Professionalism + Compliance
18%of exam
Patient ID + Site Prep
17%of exam
Infection Control + Safety
16%of exam
Equipment Selection + Maintenance
10%of exam
Blood + Non-Blood Collection
29%of exam
Specimen Processing + Transport
10%of exam
Quick Facts
- Credential
- AMCA PTC
- Full name
- Phlebotomy Technician Certification
- Scored items
- 100 multiple-choice
- Time
- 2 hours
- Passmark
- 70 or 74 correct
- Format
- Online or paper
- Proctoring
- Live remote available
- Biggest domain
- Collection, 29%
- Valid
- 2 years
- Accreditation
- NCCA accredited
OSHA vs CLIA
OSHA
- Worker safety
- Bloodborne pathogens
- PPE and sharps
CLIA
- Test quality
- Lab certification
- Personnel standards
Employee vs test quality
Laws and Agencies
- OSHA
- Worker safety enforcement
- 29 CFR 1910.1030
- Bloodborne Pathogens Standard
- CLIA
- Laboratory testing quality
- HIPAA
- Protected health information privacy
- Minimum necessary
- Share only what's needed
- CDC
- Recommends, does not enforce
- CLSI
- Order of draw standards
- NCCA
- Accredits the PTC credential
- Exposure Control Plan
- Written, reviewed annually
- Sharps injury log
- Employer must maintain
Assault vs Battery
Assault
- Threat only
- No contact made
- Patient fears harm
Battery
- Actual contact
- Drawing after refusal
- Unauthorized touching
Threat vs touch
Legal and Ethical Terms
- Assault
- Threatening to draw
- Battery
- Drawing without consent
- Negligence
- Below reasonable standard of care
- Malpractice
- Professional negligence
- Respondeat superior
- Employer liable for employee
- Expressed consent
- Spoken or written permission
- Implied consent
- Patient offers the arm
- Refusal
- Document, notify the nurse
- Scope of practice
- Never interpret results
- Chart correction
- Single line, initial, date
Chain of Custody
- When required
- Forensic, drug, paternity testing
- Identity check
- Photo ID required
- Seal
- Tamper-evident, donor witnesses
- Documentation
- Every handler signs, dates
- Unbroken record
- Collection through final testing
- Legal alcohol prep
- Non-alcohol antiseptic only
- Broken chain
- Result inadmissible in court
AMCA PTC Exam Logistics
- Scored items
- 100 multiple-choice questions
- Pilot items
- Unscored, no score effect
- Passmark
- Varies by exam form
- Forms C, D
- 74 correct required
- Forms E, F
- 70 correct required
- Retake waits
- 30 days, then 60
- Attempt limit
- Three within one year
- Recertification
- 10 CE credits, 2 years
- Reinstatement
- Within one year, $25
- AMCA recommends
- 30 venipunctures, 10 capillaries
- Louisiana rule
- 100 venipunctures, 25 capillaries
Vein Order
Median cubital, cephalic, basilic last
Median cubital: safestCephalic: rolls moreBasilic: median nerveBasilic: brachial artery
Site Picker
- Routine adult draw→Median cubital(Least nerve risk)
- Median cubital unusable→Cephalic(Anchor well, rolls)
- Both unavailable→Basilic last(Nerve, artery nearby)
- Arm veins unusable→Dorsal hand(23G butterfly)
- Mastectomy one side→Opposite arm(No approval needed)
- IV in one arm→Other arm(Always preferred)
- Only IV arm available→Draw below IV(Discard 5 mL)
- Infant under 1→Heel stick(Never a finger)
- Foot or ankle→Provider approval(Clot risk)
Antecubital Veins
- Median cubital
- First choice, well anchored
- Cephalic
- Second choice, thumb side
- Basilic
- Last resort, highest risk
- Median nerve
- Lies near basilic vein
- Brachial artery
- Deep to basilic vein
- Dorsal hand
- Butterfly, shallow angle
- Vein feel
- Bouncy, spongy, no pulse
- Artery feel
- Pulsing, thick walled
- Tendon feel
- Hard, does not bounce
Tourniquet Rule
One minute on, 3-4 inches above
Over 1 minute: hemoconcentrationRelease once blood flowsNo fist pumpingNever over a wound
Sites to Avoid
- Edema
- Tissue fluid dilutes specimen
- Hematoma
- Draw below or elsewhere
- Scars, burns
- Poor flow, painful
- Sclerosed veins
- Hard, cord-like, no return
- Mastectomy side
- Lymphostasis, needs provider approval
- Dialysis fistula
- Never without provider approval
- Above an IV
- Always draw below
- Foot, ankle
- Provider approval, clot risk
- Tattoo, rash
- Infection and dye interference
Patient ID Rules
- Two identifiers
- Full name, date of birth
- Active identification
- Patient states and spells
- Never ask
- Are you Mr. Diaz?
