Phlebotomist error in a Top 100 hospital
It is risky to assume that healthcare workers are proficient because too many of them are inept, even when performing simple procedures such as drawing blood. Want an example?
I went to a hospital (I'll call them Mediocre Medical Center or MMC) to have two lab tests performed. On the left side of the following list is the procedure followed by the phlebotomist; the right side shows my comments:
|What the phlebotomist did||What he should have done|
|Shove his right hand into the box of latex gloves and fish around for them while I stared in disbelief, wondering why he had such difficulty snaring a glove or two.||1) Washed his hands immediately before the procedure. By NOT doing that, he transferred dirt and germs from his hands onto the outside of the gloves he touched in the box, including the ones he used on me.
2) Inquired if I am allergic to latex.
|After informing him that I am allergic to latex, he repeated the above procedure, this time fishing his hand into the box of vinyl gloves.||Even if he had washed his hands before plunging into the latex glove box, he should have washed them again afterwards to remove the latex that was transferred to the gloves that later touched me, AND to other vinyl gloves still in the box.|
|Quickly swipe my skin once with a single alcohol pad.||Medical personnel (and many laymen) often mistakenly assume that alcohol is an effective germ killer. The reality is that it would take several swipes from several alcohol pads to do even a halfway decent job of just cleaning the skin. To effectively disinfect it requires use of something more powerful, such as Betadine® solution (10% povidone-iodine), which he did not use.|
|Before waiting for the alcohol to dry, he picked up a gauze pad resting on his desk and wiped the skin over my vein with that pad. He then inserted the needle, withdrew blood, and swiped the blood drop on my skin with another gauze pad—which, like the first one, was probably once sterile.||Let's give the phlebotomist the benefit of the doubt and assume that he used sterile gauze pads. However, they certainly were NOT sterile after he set them on his desk! I know the difference between a sterile field and an ordinary desk, and his desk was hardly sterile! Further contamination undoubtedly occurred when he touched the pads with his nonsterile gloves that became even less sterile after his unwashed hands touched them.|
Most medical and dental personnel suffer from the misconception that gloves are some magical barrier to infection. What they often fail to grasp is that gloves have a dual function:
- To lessen the probability of transmitting germs from a patient to the healthcare provider.
- To lessen the probability of transmitting germs from a healthcare provider (or some surface touched by him) to the patient.
By touching the outside of the gloves with unwashed hands, the phlebotomist mentioned above was behaving as if his sole concern was the first function listed. That sends a strong signal to the patient:
“I matter. You don't.”
Drawing blood is one of the most simple medical procedures; elementary students could be taught to do it correctly. An adult like the phlebotomist mentioned above (who presumably was trained) should be able to perform it flawlessly day after day for years without making a mistake. Furthermore, this occurred in a major medical center in the United States, not some backwoods hospital in a Third-World country.
As I documented in other articles, MMC does less than it should to protect patients and the community. They permit employees to wear uniforms outside the hospital, which inevitably transfers drug-resistant superbugs into the community. I accompanied a patient having a medical procedure performed, and was alarmed to witness the technician commit multiple errors; she did not even know how to properly wash her hands!
Nonsterile glove germ transmission risk
Given that many healthcare personnel do not wash their hands (properly or at all) before donning nonsterile gloves, and given that most do not know the correct procedure for that, even the first glove extracted from a nonsterile glove box is often contaminated. Now think of the last glove extracted from a box containing 100 gloves: 100 hands, most of them not properly cleaned or washed at all, were previously jammed into the box to extract a glove. Considering that, what is the probability of that last glove being contaminated? It's either 100% or dangerously close to it.
The attitude of many healthcare personnel is that “it doesn't matter.” Oh yes it does! Whether transferred directly or indirectly, spreading germs from patient to patient is a serious matter, even if the germs are deposited onto intact skin. The risk is even greater if germs are transferred into the eyes, nose, mouth, vagina, or other mucosal surface, such as when an ultrasound technician in a Top 100 hospital committed multiple errors that inevitably transferred germs onto the vaginal probe cover.