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Phlebotomist Be Safe!

Pat is a certified Registered Phlebotomy Technician working in an accredited healthcare facility. One day while preparing to draw blood from the first patient of the day, Pat's nose was filled with a sneeze coming on. While reaching for a tissue near the phlebotomy chair, Pat accidentally knocked the sharps container over spilling some of its contents. One of the needles from the sharps container punctured Pat's hand. Pat dutifully sneezed in the crux of the elbow, cleaned up the mess, and successfully completed the blood draw. But there is much more Pat needs to do.

As an Instructor in Phlebotomy, I place a lot of emphasis on safety. Keeping the Phlebotomist safe; and keeping the patient safe. In class, I naturally focus more on keeping the phlebotomy student safe. But once the student becomes an employed phlebotomist, the emphasis seems to quickly turn to patient safety. I get it, hospitals and other healthcare centers want to keep the patient safe to prevent complaints and lawsuits. Healthcare employees are there because they want to help patients, and therefore put their energies towards the patient. Plus, it isn't good for anyone when patients are injured. However, if we don't keep the Phlebotomist safe, there won't be anyone left to keep the patients safe and help them to heal. Healthcare workers MUST spend the time and energy taking care of themselves too. Therefore, this article will focus on the safety of you, the Phlebotomist.

There are many organizations out there that make it their business to keep you safe. The US Federal Government backed organizations go by an alphabet of acronyms, such as OSHA, NIOSH, CDC, NHSN, HICPAC, and others. Other organizations like AMT also provide training and resources for your safety, such as this article.
OSHA     Occupational Safety and Health
         Administration (US Dept of Labor)

CDC      Centers for Disease Control and
         Prevention (US Dept of Health and
         Human Services)

NIOSH    National Institute for Occupational
         Safety and Health (CDC)

NHSN     National Healthcare Safety Network
         (CDC)

HICPAC   Healthcare Infection Control Practices
         Advisory Committee (CDC)


The key player in keeping you safe is your employer. OSHA Publication 2254, Training Requirements in OSHA Standards (2015), lays out the requirements of your employer to provide enough training to you at no charge to keep you safe in your work place. This publication is a result of the Occupational Safety and Health Act of 1970, which states:

"Employers are responsible for providing a safe and healthful workplace. No person should ever have to be injured, become ill, or die for a paycheck." (2015, p. 1)

This publication requires that your employer provide training to you on personal protective equipment (PPE), bloodborne pathogens, hazardous materials, and any other hazards they can identify. At a minimum, the training must occur upon initial hire, and annually thereafter. Furthermore, they must write, update, and provide easy access to documents such as the Bloodborne Pathogen Standard, Exposure Control Plan, and Safety Data Sheets (SDS).

Every place of work varies as to the hazards present. However, there are some commonalities that we can address here.

The first, and easiest, thing you can do is practice good preventive health. This includes measures taken to maintain good health and prevent disease. If you don't care for your own health, you won't be available to help your patients manage their health. Eat a healthy, balanced diet in moderation. Drink plenty of clean water. Get a restful 6-8 hours of sleep per night. Wash your hands and your body often. Keep your hair and your clothes clean. Practice good hygiene. These are basic steps that can do a lot for your health.

Also included in preventive healthcare is getting vaccinated. If you attended a formal school, you probably were required to get vaccines then. But you must keep your vaccines up to date; some require annual vaccinations or periodic boosters. Your Infection Control staff at your medical facility can provide you with expert guidance, and help you keep your vaccinations up to date. The Centers for Disease Control (CDC) (1997) recommends at a minimum that you get vaccinated for Hepatitis B (Hep B), Influenza (Flu), Measles, Mumps, Rubella (MMR), and Varicella (chicken pox/shingles). Based on where you work, you may also need pertussis, hepatitis A, meningococcal disease, typhoid fever, and vaccinia; and be tested for tuberculosis.

The next step is the setup of the phlebotomy area. Drawing area setup is often limited to the space available, and phlebotomists aren't typically consulted when the space is designed and installed. However, there are few things that you can do.