- Armband
- Must match the requisition
- Never accept
- Room or bed number
- No ID band
- Nurse must attach first
- Unconscious patient
- Nurse or relative identifies
- Any mismatch
- Stop, do not draw
- Introduce yourself
- State role, explain procedure
Pre-Analytical Variables
- Fasting
- 8-12 hours, water only
- Basal state
- Morning, rested, fasting
- Tourniquet limit
- 1 minute maximum
- Tourniquet placement
- 3-4 inches above site
- Hemoconcentration
- Raises protein, potassium, calcium
- Fist pumping
- Falsely raises potassium
- Alcohol dry time
- 30 seconds, air dry
- Posture
- Standing raises protein, cholesterol
- Diurnal rhythm
- Cortisol, iron peak morning
- Timed test
- Collect at ordered hour
PPE Sequence
Gown, mask, goggles, gloves; reverse off
On: gloves lastOff: gloves firstDoff dirtiest firstHand hygiene after
Standard vs Transmission-Based
Standard
- Every patient, always
- Assume all infectious
- Hand hygiene, gloves
Transmission-based
- Known or suspected organism
- Contact, droplet, airborne
- Added to Standard
Always vs in addition
Precaution Picker
- MRSA or C. difficile→Contact precautions(Gown, gloves)
- Influenza or pertussis→Droplet precautions(Surgical mask)
- Tuberculosis or measles→Airborne precautions(Fit-tested N95)
- Immunocompromised patient→Protective isolation(Shield the patient)
- Hands visibly soiled→Soap and water(20 seconds)
- Hands not soiled→Alcohol rub(Routine choice)
Standard Precautions and PPE
- Standard Precautions
- All patients, all fluids
- Only exception
- Sweat is not infectious
- Donning order
- Gown, mask, goggles, gloves
- Doffing order
- Gloves, goggles, gown, mask
- Alcohol rub
- Routine, hands not soiled
- Soap and water
- Visible soil, C. difficile
- Wash duration
- At least 20 seconds
- Contact precautions
- Gown and gloves
- Droplet precautions
- Surgical mask, 3-6 feet
- Airborne precautions
- Fit-tested N95, negative pressure
Inversion Counts
Blue 3-4, serum 5, rest 8-10
Culture: 8-10Light blue: 3-4Red, gold: 5Green, lavender, gray: 8-10Glass red: none
EDTA vs Citrate
EDTA
- Binds calcium tightly
- CBC, ESR, HbA1c
- Lavender, 8-10 inversions
Citrate
- Binds calcium reversibly
- PT INR, aPTT
- Light blue, exact fill
Cell counts vs coagulation
Tube Picker by Test
- CBC or HbA1c→Lavender EDTA(8-10 inversions)
- PT INR or aPTT→Light blue citrate(Fill to line)
- Serum chemistry panel→Gold SST(5 inversions)
- Type and crossmatch→Pink EDTA(No gel)
- STAT potassium→Green heparin(No clot wait)
- Glucose or alcohol→Gray fluoride(Antiglycolytic)
- Suspected sepsis→Culture bottles(Two sites)
- Lead level→Royal blue(Trace element free)
- Westergren ESR→Black citrate(Or lavender EDTA)
Additive Mechanisms
- SPS
- Anticoagulant, inhibits complement
- Sodium citrate
- Binds calcium reversibly
- Clot activator
- Silica speeds clotting
- Separator gel
- Barrier between serum, cells
- Heparin
- Activates antithrombin, blocks thrombin
- EDTA
- Chelates calcium, preserves cells
- Sodium fluoride
- Antiglycolytic, preserves glucose
- Potassium oxalate
- Anticoagulant paired with fluoride
- ACD
- Citrate dextrose, DNA testing
Plain Red vs Gold SST
Plain red
- No gel
- Blood bank, serology
- Yields serum
Gold SST
- Clot activator, gel
