When should a phlebotomist remove the tourniquet when using the syringe method for venipuncture?

ALERT

Strictly adhere to guidelines for hand hygiene, standard precautions, and site preparation to minimize the risk of a health care–associated infection.undefined#ref15">15

Signs of nerve injury include severe, unusual or shooting pain, tingling or numbness, or a tremor in the arm. If the patient complains of any of these symptoms during venipuncture, withdraw the needle immediately.2

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

OVERVIEW

Infection control standards must be followed when obtaining a blood specimen. Appropriate safety devices should always be used and blood-borne pathogen standards should be followed to minimize the risk of exposure to blood-borne pathogens.16 The use of safer needleless devices, such as those with a reliable integrated safety feature, is recommended.16 Venipuncture requires an aseptic, no-touch technique.8 Veins used for venipuncture should be repeatedly assessed for infiltration, extravasation, infection, and phlebitis using standardized scales.11,12,13 Pain, burning, stinging, erythema, warmth, and subcutaneous swelling should be reported to the practitioner.

Venipuncture with a syringe requires the nurse to exert aspiration pressure against the syringe plunger. This method involves inserting a hollow-bore needle attached to a syringe into the lumen of a large vein to obtain a blood specimen. A hollow-bore straight needle or winged-butterfly needle with a short length of tubing is connected to an appropriate-size syringe. After blood is drawn into the syringe, the needle is withdrawn from the patient’s vein while a safety device is engaged and then detached from the syringe. The syringe is then connected to a blood-transfer device housing a rubber-sheathed needle with a Luer lock. The rubber-sheathed needle housed in the collection barrel is used to puncture the rubber top of a vacuum test tube. Once punctured, the vacuum in the blood collection tube extracts a set volume of blood from the syringe.

The correct amount of blood required by the laboratory must be drawn into each blood collection tube to ensure accurate laboratory test results and decrease the patient’s risk of anemia.10 Some blood collection tubes contain fixative agents that require an exact amount of blood in the collection tube. Blood collection tubes without fixative agents allow variable amounts of blood. Some laboratory tests require less blood than others; the minimum amount needed for a required laboratory test should be confirmed with the organization’s laboratory.10 Some fixatives are more likely to contaminate other blood specimens when blood collection tubes are sequentially engaged in the rubber-sheathed needle. Knowing the prescribed laboratory order of the blood specimens into the collection tubes is essential.17 The sequence of collecting blood specimens is different when using a syringe and transfer device than when using a vacuum-extraction blood collection system. Blood specimens should be transported to the laboratory immediately after collection per the organization’s practice.17 Some blood specimens may require special storage or handling, such as being placed on ice, refrigerated, or frozen.17

Because limited venous access may be a life-threatening complication of venipuncture, maintaining the patient’s vein’s integrity is essential. A patient with veins that may collapse or become injured from the vacuum pressure may require an alternative method of blood specimen collection or the use of a smaller syringe. In addition, a patient whose veins may be difficult to locate because of unusual anatomy, trauma from repeated phlebotomy, or edema may also require an alternative method of blood specimen collection.

Tourniquets should be used with caution. If a tourniquet is deemed necessary, the nurse should not apply the tourniquet for longer than 1 minute.10 Prolonged tourniquet application can cause stasis and hemoconcentration.10 Infection control standards require that tourniquets be single use.7 Contamination from Staphylococcus aureus from reused tourniquets is a common finding.18

When preparing a specimen label, the nurse should confirm the patient’s identifying information per the organization’s practice. A laboratory cannot process a mislabeled blood specimen or one that does not arrive in a timely manner. Errors in any aspect of blood sampling may require repeat samples, placing the patient at risk for blood loss and venous injury. Accuracy in obtaining, labeling, and handling blood specimens reduces the need for redrawing specimens.

Venipuncture can be painful, and the patient may experience anxiety or fear before the procedure. In some cases, just the appearance of a needle is frightening. A calm approach and skilled technique may help limit a patient’s aversion to venipuncture. Anxiety may be assuaged by communicating with the patient about how to help relieve the patient’s concerns.

