Difficult Draws & Complications

Even experienced phlebotomists encounter difficult draws and complications. Knowing how to prevent, recognize, and manage these situations is essential for patient safety and specimen quality.

---

Common Complications

1. Hematoma (Most Common Complication)

A hematoma is a bruise caused by blood leaking from the vein into surrounding tissue.

Causes:

• Needle inserted through both walls of the vein
• Needle partially in the vein
• Tourniquet left on too long
• Inadequate pressure applied after needle removal
• Fragile or small veins

Prevention:

• Use proper needle insertion technique (15-30 degree angle)
• Anchor the vein well before puncture
• Apply firm pressure for 3-5 minutes after the draw
• Do not bend the arm after the draw — this does NOT help and can worsen bleeding

Management:

• If a hematoma forms during the draw: immediately remove the needle, apply firm pressure, and elevate the arm
• Apply cold compress for 15-20 minutes to reduce swelling
• Document the occurrence

2. Syncope (Fainting)

Signs of impending syncope:

• Lightheadedness, dizziness
• Pale, cool, clammy skin
• Nausea
• Tunnel vision or loss of vision

Management:

1. Stop the draw immediately and remove the needle safely
2. Apply pressure to the puncture site
3. If seated: lower the patient's head between their knees (or recline the chair)
4. If supine: elevate the legs
5. Apply cold compress to the forehead or back of the neck
6. Loosen tight clothing
7. Use ammonia inhalants (smelling salts) if available — wave under the nose, do NOT hold directly against the nostrils
8. Never leave a fainting patient unattended
9. Document the incident

3. Nerve Injury

Signs:

• Sharp, shooting, electric-like pain radiating down the arm or into the fingers
• Numbness or tingling
• This is DIFFERENT from the normal brief sting of needle insertion

Management:

• IMMEDIATELY remove the needle — do NOT redirect or reposition
• Apply pressure to the site
• Document the incident and notify the patient's physician
• Nerve injuries can result in long-term pain, numbness, or loss of function

4. Hemolysis (Red Blood Cell Destruction)

Hemolysis is the #1 cause of specimen rejection in laboratories.

Causes of hemolysis:

Visual Sign: Hemolyzed serum/plasma appears pink to red (cherry-colored) instead of the normal straw-yellow color.

5. Accidental Arterial Puncture

Signs:

• Bright red blood (vs. dark red/maroon for venous blood)
• Pulsating blood flow — tube fills rapidly
• Patient may report unusual pain

Management:

• Remove the needle immediately
• Apply firm, direct pressure for at least 5 minutes (longer than venous bleeding)
• Do NOT apply a tourniquet — this can worsen bleeding
• Monitor the site after pressure release
• Document and report the incident

6. Petechiae

Petechiae are tiny, pinpoint red spots that appear on the skin (often above the tourniquet site).

Causes:

• Tourniquet too tight or applied too long
• Platelet disorders (thrombocytopenia)
• Fragile capillaries (common in elderly patients or those on anticoagulants)

---

The Two-Attempt Rule

Most facilities follow a two-attempt rule:

• If a phlebotomist is unsuccessful after two venipuncture attempts, they must stop and ask another qualified phlebotomist to try
• Making more than two attempts increases patient discomfort, anxiety, and risk of complications
• Document all failed attempts
• Never attempt a draw more than twice on the same patient

---

Failed Venipuncture: Troubleshooting

---

Vein Assessment Techniques

Proper vein assessment is a critical skill that improves first-stick success rates:

Palpation Technique

• Always use your index finger for palpation — NEVER your thumb (your thumb has its own pulse and you may confuse it with an artery)
• A healthy vein feels bouncy, resilient, and spongy — it compresses when pressed and rebounds when released
• An artery pulsates rhythmically — never puncture a pulsating vessel
• A tendon feels hard, cord-like, and does NOT rebound — tendons do not contain blood

Difficult-to-Find Veins

For patients with difficult-to-find veins, try these techniques:

Veins vs. Arteries vs. Tendons

---

Documentation

Proper documentation is essential for every blood collection. The phlebotomist should document:

• Patient identification verification
• Date and time of collection
• Tests ordered and tubes collected
• Site used (e.g., right median cubital, left hand dorsal)
• Number of attempts (including failed attempts)
• Complications (hematoma, syncope, nerve pain, refusal)
• Disposition — specimen sent to lab, transported by (method)
• Phlebotomist signature/ID

Incident Reporting

• Any adverse event (needlestick, patient injury, syncope, nerve pain) must be documented in an incident report
• Include: date, time, description of event, patient and staff involved, actions taken, and follow-up plan
• Incident reports are used for quality improvement and are NOT punitive documents

---

Anticoagulant Therapy and Phlebotomy Considerations

Many patients seen by phlebotomists are on anticoagulant therapy. Understanding these medications helps ensure safe blood collection:

Critical Clinical Tip: Always ask patients if they are taking any blood thinners or anticoagulants before the draw. Apply firm pressure for at least 5 minutes (or longer) after the venipuncture to prevent hematoma formation. DO NOT apply a bandage until bleeding has completely stopped.