Diagnostic blood samples collected by phlebotomy are the most common type of biological specimens drawn and sent to laboratory medicine facilities for being analyzed, thus supporting caring physicians in patient diagnosis, follow-up and/or therapeutic monitoring. Phlebotomy, a relatively invasive medical procedure, is indeed critical for the downstream procedures accomplished either in the analytical phase made in the laboratory or in the interpretive process done by the physicians. Diagnosis, management, treatment of patients and ultimately patient safety itself can be compromised by poor phlebotomy quality. We have read with interest a recent article where the authors addressed important aspects of venous blood collection for laboratory medicine analysis. The authors conducted a phlebotomy survey based on the Clinical and Laboratory Standard Institute (CLSI) H03-A6 document (presently replaced by the GP41-A6 document) in three government hospitals in Ethiopia to evaluate 120 professionals (101 non-laboratory professionals vs. 19 laboratory professionals) as regards the venous blood collection practice. The aim of this mini (non-systematic) review is to both take a cue from the above article and from current practices we had already observed in other laboratory settings, and discuss four questionable activities performed by health care professionals during venous blood collection. We refer to: i) diet restriction assessment; ii) puncture site cleansing; iii) timing of tourniquet removal and; iv) mixing specimen with additives
1. International Organization for Standardization. Medical laboratories - Particular requirements for quality and competence ISO document 15189. 2nd ed. Geneva, Switzerland: International Organization for Standardi - zation; 2007.
2. Serteser M, Coskun A, Inal TC, Unsal I. How ISO-15189 laboratory accreditation assures patient safety? J Med Biochem 2012; 31: 271-80.
3. Majkić-Singh N, [umarac Z. Quality indicator of the preanalytical phase. J Med Biochem 2012; 31: 174-83.
4. Šimundić AM, Bilić-Zulle L, Nikolac N, Šupak-Smolčić V, Honović L, Avram S, et al. The quality of the extra-analytical phase of laboratory practice in some developing European countries and Mexico - a multicentric study. Clin Chem Lab Med 2011; 49: 215-28.
5. Nikolac N, Šupak-Smolčić V, Šimundić AM, Celap I. Croatian Society of Medical Biochemistry and Laboratory Medicine: national recommendations for venous blood sampling. Biochem Med 2013; 23: 242-54.
6. Melkie M, Girma A, Tsalla T. The practice of venous blood collection among laboratory and non-laboratory professionals working in Ethiopian Government Hospitals: a comparative study. BMC Health Serv Res 2014; 14:88 doi: 10.1186/472-6963-14-88.
7. Clinical Laboratory Standards Institute. Procedures for the collection of diagnostic blood specimens by venipuncture. CLSI H3-A6 document. 6th ed. Wayne, PA: Clinical Laboratory Standards Institute; 2007.
8. Kackov S, Šimundić AM, Gatti-Drnic A. Are patients well informed about the fasting requirements for laboratory blood testing? Biochem Med 2013; 23: 326-31.
9. Lima-Oliveira G, Salvagno GL, Picheth G, Guidi GC. Eating, Eating, Eating. What Time was your Last Food Intake? J Med Diagn Meth 2013; 2:e107 doi: 10.4172/2168-9784.1000e107.
10. Lima-Oliveira G, Salvagno GL, Lippi G, Gelati M, Montagnana M, Danese E, et al. Influence of a regular, standardized meal on clinical chemistry analytes. Annals of Laboratory Medicine 2012; 32: 250-6.
11. Lippi G, Lima-Oliveira G, Salvagno GL, Montagnana M, Gelati M, Picheth G, et al. Influence of a light meal on routine haematological tests. Blood Transfus 2010; 8: 94-9.
12. Simundic AM, Cornes MP, Grankvist K, Lippi G, Nybo M. Standardization of collection requirements for fasting samples: For the Working Group on Preanalytical Phase (WG-PA) of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM). Clin Chim Acta 2013; doi: 10.1016/j.cca.2013.11.008.
13. Nikolac N, Šimundić AM, Miksa M, Lima-Oliveira G, Salvagno GL, Caruso B, et al. Heterogeneity of manufacturers’ declarations for lipemia interference - an urgent call for standardization. Clin Chim Acta 2013; 426: 33-40.
14. Nikolac N. Lipemia: causes, interference mechanisms, detection and management. Biochem Med 2014; 24: 57-67.
15. Saračević A, Nikolac N, [imundic AM. The evaluation and comparison of consecutive high speed centrifugation and LipoClear® reagent for lipemia removal. Clin Bio - chem 2014; doi: 10.1016/j.clinbiochem.2014.01.001.
16. Salvagno GL, Danese E, Lima-Oliveira G, Guidi GC, Lippi G. Avoidance to wipe alcohol before venipuncture is not a source of spurious hemolysis. Biochem Med 2013; 23: 201-5.
17. Lima-Oliveira G, Lippi G, Salvagno GL, Montagnana M, Picheth G, Guidi GC. The effective reduction of tourniquet application time after minor modification of the CLSI H03-A6 blood collection procedure. Biochem Med 2013; 23: 308-15.
