SOP-P-002 — Adult and Pediatric Venipuncture Procedure SOP

1.0 Purpose

This SOP gives step-by-step bench instructions for collecting diagnostic venous blood specimens from adult, pediatric, and adolescent patients. It covers positive patient identification, proper vein selection, correct order of draw, immediate bedside labeling, and patient comfort and safety.

2.0 Scope

This SOP applies to all venous blood collection by Medical Technologists and authorized healthcare personnel in inpatient units, the emergency area, and outpatient phlebotomy stations at Tarangnan Community Hospital (TCH). It includes pediatric immobilization and pediatric blood-volume limits. Capillary skin puncture and neonatal heel-stick procedures are covered in Capillary Blood Collection By Skin Puncture Sop.

3.0 Definitions

• Venipuncture: Transcutaneous entry into a vein with a sterile needle for the purpose of collecting diagnostic blood specimens.
• Order of Draw: Sequence in which color-coded collection tubes are filled to prevent chemical additive cross-contamination between tubes.
• Winged Infusion Set (Butterfly): Short needle with flexible plastic wings and tubing, designed for delicate, small, or difficult veins.
• Immobilization: Safe physical restraint by a trained assistant or willing caregiver to stabilize a pediatric patient's limb and prevent sudden movement during puncture.
• Syringe-and-Needle Method: Blood collection using a hypodermic syringe and needle, followed by safe transfer into evacuated blood tubes.

4.0 Responsibility

4.1 Hospital Director

• Approves this procedure.
• Ensures approved phlebotomy supplies, safety equipment, and PPE are available.

4.2 Pathologist

• Reviews this procedure for technical and clinical accuracy.
• Advises on difficult venous access protocols and volume considerations in anemic or fragile patients.

4.3 Chief Medical Technologist / Laboratory Quality Manager

• Maintains version control and monitors compliance with collection protocols and quality indicators.
• Assesses staff competency in venipuncture, pediatric immobilization, and safety practices.

4.4 Medical Technologists

• Verify patient identity with two independent identifiers and confirm consent before every draw.
• Perform venipuncture as written in this procedure, using aseptic technique and observing attempt limits.
• Label all containers at the patient's bedside immediately after collection.

4.5 Laboratory Aides

• Clean and stock phlebotomy chairs, trays, and collection carts.
• Help comfort patients and stabilize limbs, under direct technologist supervision, when requested.
• Shall not perform venipuncture, select veins, or handle exposed needles.

4.6 Patient Care Area Personnel (Nursing)

• Coordinate patient availability on the wards and help with pediatric holding.
• For neonates below 30 days of age, qualified nursing staff perform venipuncture with laboratory assistance.

5.0 Policy / Procedure

5.1 General Venipuncture Requirements

• Perform hand hygiene and apply clean gloves before every venipuncture. Change gloves between patients.
• Use only sterile, single-use safety needles, syringes, or winged infusion sets. Reusing, recapping, or manual bending of needles is prohibited.
• Label every collected specimen container at the patient's bedside immediately after collection before leaving the patient. Pre-labeling tubes before collection is prohibited.
• No collector shall make more than two venipuncture attempts on a patient during a single encounter. If unsuccessful after two attempts, follow the escalation pathway in Phlebotomy Workflow Unacceptable Specimens and Adverse Reactions Sop.

5.2 Requisition Verification and Supply Assembly

• Inspect the laboratory request form: confirm full patient name, medical record number (MRN), age, sex, clinical location, ordering physician, and ordered tests.
• Note any special test conditions, such as fasting requirement (FBS, lipid profile) or medication schedule.
• Assemble required collection supplies on a clean phlebotomy tray: - Sterile hypodermic needles (21G or 22G standard; 23G winged infusion set for small or fragile veins) - Sterile disposable syringes (volume matched to the required draw volume: 3 mL, 5 mL, or 10 mL) - Color-coded blood collection tubes (inspect for vacuum integrity and expiration date; discard expired tubes) - Clean non-latex tourniquet - 70% isopropyl alcohol prep pads - Sterile gauze pads and hypoallergenic adhesive tape or bandage - Point-of-use puncture-resistant sharps disposal container

5.3 Patient Identification and Informed Consent

• Identify every patient using at least two independent identifiers: - For conscious adult or pediatric patients, ask the patient or legal guardian to state their full name and date of birth or hospital MRN. Compare spoken information with the requisition and wristband. - For incapacitated or unconscious inpatients, confirm identity through the hospital wristband and verify with the attending ward nurse. Document the verifier's name. - For emergency or unidentified trauma patients, use the temporary emergency master trauma registration number until formal identification is established.
• Room or bed numbers shall never be accepted as patient identifiers.
• Greet the patient, explain the purpose and steps of the procedure, confirm willingness to proceed, and answer questions.