First is to set up the area as ergonomically comfortable as possible. Ergonomics involves human engineering that result in designing systems that maximize safety, comfort, and efficiency for the people that use them. The Clinical and Laboratory Standards Institute (CLSI), standard GP41 (2017, p. 51), states, "Work benches and tables should be set up in an ergonomic manner for the phlebotomist to function with minimum physical stress." Your employer has a responsibility to provide ergonomic workspace for you. Place the phlebotomy chair on a flat surface, or on a raised platform to minimize bending and twisting by the phlebotomist. There should be adequate space in front of the chair for the phlebotomist to maneuver without bumping into furniture, walls, or other people. The supply tables, and other workbenches used in conjunction with the phlebotomy chair should also be at a height comfortable for the phlebotomist and placed in an easily accessible location. Not all phlebotomists that use the space are the same height and build, so this will need to be considered when designing the space. If it's possible to make the chairs and workbenches adjustable, this would be ideal.

Besides being ergonomic, the work space also needs to have all equipment and supplies in easy reach from the phlebotomy chair, but not intrusive to the procedure. Sharps containers should be securely fastened to an accessible wall or bolted to a work bench. Extra collection tubes, gauze and other supplies should be within easy reach of the phlebotomists while performing a venipuncture. Anything used by the phlebotomist, but not necessary DURING the venipuncture, should still be in a location where the phlebotomist can continue to monitor the patient while using these items. This would include computers, time-recording devices (stampers, etc.), and processing equipment.

The most common injuries to phlebotomists are caused by sharps, especially accidental needle sticks. In the preceding paragraph I mentioned securing the sharps container. In the phlebotomy room, the sharps container holder should be securely fastened to the wall, and the container locked inside the holder. When using a mobile tray, the sharps container must be properly secured within the tray so that it cannot fall out during normal use of the tray. Patients, in any setting, should not have access to the phlebotomist's sharps container.

Commercially made sharps containers have a line on them indicating when they are FULL. Sharps may be added to the container until they first begin to protrude above the FULL line. Once the container is "full," it must be properly sealed in accordance with the manufacturer's directions and replaced. The full containers are then disposed of in accordance with your employer's policies and procedures.

Blood collection needles and lancets today are made with safety devices designed to prevent accidental needle sticks. Current regulations and accreditation requirements state that these devices must be available and used. Additionally, CLSI Standard GP41 (2017, p. 55) states that, "the safety feature must be activated immediately after specimen collection and discarded according to manufacturer's instructions and regulatory and accreditation requirements." The standard goes on to emphasize that the use of these needle safety devices "is strongly encouraged."

It is important to always pay close attention when using sharps. I was watching a cooking competition show on television recently. When a chef walked behind another contestant with a hot pan, they always shouted out, "hot pan" to prevent injury. My first thought was that we should be doing that in the phlebotomy area too! No one should be walking around with an exposed needle, but if you do need to move away from direct contact with the patient, you should shout out to others around, "sharps" so that everyone in the area can be aware and pay close attention. Here's an acronym to help you with your focus: STAR.

STOP what you are doing for a moment.

THINK safety, and about what you are doing and will need to do next.

ACT on your next step and any safety steps you need to take.

REVIEW what you did, and ensure you covered all aspects of sharps safety.

Let's back up for a moment here. While the S in STAR stands for STOP, before even getting that far, you need to slow down! I know that the waiting room can sometimes back up, and patients can be in a hurry, but you should never rush when sharps are involved. Take the appropriate amount of time and precautions to ensure safety to you and your patient. Listen to your intuition; if you feel there is danger, you are probably right! Before you do anything, take a moment to identify any potential distractions prior to using sharps. Find ways to minimize or eliminate those distractions before exposing a sharp.

The most critical time for safety is after the blood collection procedure is completed; now you have a contaminated sharp. Immediately activate the safety device. If it has an autoactivating device, check to make sure it worked properly. Next, immediately dispose of the sharp at the point of care. Always use an approved sharps container, with the lid on tight, and properly secured. Remember, the best time to practice safety, is immediately!

