Version 1.1 Sept 2018

Phlebotomy

Target Audience

Who Should Read This Policy

All Clinical Staffs

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Ref. Contents Page

1.0 Introduction 4

2.0 Purpose 4

3.0 Objectives 4

4.0 Process 4

5.0 Procedures connected to this Policy 8

6.0 Links to Relevant Legislation 8

6.1 Links to Relevant National Standards 9

6.2 Links to other Key Policies 9

6.3 References 9

7.0 Roles and Responsibilities for this Policy 10

8.0 Training 11

9.0 Equality Impact Assessment 11

10.0 Data Protection and Freedom of Information 12

11.0 Monitoring this Policy is Working in Practice 12

Appendices

1.0 Training Needs Analysis 13

2.0 Phlebotomy Clinical Practice Competencies 14

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Explanation of terms used in this policy Phlebotomy - the drawing of blood from a vein by the insertion of a needle.

Antecubital fossa - triangular cavity of the elbow that contains a tendon of the biceps, the median nerve, and the brachial artery.

Tourniquet - a disposable single use device that promotes vein distension for insertion of a needle.

Vacutainer - blood collection sterile glass or plastic tube with a closure that is evacuated to create a vacuum inside the tube facilitating the draw of a predetermined volume of liquid.

BBV - Blood borne virus e.g. Hepatitis B & C, HIV/Aids.

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1.0 Introduction The Black Country Partnership NHS Foundation Trust (hereafter called the Trust) recognises the relationship between physical health/illness and mental illness. It is only in recent times that physical health issues have been raised and risk factors and assessment priorities identified to provide clinical insight into how best to ensure patients health is assessed and improved. In their report “Your Choice” (September 2008) Rethink reported that only 49% of patients stated that they had ever been offered a physical health check. Nash (2005) expressed concern that the physical health of patients under mental health services was not only poor but a largely unaddressed area of need. Patients with mental illness often have other co-morbid conditions such as diabetes, ischaemic heart disease, hypertension and hyperlipidaemia. Poor physical health directly affects mental well-being and can adversely impair the rate of recovery. The Trust standard requires that all patients admitted into hospital are offered a physical health assessment and an important part of this is a blood test. A blood test can be seen as the first step in the diagnosis of a physical health related condition.

2.0 Purpose The purpose of the policy is to ensure that the Trust has a standardised approach to obtaining blood samples from patients for analysis in the laboratory while establishing safe criteria for the process. The policy recognises the health practitioner must provide a high standard of practice at all times in line with NMC and WHO guidelines for drawing blood, must have received training and have their knowledge and skills up to date. The health practitioner will work closely with other professionals to ensure that the patient’s care is co-ordinated, of a high standard and has the best possible outcome.

3.0 Objectives The policy is applicable to all staff who under-take phlebotomy as part of their duties on behalf of the Trust. Although phlebotomy /venepuncture can be seen as a relatively simple procedure, all staff undertaking phlebotomy duties should be trained in the procedure to prevent unnecessary risk of exposure to blood and reduce adverse events for patients. Objectives are:-

To improve knowledge and awareness of the risks associated with phlebotomy

Promote safe practice

Improve patient comfort and confidence

Work within the boundaries of trust policies

Ensure all equipment is checked, maintained and ready for use at all times

Ensure the quality and validity of the blood samples for laboratory analysis.

4.0 Process Phlebotomy is performed to provide diagnostic or therapeutic monitoring information, including the provision of compatible samples for blood transfusion. It is essential that samples obtained are accurate and representative of the patient’s true condition and free from artefacts. Correctly matching patient details to the blood sample(s) is absolutely vital.

Only TWO attempts should be made to obtain a blood sample from the patient, using new equipment on each occasion. If unsuccessful obtain support from another member of staff qualified to perform phlebotomy. Failed attempts should be documented in the patient notes.

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The recommended site for phlebotomy is the ante-cubital fossa. If this site is not available, refer to professional who carries out venepuncture from other sites.

Identify the clinical need for phlebotomy.

Identify the patient by surname, first name, date of birth, address and/or NHS number.