Appropriate laboratory tubes should be obtained before the home visit. If needed, the laboratory should be called so that the proper tubes and the volume required to process the specimens can be confirmed.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the purpose of collecting the blood specimen and the method to be used.
• Explain how a tourniquet, antiseptic swab, and venipuncture may feel.
• Explain that pressure is applied to the venipuncture site briefly after the needle is withdrawn, without bending the patient's arm.
• Explain that the patient may apply pressure if able.
• For a patient who has a bleeding disorder or is undergoing anticoagulant therapy, explain that pressure may have to be applied for a longer period of time to achieve clotting.
• Teach the patient on the signs and symptoms of a vasovagal response (e.g., pale skin, lightheadedness, tunnel vision, nausea) and provide instructions on when to seek additional care.
• Teach the patient on the signs and symptoms of venipuncture complications (e.g., hematoma, nerve pain, extravasation, excessive bleeding, arterial puncture, infection, phlebitis) and provide instructions on when to seek additional care.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to bodily fluids.
2. Introduce yourself to the patient, family, and caregivers.
3. Verify the correct patient using two identifiers.
4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
5. Verify the practitioner’s order and assess the patient for pain.
6. Prepare an area in a clean, convenient location and assemble the necessary supplies.
7. Consult with the practitioner to minimize venipuncture and conserve blood by substituting point-of-care testing for venipuncture, using low-volume collection tubes, performing all daily tests during one venipuncture, and eliminating routine testing.10
8. Assess the patient's history for risks associated with venipuncture, such as anemia, anticoagulant therapy, low platelet count, a bleeding disorder, venous collapse, traumatic venipuncture, or phlebitis.
9. Review the patient's history for adverse reactions to previous venipuncture, including a vagal response.
10. Determine the patient's ability to cooperate with the procedure and the patient's experience with blood specimen collection (e.g., anxiety or fear related to venipuncture).
11. Review the patient's history for an allergy or sensitivity to antiseptic solutions,7 adhesives, and dressings.14
12. Review the patient's anatomy for sites contraindicated for venipuncture, such as IV access sites; a site with signs of a hematoma or signs of phlebitis or previous infiltration; potential site on the arm on the side of a mastectomy or other lymphatic system compromise; a site affected by radiation, tissue injury, or infection; a site on the arm on the side affected by a stroke; or current or planned hemodialysis shunt.10

    Rationale: Drawing blood specimens from contraindicated sites can result in false test results or may injure the patient.

13. Determine the patient's hydration and perfusion status.
14. Assess for the need to apply a local anesthetic to reduce pain from the venipuncture per the organization's practice.
15. Review the anatomy of the venous system and the organization's practice for the preferred veins for venipuncture.
16. Review the manufacturer's instructions for using blood collection tubes and transfer devices.
17. Identify whether cautions or preconditions must be met before the specimen can be collected. Specimen timing can be related to medication administration, nutritional intake, procedures, or diagnostic testing.
18. Identify the appropriate laboratory tubes and validate the order in which the specimens are to be transferred into the collection tubes (if multiple specimens are required) and the volume required for each test with the laboratory.
19. Review the laboratory's requirements for labeling and handling the blood specimens.
20. Gather supplies and equipment, including specimen labels, blood collection tubes, and vascular visualization devices, if required, and bring them to the patient's side. Replace latex equipment with nonlatex equipment if the patient has a latex allergy.
    1. Ensure that all equipment has been cleaned and disinfected using an Environmental Protection Agency (EPA)–registered disinfectant per the organization's practice.
    2. Ensure that all work surfaces used to hold blood specimen collection equipment, including chair arm extensions and tables, have been disinfected to protect the patient and the blood specimen from contamination.18
    3. Ensure that the blood collection tubes' expiration dates have not passed and that all equipment and tubes are intact and free from defects or compromises.1
    4. Ensure that the blood collection tubes have been stored upright and at the correct temperature (e.g., tubes with some fixative agents require refrigeration).17
    5. Do not preassemble devices before patient identification.1
    6. Ensure that devices for the blood specimen collection process are from the same manufacturer.4
21. Provide privacy for the patient.
22. Ensure proper lighting to aid observation of vein contours and colors.
23. Assist the patient to a comfortable position and have the patient remove food as well as gum and mints from the mouth.

    Rationale: A low, supported position and an empty mouth1 reduce the risk of injury if the patient experiences lightheadedness or a seizure or faints from vagal stimulation.