5.4 Patient Positioning and Vein Selection

• Position the patient safely before inspection: - Inpatients shall be drawn while lying comfortably supine. - Outpatients shall be seated in a dedicated phlebotomy chair with padded arm supports. - Ensure the selected arm is fully extended in a downward diagonal line from shoulder to wrist without bending at the elbow.
• Apply the tourniquet 7–10 cm (3–4 inches) above the intended puncture site. Tourniquet application time shall not exceed 60 seconds to avoid hemoconcentration and altered analyte levels. If site selection takes longer, release the tourniquet for at least 2 minutes before reapplying.
• Palpate with the index finger to assess depth, direction, and rebound elasticity, differentiating veins from the pulsatile brachial artery. Select veins in the following priority order: - Median cubital vein (anchored, less painful, lowest risk of nerve injury) - Cephalic vein (lateral aspect of arm, well-anchored) - Basilic vein (medial aspect, close to brachial artery and median nerve; approach with care)
• Dorsal hand veins may be used if antecubital veins are inaccessible. Avoid veins in arms with intravenous infusions, arteriovenous fistulas, extensive scarring, active hematomas, or on the ipsilateral side of a mastectomy.

5.5 Pediatric Venipuncture and Volume Considerations

• For neonates under 30 days of age, venipuncture shall be performed by a qualified pediatric or ward nurse with Medical Technologist assistance, unless capillary sampling is clinically acceptable per Capillary Blood Collection By Skin Puncture Sop.
• Always secure assistance from a colleague or instructed parent before puncturing an infant or young child. The child may sit on the parent's lap with the child's arm extended and held firmly across the parent's chest, or lie supine with the arm held steady.
• Minimize total blood volume collected to prevent iatrogenic anemia. Never exceed 2.5% of total blood volume in a single draw, or 5% over a 30-day period (approximately 1–2 mL for infants under 10 kg). Use pediatric micro-volume tubes or 23G winged infusion sets where compatible with analyzer requirements.

5.6 Venipuncture Technique and Syringe Transfer

• Cleanse the selected puncture site with a 70% isopropyl alcohol pad using expanding concentric circular strokes. Allow the skin to air-dry completely for 30 seconds. Do not touch or re-palpate the dried site.
• Anchor the vein 2.5–5 cm (1–2 inches) below the site by gently pulling the skin taut with the thumb of the non-dominant hand.
• Align the needle with the vein, bevel pointing upward, at an angle of 15–30 degrees relative to the skin surface.
• Insert the needle smoothly into the vein lumen until blood flash appears in the syringe hub or butterfly tubing.
• Slowly and steadily pull back the syringe plunger to aspirate blood. Avoid rapid or forceful pulling, which causes hemolysis and vein collapse.
• Once blood begins flowing freely, loosen and release the tourniquet.
• Lightly place a sterile gauze pad over the puncture site without exerting pressure.
• Withdraw the needle in a smooth, swift motion, and immediately apply firm direct manual pressure on the site with the gauze.
• Engage the needle safety shield immediately and dispose of the sharp directly into the bedside sharps container.
• If using a syringe, puncture the rubber stopper of each evacuated tube vertically using a safety transfer device or sterile technique. Allow the tube vacuum to draw the required volume of blood naturally from the syringe. Never force down the syringe plunger, as forceful injection causes severe mechanical hemolysis. Invert each tube gently immediately upon filling.

5.7 Order of Draw for Blood Collection Tubes

To eliminate additive carryover between tubes, specimens shall be dispensed into tubes in the strict sequence shown below:

Note: Never shake collection tubes vigorously; gentle, complete 180-degree inversions are required.

5.8 Post-Collection Care, Immediate Bedside Labeling, and Transport

• Maintain firm direct gauze pressure over the puncture site for 3–5 minutes until bleeding stops completely. For patients aged 2 years and older, apply an adhesive bandage and advise keeping it in place for 15 minutes. For infants under 2 years, do not apply adhesive tape (to avoid skin tearing or aspiration choking risk); maintain direct pressure until sealed.
• While still at the patient's bedside, affix a printed or clearly handwritten label to each tube. The label shall contain: Patient Full Name, Hospital MRN, Collection Date and Exact Time, and Phlebotomist Initials. Never leave the bedside or set specimens on common counters before labeling.
• Discard all contaminated gauze, gloves, and wrappers into biohazard waste. Perform hand hygiene immediately after glove removal.
• Place labeled tubes upright in a leak-proof specimen rack or carrier and transport promptly to the laboratory per Specimen Handling Packaging Transportation Policy.

6.0 Records

7.0 References

• DOH Clinical Laboratory QMS Tool, Section 3 — Service Delivery
• DOH Administrative Order No. 2021-0037, Annex B1 — Technical Standards for Clinical Laboratories
• ISO 15189:2022, Section 7.2 — Pre-examination Processes
• WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy (2010)
• CLSI GP41, Collection of Diagnostic Venous Blood Specimens

Companion policies:

• Specimen Collection Policy — Laboratory-wide specimen collection rules and order of draw
• Phlebotomy Workflow Unacceptable Specimens and Adverse Reactions Sop — Pre-analytical screening, unsuccessful collection, and adverse reaction management
• Laboratory Retention Schedule Policy — Master retention schedule for phlebotomy records and requisitions