Explain the procedure to the patient, discuss the need for the blood sample to be taken, obtain informed consent for the procedure, establishing whether the patient has any known allergies.

If the patient is anxious or expresses that they are needle phobic, or any other condition that might make phlebotomy difficult, they may benefit from a topical anaesthetic. This requires a prescription.

Two possible phlebotomy sites should be chosen for application of the topical anaesthetic to give the person obtaining the blood sample a choice of site. These areas should be covered with a transparent film dressing and left on for 45-60 minutes as per prescription advice. Prior to obtaining samples the cream must be removed from the sites.

When taking blood, health workers should wear well-fitting non-sterile gloves and should also carry out hand hygiene before and after each patient procedure before putting on gloves and after removing them.

As a professional, you are “personally accountable for actions and omissions in your practice and must always be able to justify your decisions.” Code of Professional Conduct (2008) Nursing Midwifery Council (NMC).

The trained nurse has the right to delegate this procedure to a health care support worker who has completed training and has been deemed as competent to practice or phlebotomist. The trained nurse must ensure the health care support worker or phlebotomist has received Trust phlebotomy training and has successfully completed the competency, and is confident and competent to perform the procedure.

The Health Care Professional (Health Care Support Worker) has the right to refuse to insert a needle to obtain a sample of venous blood if they have concerns about the patient’s veins or the patient’s condition, or do not feel confident to undertake the procedure.

All record keeping must adhere to standards set out by the NMC Record Keeping Guidance for Nurses and Midwives (2009).

Restraint When considering using restraint there must be objective reasons to justify that restraint is necessary. It should be a multidisciplinary decision making process, and will require assessment for mental capacity to consent to phlebotomy. Staff should be able to identify that the person being cared for is likely to suffer harm should the blood test not be performed. Proportionate restraint should be used. A carer or professional must not use restraint just so that they can do something more easily. The recording of the decision making process and the rationale must be documented in the patients notes. If restraint is necessary to prevent harm to the person who lacks capacity, it must be the minimum amount of force for the shortest amount of time possible. Patients who require phlebotomy, who are detained under the Mental Health Act (2007), may require restraint to obtain the blood sample. Staffs are advised to consult the Restrictive Physical Intervention policy, section 4.4.15 Clinical Holding Interventions for further advice.

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Paediatrics

Venepuncture should only offered to children as agreed by the Trust and should be undertaken by experienced phlebotomists/nursing staff who have received training specifically for children.

All children under the age of 4 should be referred to the GP or District General Hospital.

Children will require help to cope with the procedure and this should be done by: - Establishing the child’s perception of pain. - Offering an explanation to the parent/carer in advance of any conversations

with the child. - Establishing a rapport with the child to gain the child’s confidence and give

necessary reassurance prior to carrying out the procedure. - Consider the use play and/or distraction techniques. - Consider involving a play specialist and psychologist to prepare the child for

the procedure. - Consider the use of local anaesthetic preparations prior to the procedure.

For very young children (under 12) a butterfly needle should be used, in order to limit the risk of venous collapse or unexpected movement causing collapse of the vein.

For Children over 12 the blood collection system used for adult should be used unless there is a defined clinical need for a butterfly to be used.

Informed consent should be obtained from the child and/or parent/legal guardian prior to the procedure. Informed consent is obtained from the parent/legal guardian or next of kin if a child is under the age of consent (16 years) or if the child does not have the cognitive ability to understand or make an informed decision. Preferences in relation to the venepuncture site should be identified such as dominant hand, clothing worn thumb sucking hand etc.)

Minimal restraint and holding should be used for the venepuncture procedure. If used it should be appropriate to age, cognitive ability and behaviour of the child.

Equipment required for venous blood sampling

Specimen request form signed by medical practitioner.

Single use disposable tourniquet.

Single use non sterile gloves and disposable apron.

Alcohol wipes.

Vacuum system components and appropriate sampling tubes.

Gauze swabs.

Appropriately labelled Sharps box.

Tape or adhesive plaster.

Procedure

Action Rationale Within the inpatient and outpatient setting,

lighting, ventilation, privacy and position must

be checked and optimized where possible.