    Be prepared to manage venipuncture-associated vasovagal or seizure reactions for a patient who is at risk.18

24. Perform hand hygiene and don gloves.
25. Support the patient’s selected arm and extend it to form a straight line from the shoulder to the wrist. Place a small pillow or towel under the upper arm or place the patient’s arm on the arm of the chair or on a table.

    Rationale: Correct patient positioning helps stabilize the patient’s arm.

26. Place a clean cloth or paper drape under the patient’s arm.18
27. Identify the best sites for venipuncture per the organization’s practice. Avoid contraindicated sites.6
    1. Choose a vein that is easily visible without applying a tourniquet.
       1. If IV fluid is being administered in one arm, choose a site on the opposite arm for blood specimen collection.3 If unable to locate a site on the opposite arm, look for a venipuncture site distal to the IV infusion site.3

          Consult with the practitioner about stopping the IV infusion before obtaining the blood specimen, as applicable.3,10

          Rationale: Stopping any infusions allows the catheter to clear any IV solutions or medications that may interfere with laboratory analysis of the specimen. Research has not established an ideal wait time for blood sampling.9

       2. Choose a vein that is straight and does not divert into another branch;18 that has no swelling, hematoma, phlebitis, infection, or infiltration; and that has not had recent venous access or venipuncture. Typically, the median cubital vein is the easiest to puncture because it lies between the muscles (Figure 1).18

          Obtain a blood specimen below a peripheral access device, if applicable.18 Obtaining a blood specimen from an arm with a peripheral access device already in place may cause blood specimen contamination or hemolysis.

          To reduce the risk of a hematoma, avoid venipuncture in locations where a vein branches. Puncturing the basilica vein is associated with damage to the underlying artery or nerve and is typically more painful.18

    2. If needed, apply a single-use tourniquet proximal to and four to five finger widths from the insertion site.18 If the venipuncture site will be on the same arm as an IV infusion site, place the tourniquet between the IV infusion site and the intended venipuncture site.3

       Rationale: A tourniquet blocks venous return to the heart from the arm, causing the veins to dilate for easier access.

       1. Encircle the arm and pull one end of the tourniquet tightly over the other, looping one end under the other (Figure 2) (Figure 3).

          Avoid using a tourniquet for a patient who has a history of bleeding, is easily bruised, has fragile skin, or has diminished circulation; however, if a tourniquet must be used, apply it loosely.

       2. Apply the tourniquet so that it can be removed by pulling one end with a single motion.

          Do not keep the tourniquet on the patient longer than 1 minute10 before the procedure is performed. Prolonged tourniquet application causes stasis, hemolysis, and hemoconcentration because of changes in the vascular epithelium from increased venous pressure and hypoxia.10

    3. Palpate the selected vein for firmness and rebound (Figure 4).

       Rationale: A healthy vein is elastic and rebounds on palpation. A thrombosed vein is rigid, rolls easily, and is difficult to puncture.18

       Do not use a vein that feels rigid or cordlike or one that rolls when palpated.

    4. If the selected vein cannot be palpated or viewed easily, apply a warm compress over the arm for several minutes per the organization's practice. If a tourniquet was deemed necessary, remove it and apply a warm compress for several minutes and then reapply the tourniquet.

       Rationale: Warming increases blood flow, making veins more prominent.

    5. Quickly inspect the vein distal to the tourniquet to confirm the selected venipuncture site.
    6. Release the tourniquet.
28. Apply a topical anesthetic as prescribed or per the organization’s practice to reduce pain, as needed. Remove the anesthetic completely from the skin after the prescribed dwell time.
29. Remove gloves and perform hand hygiene.
30. Prepare the blood collection equipment using blood collection tubes, holders, needles, and syringes from the same system and manufacturer to prevent equipment incompatibility.4

    Rationale: Combining systems may cause injury to the patient or yield incorrect laboratory test results. Incompatibility of components may cause failure of the process.4

    1. Choose an appropriate-size needle that is small enough to fit in the vein but will accommodate the prescribed therapy and the patient’s need.5
       1. Adults: 20 G to 24 G5
       2. Older adults or patients with limited venous access options: 22 G to 26 G5

          Rationale: Needles that are 22 G or smaller minimizes insertion-related trauma to the vein.5

    2. Ensure that the single-ended straight needle or winged-butterfly needle with tubing is securely attached to the syringe.

       Keep the needle hub and the connection sites sterile.