- Chemistry panels
- Not for blood bank
Gel blocks blood bank
Tube to Test Map
- Yellow SPS
- Blood cultures
- Light blue
- PT INR, aPTT, D-dimer
- Plain red
- Serology, blood bank
- Gold SST
- Serum chemistry panels
- Green heparin
- Ammonia, lactate, STAT chemistry
- Lavender EDTA
- CBC, ESR, HbA1c
- Pink EDTA
- Type and screen
- Gray
- Glucose, lactate, blood alcohol
- Royal blue
- Lead, zinc, copper
- Black
- Westergren ESR
Inversions Per Tube
- Culture bottles
- 8-10 inversions
- Light blue
- 3-4 inversions
- Red, clot activator
- 5 inversions
- Gold SST
- 5 inversions
- Green heparin
- 8-10 inversions
- Lavender EDTA
- 8-10 inversions
- Gray fluoride
- 8-10 inversions
- Glass plain red
- No mixing needed
- Technique
- Gentle, end-over-end
- Too few
- Microclots, platelet clumping
Needle Gauges and Devices
- Higher gauge
- Smaller bore
- 16-18G
- Blood donation, apheresis
- 21G
- Routine venipuncture standard
- 22G
- Small or fragile veins
- 23G butterfly
- Hand veins, pediatrics
- ETS holder
- Single use, discard attached
- Syringe draw
- Fragile veins, controlled pull
- Transfer device
- Syringe to tube safely
- Bevel angle
- Up, 30 degrees maximum
- Lancet depth
- 2.0 mm maximum
Equipment Quality Control
- Needle check
- Inspect bevel for burrs
- Expired tube
- Lost vacuum, weak additive
- Short draw
- Wrong blood to additive
- Centrifuge
- Documented calibration schedule
- Point-of-care meter
- Run controls each shift
- Antiseptic choice
- Alcohol routine, chlorhexidine cultures
Order of Draw
Better Learn Real Good, Great Lab Guys
B: blood cultureL: light blueR: redG: goldG: greenL: lavenderG: gray
Hematoma vs Nerve Injury
Hematoma
- Site swells
- Blood leaks out
- Pressure and elevate
Nerve injury
- Shooting electric pain
- Tingling, numbness
- Remove, never restick
Swelling vs shooting pain
Complication Response
- Patient feels faint→Stop, lay flat(Never leave alone)
- Site swells→Release, remove needle(Hematoma)
- Shooting electric pain→Remove immediately(Nerve, report)
- Bright pulsing blood→Remove, press firmly(Arterial nick)
- Bleeding will not stop→Pressure, notify nurse(Elevate arm)
- Seizure begins→Remove needle, protect(Call for help)
- Two failed sticks→Hand off(Never probe)
- Patient vomits→Stop, position safely(Call the nurse)
CLSI Order of Draw
- Blood culture
- Yellow SPS, sterile first1
- Light blue
- Sodium citrate, coagulation2
- Red, gold
- Serum, clot activator, gel3
- Green
- Heparin, plasma chemistry4
- Lavender, pink
- EDTA, whole blood5
- Gray
- Fluoride oxalate, glucose6
- Royal blue
- Follows its own additive
- Discard tube
- Butterfly before light blue
- Why it matters
- Additive carryover skews results
Stop Signals
Shooting pain or pulsing blood: stop now
Electric pain: nerveBright pulsing: arterySwelling: hematomaPale, sweaty: syncope
Venipuncture vs Capillary
Venipuncture
- Pure venous blood
- Large volumes
- CLSI order of draw
Capillary
- Mixed arterial, venous, tissue
- Small volumes
- Blood gas drawn first
Volume decides method
Carryover Errors
- EDTA into chemistry
- Potassium high, calcium low
- Clot activator into blue
- Shortens PT and aPTT
- Fluoride into chemistry
- Sodium high, enzymes inhibited
- Heparin into lavender
