Learning Contract: Obtaining Venous Blood Sample

A learning contract is a written form of agreement. This agreement is a negotiation that takes place between a student and a teacher with the aim of changing the student's perception hence improve upon their learning opportunities. Its benefit is that it has the potential to affect positive change in the behavior and attitude of a student while simultaneously having the student actively involved in the class.

The learning contract is comprised of specific and well-detailed learning and behavioral objectives that the involved parties have an agreement on its need for it to be attained. The contract also has the specification of the following:

The goals of the contract

The duties and obligations of the involved parties to the contract

The time-frame for its achievement

The basis of which there will be a determination that the conditions stipulated were met

Learning contract are based on social systems which according to the argument by Donald Schon state that in social systems the teacher has to be in a position to present learning opportunities to the students in such a way that the student acquires the capability of transforming him/herself without having any intolerable disruption.

"A learning system Must be one in which dynamic conservatism operates at such a level and in such a way as to permit change of state without intolerable threat to the essential functions the system fulfills for the self. Our systems need to maintain their identity, and their ability to support the self-identity of those who belong to them, but they must at the same time be capable of transforming themselves(Schon 1973,p.57).

In the process where you have a patient to obtaining a venous blood sample, it is your responsibility to ensure that first of all your patient is safe, then as the medic you are safe then all others within the clinical environment are safe. The key here is full preparation before approaching the patient. This means you should have the following safety equipment:

Personal Protective Equipment (PPE), e.g., apron, gloves and protective eyewear.

Other essential equipment such as a rigid tray that is to be used in carrying the equipment used in blood sampling, e.g., a portable sharps bin, a rigid tray

The medical practitioner needs to ensure that the sharps are safely disposed of the moment you leave the side of the patient. During a venepuncture procedure, it is important to keep in mind that the patient should be approached calmly with confidence. One needs to make sure that the patient is comfortable and their arm is supported well using a pillow or an armrest before carrying out the procedure. There are patients who are needle-phobic, hence in this situation, one needs to take a particularly sensitive approach. This is because these patients are likely to jerk their arm away and in extreme situations, some may have a vast vague episode hence faint therefore one needs to make sure that they are resting in such a way that they will not fall hence hurt themselves. NB. When handling a patient who is seated and reports a feeling of faintness, the correct thing to do is ensure that you are seated directly in front of this patient and get him/her to lie forward resting on your lap. This enables the blood to reach their brain at a faster rate as well as preventing them from falling. A vital thing to do at all times is maintaining strict measures in infection control like washing hands and following the hospital policy with regards to cleansing the skin before carrying out the venepuncture.

The process of obtaining venous blood samples has the potential of being a Critical task. This is because there is the risk of making a mistake when it comes to identifying a patient which has the potential of leading to the death of the patient. Having this in mind, it is important to keep in mind that a sample that has been taken from a line not having eliminated all the infusion fluid will not give an accurate Hb. This being so, the preventive measure is to clean the site in line using the local Trust policy. The caregiver needs to use incorporate an appropriate use of tourniquet so as to minimize the level of discomfort the patient is in. The blood sample should be drawn into the appropriate blank tube. The venipuncture site should be dressed as stipulated in the local Trust policy NB. When handling critical care as well as other areas, the likely appropriate procedure is that of taking the venous samples from lines already in situ such, e.g., arterial lines. One must be careful so as to make sure that sufficient IV fluid has been removed hence ensuring that there is no occurrence of an erroneous Hb result.

Details on the sample tube should be handwritten NB It is not acceptable to use addressograph labels on the tube. This can only be used in the event where your Trust is using an electronic system that has been approved). It is acceptable to use addressograph labels in the event where the request form has labeled the sample that is at the side of the patient. The label needs to have the inclusion of the minimum data set of the patient; the word, date, time and the signature of the medical practitioner who is drawing the sample. The following also needs to be clear on the request form that is the printed name, a signature as well as the details of the contact of the medical practitioner drawing the sample. The details indicated on the sample tube and request form has to be a match in regardless of the aspect.

As reported to SHOT (Serious Hazards of Transfusion) the most Sample errors are the frequent near miss events. These can include the following:-

In the event where a sample that has been taken from the intended patient is labeled with the details of another patient.

In the event where the sample is labeled with the details of the intended patient after being taken from the wrong patient.