31. Relocate the selected venipuncture site.
32. Perform hand hygiene and don gloves.
33. Prepare the venipuncture site.
    1. Cleanse the site with friction using a gauze pad and 70% isopropyl alcohol solution.1
    2. Allow the area to air-dry.

       If the specimen is being collected for a blood alcohol level, use a nonalcohol based cleanser.1

       Do not touch the site after preparation unless sterile gloves are worn.1

34. Obtain the blood specimen.
    1. Reapply the tourniquet and relocate the vein.
    2. Remove the cap from the venipuncture needle, maintaining the needle’s sterility. Inform the patient that he or she will feel a stick.

       If contamination occurs, discard the needle and the collection barrel or syringe in a sharps container and prepare a new venipuncture set.

    3. Place the thumb or forefinger of the nondominant hand distal to the selected venipuncture site and gently pull and stretch the patient’s skin distal to the patient until it is taut and the vein is stabilized.

       Rationale: Gently pulling and stretching the patient’s skin help stabilize the vein and prevent it from rolling during needle insertion.

    4. Hold a butterfly needle (if used) by its wings; hold a straight needle (if used) at the hub. Insert the needle at a 30-degree angle18 from the patient’s arm with the bevel facing upward, just distal to the selected site for vein penetration.1

       Rationale: The smallest and sharpest point of the needle should puncture the skin first to reduce the chance of penetrating the sides of the vein during insertion. Keeping the bevel up causes less trauma to the vein. Entering the skin distal to the vein prevents unanticipated vein puncture, which may result in inadequate blood specimen retrieval and hematoma.

    5. Slowly insert the needle into the vein (Figure 5). If using a butterfly needle, look for blood return in the tubing of the butterfly set up.

       Rationale: Inserting the needle slowly prevents puncture through the opposite side of the vein.

    6. Hold the syringe securely, then slowly and gently pull back on the plunger.

       Rationale: Holding the syringe securely prevents the needle from advancing, which could cause the needle to puncture the other side of the patient’s vein. Gently pulling on the plunger creates just enough vacuum needed to draw blood into the syringe. If the plunger is pulled back too quickly, pressure may collapse the vein.

       Carefully assess the patient for the potential for venous collapse when using a syringe barrel that is 10 ml or larger.18 Consider that some older adults and those who have received treatments damaging to the veins may not be able to withstand high pressure or may require a smaller syringe size.

    7. Observe for blood return into the syringe (Figure 6).

       Rationale: If blood does not appear, the needle may not be in the vein.

    8. Obtain the required amount of blood for all the ordered laboratory tests, keeping the needle stabilized in the patient’s vein.

       Rationale: Laboratory results are more accurate when the required amount of blood is obtained.

    9. If the blood is flowing sufficiently into the syringe and a tourniquet was used, release the tourniquet just before collecting the total amount of blood required for the laboratory tests. If blood flow is slow, wait to release the tourniquet until the syringe is almost full.

       Rationale: Releasing the tourniquet before obtaining the required amount of blood for the laboratory tests reduces bleeding at the site when the needle is withdrawn.

    10. Apply a sterile 2 × 2-inch gauze pad over the venipuncture site without applying pressure. Quickly but carefully withdraw the needle from the patient’s vein, activating the safety mechanism to prevent an accidental needlestick injury.4

        Rationale: Applying pressure over the needle can cause discomfort and injury to the patient. Carefully removing the needle minimizes discomfort and vein trauma.

    11. Immediately apply pressure over the venipuncture site with the gauze pad until the bleeding stops (Figure 7).

        Rationale: Direct pressure minimizes bleeding and prevents hematoma formation. A hematoma may cause compression and nerve injury.

        For a patient who has a bleeding disorder or is undergoing anticoagulant therapy, hold pressure for several minutes, as needed, until the bleeding stops.

        Do not use a cotton ball or a rayon ball when applying pressure because of the potential for dislodging the platelet plug at the venipuncture site.1

    12. Observe the venipuncture site for bleeding for 5 to 10 seconds before applying tape or a bandage.1 Use tape or a bandage to secure the gauze pad and allow it to remain in place for at least 15 minutes.1

        Rationale: Applying gauze with tape or a bandage keeps the venipuncture site clean and controls final oozing.

        Instruct the patient not to bend the arm of the venipuncture site.