- Distorts cell staining
- Non-sterile before culture
- Contaminates the culture bottle
- Underfilled citrate
- Falsely prolonged PT
- Overfilled citrate
- Falsely shortened PT
Puncture Depth Limits
Finger and heel: 2.0 mm maximum
Heel: medial or lateralNever the posterior curveNo finger under 1Warm to 42 C
Complications and Response
- Syncope
- Stop, lower head, stay
- Hematoma
- Remove needle, pressure, elevate
- Nerve injury
- Shooting pain, stop immediately
- Arterial nick
- Bright pulsing, press 5 minutes
- Petechiae
- Warns of prolonged bleeding
- Seizure
- Remove needle, protect patient
- Excessive bleeding
- Hold pressure, notify nurse
- Iatrogenic anemia
- Blood loss from overdrawing
- Latex reaction
- Switch to latex-free supplies
- Two-stick rule
- Stop, ask another phlebotomist
Hemolysis Causes
- Wet alcohol
- Lyses cells on entry
- Bore too small
- Shears red cells
- Shaking tubes
- Invert gently instead
- Forced syringe transfer
- Use a transfer device
- Milking a finger
- Squeezing lyses, adds fluid
- Underfilled additive tube
- Excess additive lyses cells
- Traumatic draw
- Probing damages cells
- Falsely raises
- Potassium, LD, AST, magnesium
Special Collections
- Blood cultures
- Two sets, two sites
- Culture skin prep
- Chlorhexidine, let dry fully
- Infants under 2 months
- Povidone-iodine instead
- Bottle tops
- Wipe with 70% alcohol
- Adult volume
- 8-10 mL per bottle
- Butterfly set
- Aerobic bottle first
- Syringe collection
- Anaerobic bottle first
- GTT timing
- Start when drink finished
- Trough level
- Just before next dose
- Peak level
- After dose, drug specific
- Legal alcohol
- Non-alcohol prep, full tube
- Newborn screen
- Fill circles, air dry
Capillary and Dermal Puncture
- Adult site
- Middle or ring finger
- Finger depth
- 2.0 mm maximum
- Direction
- Across the fingerprint lines
- First drop
- Wipe away, tissue fluid
- Infant site
- Medial or lateral heel
- Heel depth
- 2.0 mm maximum
- Never puncture
- Posterior curve, arch, calcaneus
- Bone contact risk
- Osteomyelitis
- No finger stick
- Under 1 year old
- Warming
- 42 C, 3-5 minutes
- Capillary fill order
- Blood gas, EDTA, others, serum
Non-Blood Specimens
- Clean-catch urine
- Cleanse, void, collect midstream
- 24-hour urine
- Discard first, keep last
- Throat culture
- Tonsils and posterior pharynx
- Throat swab avoid
- Tongue, cheeks, lips
- Sputum
- Deep cough, first morning
- Stool, semen
- Patient collects, instruct clearly
Serum vs Plasma
Serum
- Clotted tube
- No fibrinogen
- Red or gold
Plasma
- Anticoagulated tube
- Contains fibrinogen
- Green or lavender
Clot means serum
Reject or Accept
- Tube has no label→Reject, recollect(Never relabel)
- Serum looks pink→Reject, hemolyzed(Potassium falsely high)
- Serum looks milky→Note lipemia(Check fasting status)
- Clots in lavender→Reject, recollect(CBC invalid)
- Light blue underfilled→Reject, recollect(Ratio wrong)
- Tube past expiration→Reject, recollect(Vacuum lost)
- Ammonia at room temp→Reject, recollect(Needed on ice)
Serum, Plasma, Whole Blood
- Serum
- Clotted tube, no fibrinogen
- Plasma
- Anticoagulated, contains fibrinogen
- Whole blood
- EDTA, cells intact
- SST clot time
- About 30 minutes
- Plain red clot time
