews.com/2010/03/08.violence-in-

hospitals ; downloaded 10/22/2012

Violence Occupational Hazards in Hospitals; http//: www.cdc.gov/niosh/docs/2002;

Downloaded 10/6/2012

World Health Organization (WHO). Modes of Transmission of Virus Causing COVID-19: Implications for
IPC Precaution Recommendations. 29 March 2020. www.who.int. Accessed 9 June 2020.

Workplace Incivility Causes Mistakes and Even Kills; http://workplacepsychology.net/2010/11/05;

downloaded 10/6/2012

QUESTIONS
Phlebotomy - It’s A Risky Business #1220820

Directions:
 Answer sheets: Read the instructions to assure you correctly complete the answer
sheets.
 Online: Log in to your User Account on the NCCT website www.ncctinc.com.
o NOTE: If the online test questions differ from the course test that follows the
reading material, the CE course you are using is outdated or the question has
been revised since you downloaded it. The online question is the most current
and it should be answered accordingly.
 Select the response that best completes each sentence or answers each question
from the information presented in the course.
 If you are having difficulty answering a question, go to www.ncctinc.com and select
Forms/Documents. Then select CE Updates and Revisions to see if course content
and/or a test questions have been revised. If you do not have access to the internet,
call Customer Service at 800-875-4404.

1. Which one of the following bloodborne infections can healthcare workers in the
United States receive vaccinations for?

a. Hepatitis B
b. Hepatitis C
c. Malaria
d. HIV

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2. According to the figure in the course material, which one of the following devices
was associated with the most sharps injuries in hospitals in the 2017 survey?

a. Disposable syringe
b. Reusable scalpel
c. Suture needle
d. Winged-steel needle

3. Of the activities below, which should be performed first following a sharps injury?

a. Notify supervisor about sharps injury

b. Have patient tested for HIV, HBC, & HCV
c. Wash the wound with soap and water
d. Receive treatment per CDC guidelines

4. Which of the following microorganisms/diseases can be transmitted via an

airborne route?

a. Hepatitis A virus
b. Measles virus (rubeola)
c. Influenza A/B viruses
d. Mumps virus

5. Which of the following infectious diseases is spread by droplets < 5 microns in

size?

a. Influenza
b. Respiratory syncytial virus
c. Tuberculosis
d. Hepatitis A

6. A hospitalized patient with chickenpox would be put in which of the following

types of transmission-based isolation?

a. Airborne Precautions
b. Contact Precautions
c. Droplet Precautions
d. Protective Environment

7. Tenosynovitis is a MSD that involves which of the following?

a. Narrowing of the sheath that surrounds a tendon

b. Inflammation of a tendon
c. Inflammation of the sheath that surrounds a tendon
d. Inflammation of unsheathed tendons

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8. Which of the following is NOT a recommendation to minimize a phlebotomist’s
risk of developing a MSD?

a. Adjust the height of the outpatient phlebotomy chair to minimize bending

b. Perform recommended exercises throughout the day
c. Place supplies so that it is necessary to reach across the body to obtain
them
d. When going to inpatient rooms, use a rolling phlebotomy cart instead of a
phlebotomy tray

9. Which of the following is a recommendation for healthcare professionals

regarding potentially violent situations?

a. Assume encounters with patients/family members will be OK

b. Always keep an open path for exiting a room
c. Be aggressive in response to angry behavior
d. Order everyone out of the room

10. The Bureau of Labor Statistics reports that hospitals have a __________ higher
rate of slips, trips, and falls from the same level as do all other industries
combined.

a. 9%
b. 19%
c. 90%
d. 190%

11. Which of the following is categorized as a physical hazard?

a. Carcinogenicity
b. Flammable
c. Eye irritation
d. Toxicity

12. How many sections are found on a Safety Data Sheet (SDS)?

a. 9
b. 11
c. 12
d. 16

13. Which type of hazard does the ‘skull and crossbones’ pictogram represent on a
GHS label?

a. Carcinogen
b. Acute Toxicity
c. Corrosives
d. Explosives

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14. If a patient is injured as a result of a phlebotomy procedure, the phlebotomist can
be sued.

a. True
b. False

15. If the veins in a patient’s antecubital area are all palpable with no bruising, which
one would be the LAST choice to select for venipuncture?

a. Median
b. Median cubital
c. Basilic
d. Cephalic

16. What could happen if a venipuncture is performed on the arm where axillary
lymph nodes have been removed on that side?

a. Nerve damage
b. Infection
c. Blood clots
d. Severe pain

17. Which of the following actions would be appropriate for performance of a

venipuncture?

a. Entering a vein with a needle at a 45° angle.

b. Placing a bandage over a venipuncture site that is still bleeding.
c. Probing an inserted needle around until the vein is accessed.
d. Removing a tourniquet that has been applied for more than one minute.

18. Which of the following is a way for a phlebotomist to deal with a stressful day?

a. Buy a bag of chips and a soft drink for lunch.

b. Take a short walk around the healthcare facility.
c. Volunteer for an extra shift as he/she will not be able to sleep anyway.
d. Watch his/her favorite “CSI” drama on TV.

19. Which of the following are recommendations for individuals who work non-
standard shifts to make it easier to adjust, stay healthy, and alert?

a. Keep your sleep schedule consistent during work and non-work days.
b. Sleep in a dark, distraction-free environment.
c. Engage in aerobic activity prior to your work shift.
d. All of the above.

*End of Test*

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 NCCT
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Course Title: Phlebotomy - It’s A Risky Business Course Number: 1220820

OBJECTIVES

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____Yes ____No 2. Did the test measure what you learned?

COURSE CONTENT

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____Yes ____No 4. Was the CE course organized and useful for learning?

____Yes ____No 5. Was this CE course written at the right level for the practicing
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VALUE

____Yes ____No 6. Did you learn anything new?

____Yes ____No ____Maybe 7. Did you learn anything you might use at work?

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What would you like to learn about in the future? Please list specific topics!

*Please include this evaluation with your answer sheet.*

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