To ensure that the patient and the operator are

both comfortable. Having adequate lighting is also beneficial as it illuminates the procedure, ensuring

the operator has a good view of the vein and

equipment (Dougherty and Lister 2008).

Approach the patient, introduce yourself and

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check patient identity – forename, surname,

date of birth - against the blood form and

obtain information regarding allergies.

To ensure that you have the correct patient and the

correct blood form. understands the procedure and

gives his/her consent.

Give explanation and rationale for

venepuncture to the patient including the

reason for the blood test.

Information giving is a vital aspect of informed

consent to a procedure and the patient has a right

to a full explanation of care.

Information giving must include post-procedure

care including the requirement to report pain, swelling, discomfort.

Venepuncture is an anxiety provoking procedure so it is important to reassure the patient and ensure

they understand their care needs and how/when to report problems.

Ask if patient has had the procedure done

before and respond appropriately to the

patient’s questions and anxieties

To check whether the patient has had any

vasovagal (fainting) episodes with the procedure

before and be prepared for this possibility.

Ascertain whether the patient has been

requested to attend for a fasting blood test.

Check whether the patient is prescribed

anticoagulants.

The result of the blood test is compromised and a wrong diagnosis could be made if incorrect

information is given.

Anticoagulants prolong bleeding time.

Ensure patient is comfortable and consents to

the procedure.

Patient comfort will prevent movement and so facilitate the procedure.

Consent to treatment is a legal requirement.

Examine both arms and select the most

suitable site. Make the patient comfortable and place the chosen arm on a pillow with the arm

fully extended downwards.

The patient should feel as comfortable and relaxed as possible.

Observe the area of the arm and palpate for a

suitable vein. The vein should feel springy

when depressed and refill immediately when

released. Avoid nodules in the veins and junctions where veins meet.

To facilitate a suitable choice for taking blood.

Apply a single use tourniquet above the elbow

ensuring it does not obstruct arterial flow. To prevent damage to tissue.

Decontaminate hands and put on apron and

gloves. To minimise the risk of infection.

Give the patient an explanation of what is

going to happen while their blood is being

taken.

To reduce anxiety.

Clean the patient’s skin using an Isopropyl

Alcohol 70% swab and allow the skin to dry.

To maintain asepsis and reduce the risk of infection.

Action Rationale

Stabilise the vein below the chosen entry site

without contaminating the cleaned area. To prevent movement of the vein and increase the likelihood of success.

Remove the needle shield and with the bevel of

the needle pointing upwards insert the needle

into the vein at an angle of 15-30⁰. Reduce the angle of the needle as soon as you

feel the resistance change or flash back is seen

along the tubing of the venepuncture device.

The bevel needs to be upwards to facilitate smooth transition through the skin and vein.

To prevent advancing the needle too far into the vein wall.

Slightly advance the needle into the vein. To secure the device and prevent displacement.

Firmly connect the blood container to the hub

of the vacutainer and allow the bottle to fill with blood to the required level.

As soon as blood is flowing the tourniquet can

be loosened.

It is no longer necessary and prolonged tourniquet

usage may lead to inaccurate blood test results.

Hold the vacutainer holder securely while

changing the bottles and collecting the blood.

To prevent the equipment from becoming

dislodged.

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Use correct order of draw with the blood

bottles. To prevent contamination of tubes without additives from the tubes that contains additives.

Immediately engage the sharp safety

mechanism and discard in the sharps bin.

To meet health and safety requirements by

preventing sharps injuries.

Ask the patient to press gently on the puncture

site and avoid bending the arm. Apply an appropriate dressing.

To prevent and/or minimise bleeding and haematoma at puncture site.

Carefully label the bottles and place in the

specimen transport bag for laboratory samples. NB use biohazard labels if patient known to

have a BBV.

To ensure the bloods are correctly labelled and

prevent identification errors & reduce the risks of cross infection.

Ensure the patient is comfortable and does not

have any symptoms or questions. Complete any necessary documentation.

To be able to recognise and/or treat problems

before the patient leaves.

Dispose of all sharps and soiled equipment. To adhere to the health and safety and infection

control policies.