I urge you to make a point of talking about employee safety with your supervisor and co-workers. This should be a daily discussion. If you have a pre-shift huddle, take turns discussing a safety issue or tip each day. Here are five safety behaviors to help keep you and your co-workers safe:

1. Prepare for the day. Discuss safety and look for hazards every day.

2. Questioning Attitude. Question anything that doesn't look right or is unfamiliar to you.

3. Clear communication. Effective communication must occur in all directions: up, down, and sideways. Talk with your supervisors, peers, and subordinates.

4. Support the team. Safety is ALWAYS a team effort.

5. Attention to detail. No detail is too small when it comes to protecting yourself and your team.

We had a saying when I was in the Army, "Everyone is a safety officer." This means that safety is the responsibility of EVERY employee. If you see an unsafe condition, report it. If you witness an unsafe act, correct it. Safety requires a team effort, be a good, safe teammate.

Even though we consistently exercise good safety practice, accidents still occur. So, what do you do if you are accidently stuck with a dirty sharp? The NIOSH (2018) lays out your next steps for you:

1. Wash needlesticks and cuts with soap and water.

2. Flush splashes to the nose, mouth, or skin with water.

3. Irrigate eyes with clean water, saline, or sterile irrigates.

4. Report the incident to your supervisor.

5. Immediately seek medical treatment.

Medical treatment will vary based on your overall health condition, whether you can identify the patient that the specimen and sharp came from, the type of fluid, the portal of entry, and other factors. Your facility should have an Exposure Control Plan that lays out the steps for an accidental needlestick. If your Plan is lacking, or you have questions, a good resource to use the Clinician Consultation Center from the University of California, San Francisco (2018). You can access them at nccc.ucsf.edu or by calling the post-exposure prophylaxis help line at 888-448-4911.

Never cover up an accident. Take immediate action to care for yourself and help prevent these in the future.

Now that you were reminded of some safety tips, or perhaps even discovered something new, let's go back and review Pat's work from the beginning of this article. Try to answer each question on your own before reading my answer.

Question 1: What about preventive healthcare?

While the scenario doesn't say, let's assume Pat is vaccinated and healthy. Pat did need to sneeze, but that doesn't necessary imply poor health. Preventive healthcare measures should be a requirement of Pat's employer.

Question 2: What about the layout of the phlebotomy drawing area?

On a positive note, the tissues, sharps container, and other supplies are apparently within easy reach of the phlebotomist. However, Pat should not be able to knock over one item to get to another. The supply storage table next to the phlebotomy chair needs to be reorganized so it is more user friendly.

Question 3: Why was the sharps container knocked over?

In an established phlebotomy area, the sharps containers should be secured in an appropriate holder, and securely fastened to the wall behind or beside the phlebotomy chair. The fact that it is loose on the table is a safety concern. If this was part of a mobile blood collection kit, the sharps container should be placed securely in the phlebotomy tray so that it cannot be knocked out or spilled.

Question 4: Why was Pat's hand stuck with a contaminated needle from the sharps container?

Apparently, Pat, or another phlebotomist, didn't properly apply the needle's safety device after drawing a patient. If the safety device was properly applied, the needle should be covered, and it cannot stick someone if it protrudes from the sharps container.

Another issue here is that the sharps container was apparently overfilled. Every reputable sharps container has a "FULL" line on it. When that line is reached by a sharp, the container must be sealed and replaced.

Question 5: What are Pat's next steps?

First, Pat must clean the puncture site thoroughly with soap and water. Pat must then immediately report the incident to the Phlebotomy supervisor. The supervisor should then assist Pat in seeking immediate medical treatment, in accordance with the Exposure Control Plan at Pat's facility.

So, what about the patient you ask? Remember, employee safety is paramount here. Pat should clean the wound and report the incident. Pat may then finish up with the patient, or have the supervisor arrange to aid the patient. Either way, Pat must follow up with medical treatment as soon as possible.

The last thing Pat needs to do with this incident is learn from it. Sit down with the supervisor, review what happened, what went well with the process, and what can be improved. And then develop a plan to improve the phlebotomy area and prevent further accidents. The plan should continue to be reassessed, and employee safety should continue to be discussed among the phlebotomy team and supervisors.

