New phlebotomists are taught the order of draw by the additive within the tubes and why there is an order of draw.
Trainees should know the "order of draw" according to the additive in the tube and the impact each additive can have if drawn in the incorrect order.
Since the document was last revised in 1998, changes in tube technology and revised OSHA (Occupational Safety and Health Administration) regulations, as well as an increased awareness of phlebotomy complications, have led to a new recommended order of draw and more detailed language to prevent phlebotomy-related injuries.
First introduced into the literature in 1977, the order of draw was developed to prevent the effects on test results that additives can exert when inadvertently carried over from one tube to the next by the needle making the transfer.
In fact, it mutated right out of existence last year when one workshop presenter astonished her attendees by stating, "There is no order of draw." Adding to the confusion are Internet phlebotomy sites, training manuals, certification study guides, and textbooks that perpetuate many variations.
For the record, the order of draw has been established by NCCLS--the National Committee for Clinical Laboratory Standards, which develops voluntary standards--through its consensus process with industry, government, and laboratory professionals and is published by NCCLS in document H3, Procedure for the Collection of Blood Specimens for Diagnostic Testing by Venipuncture.
The system is engineered to positively identify the patient and the caregiver via barcodes, verify the tests that have been ordered for the patient, verify that the correct specimen container is being used, verify the correct order of draw
and time of collection, and print the barcoded specimen label at the patient's bedside.
Current hot topics include safety needles, conversions to plastic tubes, the order of draw, phlebotomy certification, tube holder reuse, and phlebotomy-related lawsuits.
The industrywide conversion from glass to plastic tubes, however, is forcing the reconsideration of one of the most basic principles of blood specimen collection: the order of draw. Often referred to as "phlebotomy's best-kept secret," the order of draw has its origins in the literature as fur back as 1977 when additive carryover from one tube to the next was observed independently at two hospitals, St.
One possibility (and the easiest to investigate) has not been addressed in this question -- order of draw in the collection process.
Several years ago, our institution did a study on calcium levels and order of draw. (1) It was determined that the difference in the calcium levels drawn at the beginning of a collection and those collected at the end were significant enough to have an impact on the clinical management of the patient.
Q We were led to believe that gel separator tubes with clot activators could be used as if they were red-top tubes and classified nonadditive tubes ("Phlebotomy tubes and order of draw
," Tips on Technology, MLO, December 1992).