Remove and dispose of apron and gloves and

wash hands.

To adhere to the infection control policies & reduce the risk of infection.

5.0 Procedures connected to this Policy

Children Community Nursing SOP 02 – Blood Specimens http://luna.smhsct.local/documents/policies-a-z/c/4368-children-community-nursing-sop-02-blood-specimens/file

Children Community Nursing SOP 02 - Transport of Microbiology Specimens http://luna.smhsct.local/documents/policies-a-z/c/4373-children-community-nursing-sop-07-transport-of-specimens/file Infection Prevention and Control Assurance - SOP 1 - Standard Infection Control Precautions http://luna.smhsct.local/documents/policies-a-z/i/4394-infection-control-assurance-sop-1-standard-infection-prevention-and-control-precautions/file Waste Management SOP 2 - Sharps Waste http://luna.smhsct.local/documents/policies-a-z/w/4336-waste-management-sop-2-sharps-waste/file 6.0 Links to Relevant Legislation

CQC Regulation 12: Safe Care and Treatment The intention of this regulation is to prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm. Providers must assess the risks to people's health and safety during any care or treatment and make sure that staffs have the qualifications, competence, skills and experience to keep people safe. Providers must make sure that the premises and any equipment used is safe and where applicable, available in sufficient quantities. Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe.

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Providers must prevent and control the spread of infection. Where the responsibility for care and treatment is shared, care planning must be timely to maintain people's health, safety and welfare. CQC understands that there may be inherent risks in carrying out care and treatment, and we will not consider it to be unsafe if providers can demonstrate that they have taken all reasonable steps to ensure the health and safety of people 6.1 Links to Relevant National Standards Care Quality Commission (CQC) NHS Litigation Authority (NHSLA) National Institute for Health & Clinical Excellence (NICE) World Health Organisation (WHO)

6.2 Links to other Key Policies

Infection Control Policy

Physical Health Policy

Deterioration Patient Policy

Hand Hygiene Policy

Restrictive Physical Intervention Policy 6.3 References

Dougherty, L. Lister, S (Ed) (2011). The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Eighth Edition. Lindon. Wiley Blackwell

Nash, M (2005). Physical Care Skills: A training need analysis of inpatient and community mental health nurses. Mental Health Practice. 9(4): P 24-27

Nursing and Midwifery Council. (2008) The Code. London. NMC Publications.

Nursing and Midwifery Council (2009). Record Keeping: Guidance for nurses and midwives. London. NMC Publications.

Rethink (200). Your Choice Report. www.rethink.org/nice. [Accessed May 2104]

The World Health Organisation (WHO). (2010). Best Practice in Phlebotomy. Switzerland. WHO Document Production Services.

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7.0 Roles and Responsibilities for this Policy

Title Role Key Responsibilities

Chief Executive

(Accountable)

Accountable - The Chief Executive is responsible for assuring that this policy is implemented within the Trust. Operational responsibility has been delegated.

Trust Board (Strategic)

Strategic - The role of the Trust Board is to have a strategic overview and final responsibility for safe and high quality care within

service areas across the Trust in accordance with its Assurance Framework and strategic priorities.

Executive Committee (Accountable)

Accountable - A sub-committee of the Trust Board has delegated responsibility for ensuring that this policy is efficient and effective in accordance with the Board’s Assurance Framework and Strategic priorities.

Care Governance

(Responsible)

Responsible - The Care Governance Committee is responsible for overseeing the implementation of a systematic and consistent approach to this policy. The group is chaired by the medical Director and provides exception and progress reports to

the Executive Committee.

Service Managers,

Deputy Modern

Matrons, Ward Managers and Lead

Nurses

Operational The above named are responsible for ensuring that:-

- They are familiar with this policy and are responsible for adhering to the procedures.

- Staffs attend training applicable to their role and for implementing the guidance across their areas of responsibility.

- Staff work to the standards set out in this policy.

Medical Staff

Adherence The above named are responsible for ensuring that:-

- They are familiar with the policy and are responsible for adhering to the procedures.

- Complete blood sample request forms as required for the patients.