In all you do out there to care for your patients, please keep yourselves safe too!

Article 462: 1 Clock Hour

Questions for STEP Participants.

Purchase STEP Online articles and submit your answers online! To order, visit the AMT website (www.americanmedtech.org), login using your user name and password to receive the member discounted price of $5 per article, click on the AMT Store on the top of the page, choose STEP Online, choose Shop for STEP Online (By Article Number), then select the article number and purchase the quiz. Access your purchased articles from your website homepage under Purchased Online Courses. Read the article in the print magazine or on the computer, take the quiz on the computer and when you pass the quiz, the CE credits are automatically transferred to your AMTrax account.

NOTE: Quiz questions will appear in a different order and may have been changed or updated since the time of printing the magazine. Be sure to read the article in its entirety prior to taking the quiz.

1. Which of the following is a US Federal Government backed organization that works to keep you safe?

A. AMT

B. OSHA

C. ASCP

D. NCCA

2. Who is primarily responsible for providing safety training in your workplace?

A. You

B. The Federal Government

C. The Centers for Disease Control

D. Your employer

3. The Centers for Disease Control recommends which of the following immunizations for phlebotomists, at a minimum?

A. Hep A, Hep B, Hep C

B. HIV, Hep B, MMR, Flu

C. Hep B, MMR, Flu, Varicella

D. Varicella, pertussis, Hep B, Hep A

4. Ergonomics basically means:

A. human engineering to maximize safety.

B. human engineering to prevent safety.

C. human engineering to prevent disease.

D. human engineering to provide vaccinations.

5. The most common injury to a phlebotomist is:

A. poor ergonomics.

B. transmission of airborne diseases.

C. sharps punctures.

D. contaminated vaccines.

6. The best place to maintain a sharps container in a phlebotomy room is:

A. on the table next to the phlebotomy chair.

B. across the room, away from the patient area.

C. secured to the floor under the phlebotomy chair.

D. secured to the wall near the phlebotomy chair.

7. When should a sharps container be sealed and replaced?

A. When sharps reach the FULL line

B. When sharps begin to protrude from the container

C. When a phlebotomist is stuck by a protruding needle

D. Just before the next sharp would protrude from the container

8. The acronym STAR was developed to help you focus on safety. What does STAR stand for in this scenario?

A. Science, Technology And Research

B. Stress, Trauma And Resilience

C. Stop, Think, Act, Review

D. Slow, Think, Achieve, Rethink

9. When is the most critical time for safety during a phlebotomy procedure?

A. When preparing equipment for a patient draw

B. While drawing blood from a patient

C. Immediately after withdrawing a contaminated needle

D. When placing a properly prepared sharp in the sharp container

10. Who has the primary responsibility to report unsafe conditions or acts?

A. All employees

B. The Phlebotomy supervisor

C. The facility safety officer

D. The facility medical director

References

Center for Disease Control. (1997). Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR, 46(RR-18). Retrieved from https://www.cdc.gov/mmwr/PDF/rr/rr4618.pdf.

Center for Disease Control--bloodborne infectious diseases--Emergency needlestick information--NIOSH workplace safety and health topic. (2018, November 21). Retrieved from https://www.cdc.gov/niosh/topics/bbp/ emergnedl.html.

Clinical and Laboratory Standards Institute. (2017). GP41: collection of diagnostic venous blood specimens.

Occupational Safety and Health Administration. (2015). Training requirements in OSHA standards. Retrieved from https://www.osha.gov/Publications/osha2254.pdf.

University of California, San Francisco, Clinician Consultation Center. (2018, January 1). PEP quick guide for occupational exposures. Retrieved from http://nccc. ucsf.edu/clinical-resources/pep-resources/pep-quickguide/.

SGM (R) Jeffrey Lavender, MBA, MT(AMT), Phlebotomy Instructor at Kirtland Community College, Grayling Michigan, and AMT's Immediate Past National President
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Title Annotation:Article 462: 1 Clock Hour
Author:Lavender, Jeff
Publication:Journal of Continuing Education Topics & Issues
Date:Apr 1, 2019
Words:3158
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