18. Lippi G, Avanzini P, Aloe R, Cervellin G. Blood collection from intravenous lines: is one drawing site better than others? Lab Med 2014.
19. Yamada K, Yamada K, Katsuda I, Hida T. Cubital fossa venipuncture sites based on anatomical variations and relationships of cutaneous veins and nerves. Clin Anat 2008; 21: 307-13.
20. Lima-Oliveira G, Lippi G, Salvagno GL, Montagnana M, Mangueira C, Sumita N, et al. New ways to deal with known preanalytical issues: use of transilluminator instead of tourniquet for easing vein access and eliminating stasis on clinical biochemistry. Biochem Med 2011; 21: 152-9.
21. Lima-Oliveira G, Lippi G, Salvagno GL, Montagnana M, Scartezini M, Guidi GC, et al. Transillumination: a new tool to eliminate the impact of venous stasis during the procedure for the collection of diagnostic blood specimens for routine haematological testing. Int J Lab Hematol 2011; 33: 457-62.
22. Lima-Oliveira G, Salvagno GL, Lippi G, Montagnana M, Scartezini M, Picheth G, et al. Elimination of the venous stasis error for routine coagulation testing by transillumination. Clin Chim Acta 2011; 412: 1482-4.
23. Dennis SC, Gevers W, Opie LH. Protons in ischemia: where do they come from; where do they go to? J Mol Cell Cardiol 1991; 23: 1077-86.
24. Lima-Oliveira G, Lippi G, Salvagno GL, Montagnana M, Picheth G, Guidi GC. Impact of the phlebotomy training based on CLSI/NCCLS H03-A6 - procedures for the collection of diagnostic blood specimens by venipuncture. Biochem Med 2012; 22: 342-51.
25. Bölenius K, Söderberg J, Hultdin J, Lindkvist M, Brulin C, Grankvist K. Minor improvement of venous blood specimen collection practices in primary health care after a large-scale educational intervention. Clin Chem Lab Med 2012; DOI 10.1515/cclm-2012-0159.
26. Plebani M, Lippi G. Hemolysis index: quality indicator or criterion for sample rejection? Clin Chem Lab Med 2009; 47: 899-902.
27. Lillo R, Salinas M, Lopez-Garrigos M, Naranjo-Santana Y, Gutierrez M, Marin MD, et al. Reducing preanalytical laboratory sample errors through educational and technological interventions. Clin Lab 2012; 58: 911-7.
28. Lowe G, Stike R, Pollack M, Bosley J, O’Brien P, Hake A, et al. Nursing blood specimen collection techniques and hemolysis rates in an emergency department: analysis of venipuncture versus intravenous catheter collection techniques. J Emerg Nurs 2008; 34: 26-32.
29. Bailey IR, Thurlow VR. Is suboptimal phlebotomy technique impacting on potassium results for primary care? Ann Clin Biochem 2008; 45: 266-9.
30. Straszewski SM, Sanchez L, McGillicuddy D, Boyd K, Dufresne J, Joyce N, et al. Use of separate venipunctures for IV access and laboratory studies decreases hemolysis rates. Intern Emerg Med 2011; 6: 357-9.
31. Lippi G, Caputo M, Banfi G, Buttarello M, Ceriotti F, Daves M, et al. Recommendations for collection of venous blood. Biochim Clin 2008; 32: 569-77.
32. Lippi G, Mattiuzzi C, Banfi G, Buttarello M, Caputo M, Daves M, et al. Proposal of a checklist for venous blood collection. Biochim Clin 2013; 37: 312-7.
33. Lima-Oliveira G, Guidi GC, Salvagno GL, Montagnana M, Rego FGM, Lippi G, et al. Is phlebotomy part of the dark side in the clinical laboratory struggle for quality? Lab Med 2012; 43: 17-21.
34. Clinical Laboratory Standards Institute. Procedures for the handling and processing of blood specimens for common laboratory tests. CLSI H18-A4 document. 4th ed. Wayne, PA: Clinical Laboratory Standards Institute; 2010.
35. Clinical Laboratory Standards Institute. Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays and Molecular Hemostasis Assays. CLSI H21-A5 document. 5th ed. Wayne, PA: Clinical Laboratory Standards Institute; 2008.
36. Parenmark A, Landberg E. To mix or not to mix venous blood samples collected in vacuum tubes? Clin Chem Lab Med 2011; 49: 2061-3.
37. Lima-Oliveira G, Lippi G, Salvagno GL, Brocco G, Gaino S, Dima F, et al. Processing of diagnostic blood specimens: Is it really necessary to mix primary blood tubes after collection with evacuated tube system? Biopreserv Biobank 2014; 12: 53-9; DOI: 10.1089/bio.2013.0043.
38. Lima-Oliveira G, Lippi G, Salvagno GL, Montagnana M, Gelati M, Volanski W, et al. Effects of vigorous mixing of blood vacuum tubes on laboratory test results. Clin Biochem 2013; 46: 250-4.
39. World Health Organization. WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy. World Health Organization press 2010; Geneva.