35. Remove the protected needle from the syringe and immediately discard it into a sharps container.1 Do not recap needles or attempt to remove the needle from the collection barrel.16

    Rationale: Using the needle to pierce blood test tube stoppers for blood transfer increases the risk of needlestick injury. Placing tubes upright in a rack, using a one-handed technique or a needle shield, and refraining from placing pressure on the syringe plunger are recommended.18

36. Transfer the blood in the syringe into the blood collection tubes.
    1. Connect the syringe to a sterile safety-transfer device to fill the blood collection tubes, ensuring that the syringe nozzle is not contaminated.

       Rationale: Safety features help reduce needlestick injuries. Using a safety-transfer device with the blood collection tubes allows the vacuum to draw the blood into the tube, reducing the risk of needlestick injury.

    2. Advance the first blood collection tube into the sheathed needle inside the transfer device so that the needle pierces the blood collection tube’s rubber top.

       Rationale: The order of the blood specimen collection that is specified by the laboratory that processes the blood specimens should be used for filling the collection tubes from a syringe. Some laboratories vary the order from national recommendations.

       Follow the laboratory’s order of the draw for filling blood collection tubes from a syringe with a collection device; it may be different from the order used to fill blood collection tubes using a vacuum-extraction system.

    3. After the blood collection tube is filled to the correct level for the ordered test(s) (indicated by the marking on the tube or by laboratory practice), grasp the transfer device firmly and remove the blood collection tube.

       Rationale: The blood collection tubes should be filled to the correct level because additives in certain tubes are measured in proportion to the filled tube.

       To prevent causing hemolysis, do not press the syringe plunger to force blood into a blood collection tube.18

    4. Insert and remove additional blood collection specimen tubes, in the order specified by the laboratory, into the transfer device and engage the sheathed needle, as needed, to fill the blood collection tubes.
    5. If the blood collection tube contains additives, gently invert the tube back and forth immediately after it is filled with blood. Follow the manufacturer’s instructions for the number of inversions.1

       Rationale: Inverting the tube gently ensures that the additives are properly mixed and prevents erroneous test results. Shaking may cause lysis of the cells, resulting in inaccurate test results.

       Do not shake the blood collection tube.

       Rationale: Shaking the blood collection tube may cause lysis of the blood cells, resulting in inaccurate test results.

37. Immediately discard the syringe and transfer device into an easily accessible sharps container.1 Do not recap needles or attempt to remove the needle from the collection barrel.16

    Rationale: Transfer devices and sheathed needles are considered sharps that are associated with needlestick injuries, and they must be disposed of in a sharps container. The sheathed needle’s flexible cover prevents blood from flowing when the needle is not engaged in a vacuum tube; however, the sheath does not prevent a needlestick injury if a finger inadvertently enters the collection barrel.16

38. Check the blood collection tubes for any signs of external contamination with blood. Decontaminate the blood collection tubes, if necessary, per the laboratory’s practice.

    Rationale: Decontamination prevents cross-contamination and reduces the risk of exposure to pathogens in the blood specimen.

39. Assist the patient to a comfortable reclining position for several minutes.
40. In the presence of the patient, label the specimen per the organization’s practice.15
41. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
42. Assess the patient’s tolerance of the venipuncture, including signs of anxiety or fear.

    Rationale: A patient may require more venipunctures in the future; therefore, addressing concerns and letting the patient express emotions may reduce an aversion to future venipunctures. Documenting the patient’s response allows for improved care planning for future venipunctures.

43. Reassess the venipuncture site to determine whether bleeding has stopped or a hematoma has formed.
44. Assess the patient for infection or phlebitis using standardized scales. Report pain, burning, stinging, erythema, warmth, or subcutaneous swelling to the practitioner.11,12,13
45. Report adverse events in an organization-approved occurrence reporting system.18
46. Assess pain, treat if necessary, and reassess.
47. Discard or store supplies, remove PPE, and perform hand hygiene.
48. Document the procedure in the patient's record.