- Are able to obtain blood samples from patients themselves and if not, to seek further training in order to gain competence.

- Should direct what blood samples need to be taken and complete specimen request forms accordingly.

- Access results and take appropriate action when any abnormalities are detected.

Clinical Staff

Adherence - All clinical staffs are responsible for ensuring that they are familiar with the policy and for adhering to the procedures referred to within the policy.

- Only staff who have completed venepuncture training and have been assessed as competent can take blood samples.

- Staff to maintain competency by an annual update of skills and regular practice of phlebotomy.

- Staff to adhere to NMC and WHO guidelines.

- Appropriately trained staff to ensure that bloods are collected as requested by the medical team.

- Ensure that bloods are transported to the laboratory promptly and are accurately labelled.

- Staff to ensure all equipment used is sterile and all equipment including the blood sample bottles are within date.

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8.0 Training

Phlebotomy training must be attended prior to any phlebotomy procedures being undertaken unless staff have received training in a previous position or with another Trust, and can provide evidence of this. (Please see Appendix 1: Training Needs Analysis).

Prior to undertaking any phlebotomy procedure, all staff must be able to demonstrate clinical competence and have a clear understanding of the underlying principles of practice. This will be achieved by:

Successful completion of the clinical practice framework. (Appendix 2). Staffs who have been trained in phlebotomy must complete a period of supervised practice. Staff who have been trained and practiced in a previous post may be allowed to demonstrate an equivalent level of competency through a period of supervised practice and the completion of the competency framework.

All staff who takes blood samples as part of their job description should attend a three yearly update as recommended by WHO 2010. Any staffs that are not competent or confident should attend a phlebotomy course prior to their practice and have successfully completed a period of supervised practise and competency.

What aspect(s)

of this policy will require staff

training?

Which staff groups require this

training?

Is this training covered in the Trust’s Mandatory and Risk

Management Training Needs Analysis document?

If no, how will the training be delivered?

Who will deliver the training?

How often will staff require

training

Who will ensure and monitor that staff have

this training?

Phlebotomy All clinical staff as appropriate

No, Staff will receive specific training where it is identified

in their individual training

needs analysis or part of their development for their

particular role and responsibilities

Theory/Practical Trust approved training provider

Refresher training every 3

years

Service area Matrons/ Physical Health Strategy

Group

9.0 Equality Impact Assessment

Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email bcpft.equalityimpactassessment@nhs.net

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10.0 Data Protection and Freedom of Information

Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.

11.0 Monitoring this Policy is Working in Practice

The Trust Care Governance Group is responsible for monitoring of compliance with this policy.

What key elements will be monitored?

(measurable policy objectives)

Where described in

policy?

How will they be monitored?

(method + sample size)

Who will undertake this

monitoring?

How Frequently?

Group/Committee that will receive and

review results

Group/Committee to ensure actions

are completed

Evidence this has happened

How staff are assessed for competency in phlebotomy

8.0 Training Competency assessment and sign off

Service Area Matrons,

Managers

On going Quality and Safety Steering Group

Quality and Safety Steering Group

Competency Documentation

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Appendix 1

Training Needs Analysis

Training Topic

Objective of training

Brief summary of key training content required

Staff Groups

applicable

to (including

numbers)

Delivery method Frequency Monitoring & Reporting

Phlebotomy theory course

To equip nurses and health care

support workers the knowledge

and skill in order

to practise phlebotomy in a

safe and competent

manner

Review of anatomy of the arm

Infection control and health & safety

Reasons for and complications of this invasive procedure

Vein selection and

demonstration of correct technique, choice of

equipment and procedure

Practical skills technique

workshop

Legal and professional

responsibilities

Identified Band 6, 5, 4

and 3 nursing staff

(inpatient

and community)

½ day theoretical training followed by a

period of supervised practice in clinical

area with a

competent practitioner

Training to be

provided externally by HEST Training

One off initial training

Followed by update

every 3 years

Attendance to be recorded by Service Area Matrons and

Professional Practice Development Nurse.