There are other cases such as samples not being fully labeled or samples having one or multiple identifiers belonging to another patient.

The most important thing to have in mind with regards to this is identifying the correct patient before drawing the blood sample. It is compulsory for all patients to be having an attached identifier such as a wristband having the Patient Minimum Dataset of the following: first name, last name (surname), date of birth(DOB) and the patient identification (PID) number which is uniquely for the patient. In the event where your Trust has adopted the use of Photo ID cards, such as in my experience, the patients who are regularly transfused need to be encouraged to always come with the card upon visitation to every hospital. In the event that they do not bring it along, then the patient has to be given a wristband. While obtaining venous blood samples, all patients should be asked to provide their details as previously stated. This is what is commonly referred to as positive verbal identification. During this, one needs to let the patient speak for themselves i.e.; you must not say anything to them, e.g., are you, Mr. Sam? To avoid the risk of patient misidentification. Therefore the correct procedure is as follows: The patient should be asked to state their names ( the first name then surname) and date of birth. Confirm if it matches with the details on the identifier and the details on as stated on the request form. In the event where the patient is incapable of responding (unconscious or a child) then only counter check the identification information on the identifier with the information found on the request form. Also in such a circumstance, as a precautionary measure, it is advisable to verify the identification with another member of staff. In the scenario where a patient has been admitted to the Emergency Department and is yet to be identified, the information that should be used at all times is the gender and the unique patient ID number and promptly attach the relevant identifier. When taking blood samples from patients, it must be taken one patient at a time and should be fully labeled at the side of the patient before doing anything else. As a medical practitioner, you should always have the severity of this task in mind hence do not at any one time let yourself to be distracted. Remember, no pre-labeling the blood sample tubes; according to the British Committee for Standards in Haematology BCSH (1999) this practice has been identified to be the major cause of errors when it comes to identification hence resulting in fatal transfusion reactions.

NB While assessing an appropriate site for taking the sample one needs to know that a sample that has been taken from an arm that has an infusion underway is likely to give a falsely low Hb that has the potential to resulting in inappropriate transfusion. Also, a sample which has been taken in a clotted syringe or a syringe which has settled is sure to also falsify the Hb.

Common errors involve the breakage of membranes of red blood cells'. It is this breakage that causes the release of internal components such as Hemolysis and hemoglobin. Although this can be attributed to pathological conditions in a patient, it is in most cases as a direct result of the following: the improper collection of the specimen, processing, or transportation.

Common preanalytical errors as a result of Poor phlebotomy practices have the potential to compromise both the validity of the test result as well as posing significant health risks to the safety of medical practitioner. WHO has highlighted many of these errors. They include:

Forcing the blood into the tube through the act of pressing the syringe plunger creating a high level of pressure enough to damage the red blood cells that is in the sample

Manually transferring blood into a tube using a needle which has the potential of causing accidental needlestick injuries to the medical practitioner as well as damaging the sample

Underfilling or overfilling the sample tube which in turn results in coagulation of the improper blood ratio hence compromising the sample

Re-use of tubes that have not been cleaned and disinfected properly which have the potential to cause infection

Phlebotomy Practices and Training vary greatly in three main ways, i.e., among the healthcare personnel, between different countries and between institutions and individuals. They include:-

variation in blood-sampling technique

Training

Use of safety devices

Methods of disposal methods, and

The reuse of devices.

Many countries either lack the formal training, or they have a very low level of formal training for medical practitioners who practice phlebotomy, hence putting both the patients and the medical practitioners at heightened risk of errors and serious injuries.

Being an assistant practitioner, my duty is to work under the directives of a health professional such as a nurse, dietician, physiotherapist, podiatrist, etc. I have come to learn that the achievement of best practice in phlebotomy when it comes to enhancing the outcomes of patients, improving the efficiency of the health as well as protecting the safety of healthcare worker safety . In my effort to accomplish this, among the several key elements that should be in the place, I will need to learn more about the guidelines and undergo further formal training which will help in standardizing my practice. In accordance with recommendations by WHO, there is need to also undergo and learn much more in structured proficiency training. During this training I will document it having the inclusion of the following:

a comprehensive understanding of best practice,

awareness of the risks from blood exposure and

consequences of poor practices.

Obtaining venous blood sample i...