EXPECTED OUTCOMES

• Venipuncture is successful without nerve or adjacent tissue injury.
• Aseptic technique is maintained.
• Venipuncture site shows no evidence of continued bleeding or hematoma after specimen collection.
• Patient tolerates procedure with minimal anxiety, fear, or discomfort.
• All required laboratory specimens are collected, and accurate results are obtained.
• Blood specimen is appropriately labeled and transported immediately after home visit

UNEXPECTED OUTCOMES

• Hematoma forms at venipuncture site.
• Needle is inserted through the vein.
• Patient has vasovagal response, including dizziness, fainting, or loss of consciousness.
• Infection or phlebitis develops at the venipuncture site.
• Nerve or adjacent tissue injury occurs.
• Hemostasis is not achieved.
• Laboratory specimen is inadequate for testing or hemolyzed and cannot be processed.
• Aseptic technique is not maintained.
• Blood specimen is not obtained.
• Needlestick injury occurs.

DOCUMENTATION

• Date and time of venipuncture, number and location of attempts, and name and credentials of person performing procedure
• Blood specimens obtained and disposition of specimens
• Location and description of venipuncture site
• Volume of blood drawn for a patient undergoing frequent blood specimens or a patient with anemia
• Laboratory to which the specimen was delivered and any information required by the laboratory
• Inability to obtain sample, if unsuccessful
• Patient’s tolerance of venipuncture
• Education
• Patient’s progress toward goals
• Unexpected outcomes and related interventions
• Assessment of pain, treatment if necessary, and reassessment

OLDER ADULT CONSIDERATIONS

• Older adults have fragile veins that are easily traumatized during venipuncture. Applying a warm compress may help when samples are obtained. Using a small-gauge needle may also help.

REFERENCES

1. Ernst, D.J. and others. (2017). Chapter 2: Blood specimen collection process. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 5-30). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
2. Ernst, D.J. and others. (2017). Chapter 4: Complications. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 35-40). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
3. Ernst, D.J. and others. (2017). Chapter 5: Special situations. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 41-48). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
4. Ernst, D.J. (2017). Chapter 6: Quality management system elements. In GP41: Collection of diagnostic venous blood specimens (7th ed., pp. 49-60). Wayne, PA: Clinical and Laboratory Standards Institute. (Level VII)
5. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 26: Vascular access device planning. Journal of Infusion Nursing, 44(Suppl. 1), S74-S81. (Level I)
6. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 27: Site selection. Journal of Infusion Nursing, 44(Suppl. 1), S63-S65. (Level I)
7. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 33: Vascular access site preparation and skin antisepsis. Journal of Infusion Nursing, 44(Suppl. 1), S96. (Level I)
8. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 34: Vascular access device placement. Journal of Infusion Nursing, 44(Suppl. 1), S97-S101. (Level I)
9. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 41: Flushing and locking. Journal of Infusion Nursing, 44(Suppl. 1), S113-S118. (Level I)
10. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 44: Blood sampling. Journal of Infusion Nursing, 44(Suppl. 1), S125-S133. (Level I)
11. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 46: Phlebitis. Journal of Infusion Nursing, 44(Suppl. 1), S138-S141. (Level I)
12. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 47: Infiltration and extravasation. Journal of Infusion Nursing, 44(Suppl. 1), S142-S147. (Level I)
13. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 50: Infection. Journal of Infusion Nursing, 44(Suppl. 1), S153-S157. (Level I)
14. Infusion Nurses Society (INS). (2021). Infusion therapy standards of practice. Standard 55: Catheter-associated skin injury. Journal of Infusion Nursing, 44(Suppl. 1), S168-S171. (Level I)
15. Joint Commission, The. (2021). National Patient Safety Goals® for the home care program. Retrieved June 28, 2021, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2021/npsg_chapter_ome_jan2021.pdf (Level VII)
16. Occupational Safety and Health Administration (OSHA®). (n.d.). Healthcare wide hazards: Needlestick/sharps injuries. Retrieved June 28, 2021, from https://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html (Level VII)
17. Pagana, K.D., Pagana, T.J. (2018). Chapter 2: Blood studies. In Mosby’s manual of diagnostic and laboratory tests (6th ed., pp. 10-476). St. Louis: Elsevier.
18. World Health Organization (WHO). (2010). WHO guidelines on drawing blood: Best practices in phlebotomy. Retrieved June 28, 2021, from http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf (classic reference)* (Level VII)

ADDITIONAL READINGS

O’Grady, N.P. and others. (2011, updated 2017). Guidelines for the prevention of intravascular catheter-related infections, 2011. Centers for Disease Control and Prevention. Retrieved June 28, 2021, from https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

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