This information will be reported via the physical health monthly

dashboard and annually within physical health annual report

Evidence of

competence for staff who

are joining the

Trust and are already

practising phlebotomy

To ensure that

staff who have worked in

organisations

outside of BCPFT are competent

and safe to practice

phlebotomy

Evidence of training from

previous role/Trust. If not able to provide evidence or if

their training was over three

years ago they should follow the training pathway above.

Clinical Staff

from a previous or

from another

Trusts

If able to provide

evidence they should complete a period of

supervised practice

until the identified assessor is satisfied

they are competent to practice

independently.

One off followed by

update every 3 years as above

If not able to provide evidence or if their

training was over three years ago they

will need to complete

training as above.

Attendance to be recorded by

Service Area Matrons and Professional Practice Development

Nurse.

This information will be reported via

the physical health monthly dashboard and annually within

physical health annual report

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Appendix 2

Phlebotomy Clinical Practice Competencies

Assessment Strategy The process of developing competence follows the stages below:- 1. Observation The nurse observes a competent practitioner practicing the skill and adheres to local policies, guidelines/protocols for the procedure of venepuncture on a minimum of two occasions. 2. Supervision A period of supervised practice is undertaken. Any medical/nurse practitioner who is competent in this procedure may act as supervisor. The supervisor gives guidance and feedback for the development of competence and agrees with the assistant when competence has been achieved. This aspect will incorporate supervision on a minimum of five occasions which means that the nurse may request additional supervision to achieve competency. If the supervisor does not agree competency with the nurse, then he/she should give the reasons in order that the nurse can rectify deficits in his/her knowledge and skills. 3. Assessment When the nurse assesses him/herself to have acquired the necessary knowledge and skills for the procedure of venepuncture without supervision, then he/she arranges to be assessed in the procedure by the appropriate medical/nursing personnel. Failure in the assessment If competence is not achieved in the assessment, then further periods of supervised practice with specific guidance for improvement in practice are given and reassessment undertaken. It is the nurse’s responsibility to forward a copy of their competency record to their Manager for retention in their personnel file.

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Phlebotomy Clinical Practice Competencies

Name

Ward Department

OBSERVATION RECORD

Date

Signature of Staff Member

Signature of Assessor

1

2

3

SUPERVISED PRACTICE RECORD

Date

Signature of Staff Member

Signature of Assessor

1

2

3

4

5

6

7

8

9

10

11

12

A copy should be retained in the staff members’ personal file

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Phlebotomy Clinical Practice Competencies

Name

Ward Department

Payroll Number

Trust

The above named nurse has attended training on Venepuncture held by the Trust

Name of Tutor

Date of training

The training has been followed by a period of Observation and Supervised Practice of the procedure for Venepuncture and competence has been assessed.

Signature of assessor

Date

Clinical Staff Statement of competence I feel that I am competent in carrying out the procedure of Venepuncture and agree to carry out this procedure in accordance with Trust Policy

Signature

Date

A copy should be retained in the staff members’ personal file

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Policy Details

* For more information on the consultation process, implementation plan, equality impact assessment,

or archiving arrangements, please contact Corporate Governance

Review and Amendment History

Version Date Details of Change

1.1 Sept 2018 Policy transferred to new Trust Template; reviewed with minor amendments to 4.0, 5.0, 6.0, 6.2 and Appendix1; updated tables 7.0, 8.0, and 11.0.

1.0 July 2014 New Policy Alignment of Policies following TCS

Title of Policy Phlebotomy Policy

Unique Identifier for this policy BCPFT-PH-POL-08

State if policy is New or Revised Revised

Previous Policy Title where applicable n/a

Policy Category Clinical, HR, H&S, Infection Control etc.

Clinical

Executive Director whose portfolio this policy comes under

Heads of Nursing

Policy Lead/Author Job titles only

Physical Health Clinical Lead

Committee/Group responsible for the approval of this policy

Nursing Board

Month/year consultation process completed *

n/a

Month/year policy approved October 2018

Month/year policy ratified and issued November 2018

Next review date Sept 2021

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

Key Words for this policy Phlebotomy, Drawing of blood, Antecubital fossa, Tourniquet, Blood borne virus (BBV)