- Up to 60 minutes
- Spin time
- About 10 minutes
- Separation limit
- Within 2 hours
- Balance rule
- Equal tubes, opposite positions
- Gel tubes
- Never re-spin
Hemolysis vs Lipemia
Hemolysis
- Pink or red
- Red cells ruptured
- Potassium falsely high
Lipemia
- Milky, cloudy
- High triglycerides
- Patient did not fast
Broken cells vs fat
Handling Picker
- Ammonia or lactate→Ice slurry(Deliver immediately)
- Cold agglutinins→37 C carrier(Warm until separated)
- Bilirubin or B12→Amber tube, foil(Light sensitive)
- Potassium sample→Room temperature(Never refrigerate)
- Serum chemistry→Clot, then spin(About 30 minutes)
- Blood smear needed→Make within 1 hour(From EDTA)
Specimen Rejection Criteria
- Unlabeled tube
- Never relabel, recollect
- Mislabeled tube
- Recollect, file incident report
- Hemolyzed
- Pink or red serum
- Clotted EDTA
- Microclots void the CBC
- QNS
- Quantity not sufficient
- Wrong tube
- Additive interferes with test
- Expired tube
- Short draw, wrong ratio
- Delayed transport
- Stability window missed
- IV contamination
- Diluted, glucose falsely high
Transport and Storage Rules
- Chilled on ice
- Ammonia, lactate, blood gases
- Warm at 37 C
- Cold agglutinins, cryoglobulins
- Light protected
- Bilirubin, B12, folate
- Never refrigerate
- Potassium leaks from cells
- Room temperature
- Most routine chemistry
- Blood smear
- Make within 1 hour
- Labeling moment
- At bedside, after collection
- Label contents
- Name, ID, date, time
- Transport bag
- Biohazard, requisition outside pocket
Common Traps
Serum vs plasma
Serum has no fibrinogen ≠ Plasma keeps fibrinogen
EDTA vs citrate
EDTA binds calcium irreversibly ≠ Citrate binds calcium reversibly
Hemolysis vs lipemia
Hemolysis looks red ≠ Lipemia looks milky
Gauge vs bore
Higher gauge, smaller bore ≠ Lower gauge, larger bore
Hematoma vs nerve
Hematoma swells up ≠ Nerve injury shoots
OSHA vs CLIA
OSHA protects the worker ≠ CLIA governs test quality
Standard vs transmission-based
Standard applies always ≠ Transmission-based is added
Gold vs pink tube
Gold for chemistry ≠ Pink for blood bank
Fasting vs basal state
Fasting is 8-12 hours ≠ Basal adds morning rest
Assault vs battery
Assault is the threat ≠ Battery is the contact
Chill vs refrigerate
Ammonia rides on ice ≠ Potassium never gets cold
Aerobic vs anaerobic first
Butterfly: aerobic first ≠ Syringe: anaerobic first
Last Minute
- 1.Culture first, gray tube last
- 2.Middle: red, gold, green, lavender
- 3.Light blue needs an exact fill
- 4.Butterfly plus citrate: discard tube first
- 5.EDTA = CBC; citrate = PT
- 6.Gold = chemistry; pink = blood bank
- 7.Blue 3-4; serum 5; rest 8-10
- 8.Median cubital first; basilic last
- 9.Tourniquet off within 1 minute
- 10.Let alcohol dry 30 seconds
- 11.Two identifiers: name and birthdate
- 12.Label at bedside, never before
- 13.Shooting pain = stop and remove
- 14.Pulsing bright blood = artery
- 15.Never recap; activate the safety device
- 16.Needlestick: wash, report, document
- 17.Hemolysis falsely raises potassium
- 18.Separate serum within 2 hours
- 19.Ammonia on ice; potassium never cold
- 20.Heel and finger: 2.0 mm max
- 21.Passmark varies: 70 or 74
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