The phlebotomy order of draw for venipuncture is reversed when blood is collected with a syringe

Blood samples must be drawn by phlebotomists in a specific order to avoid cross-contamination of the sample by additives found in different collection tubes. Phlebotomy order of draw is the same for specimens collected by syringe, tube holder, or into tubes preevacuated at the time of collection. The correct order of draw follows:

1. Blood culture tube or bottle
2. Sodium citrate tube (eg, blue closure)
3. Serum tubes, including those with clot activator and gels (eg, red, red-speckled, gold closures)
4. Heparin tube with or without gel (eg, dark green, light green, speckled green closures)
5. EDTA tube with or without gel separator (eg, lavender, pearl, pink closures)
6. Sodium fluoride/potassium oxalate glycolytic inhibitor (eg, gray closure)

The placement of tubes not listed here should take into consideration the potential for their additive to alter results obtained from the next tube if carryover were to occur. Plastic serum tubes containing a clot activator may cause interference in coagulation testing. Only blood culture tubes, glass nonadditive serum tubes, or plastic serum tubes without a clot activator may be collected before the coagulation tube.

Numerous errors can occur during the collection and handling of blood specimens, which pose significant and avoidable risks to the patient and the phlebotomist. When global standards are not fully implemented, it is more likely that patients will be injured during the procedure, biologically representative specimens will not be obtained from patients, and test results will not be comparable from one facility to another.

CLSI’s GP41 —Collection of Diagnostic Venous Blood Specimens provides a descriptive, stepwise process and procedures reflecting the quality system essentials format for diagnostic venous blood specimen collection. Special considerations for collections from vascular access devices, blood culture collection, and collections in isolation environments are included, as well as how to handle emergency situations. An expanded appendix section provides helpful tips for collecting specimens from pediatric and other challenging patients.

← Go Back

1. Galazzi A., Rancati S., Milos R. A survey of accidents during the clinical rotation of students in a nursing degree program. G Ital. Med. Lav. Ergon. 2014;36:25–31. [PubMed] [Google Scholar]

2. Wiwanitki V. Types and frequency of preanalytical mistakes in the first Thai ISO 9002:1994 certified clinical laboratory, a 6-month monitoring. BMC Clin. Pathol. 2002;1:5. doi: 10.1186/1472-6890-1-5. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

3. Bonini P., Plebani M., Ceriotti F., Rubboli F. Errors in laboratory medicine. Clin. Chem. 2002;48:691–698. doi: 10.1093/clinchem/48.5.691. [PubMed] [CrossRef] [Google Scholar]

4. World Health Organization WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy. [(accessed on 28 April 2020)]; Available online: http://whqlibdoc.who.int/publications/2010/9789241599221_eng.pdf

5. Clinical and Laboratory Standards Institute . Procedures for Collection of Diagnostic Blood Specimens by Venipuncture. Approved Standard. 6th ed. CLSI; Wayne, PA, USA: 2007. pp. H3–A6. [Google Scholar]

6. Sun N., Knauf R. Cross contamination solved by technique. ASCP Summ. Rep. 1977;14:3. [Google Scholar]

7. Calam R.R., Cooper M.H. Recommended "order of draw" for collecting blood specimens into additive-containing tubes. Clin. Chem. 1982;28:1399. doi: 10.1093/clinchem/28.6.1399. [PubMed] [CrossRef] [Google Scholar]

8. Ernst D.J., Calam R. NCCLS simplifies the order of draw: A brief history. MLO Med. Lab. Obs. 2004;36:26–27. [PubMed] [Google Scholar]

9. Chadwick K., Whitehead S.J., Ford C., Gama R. kEDTA Sample Contamination: A Reappraisal. J. Appl. Lab. Med. 2019;3:925–935. doi: 10.1373/jalm.2018.027920. [PubMed] [CrossRef] [Google Scholar]

10. Logie J.J., Chaloner C. A national survey of specimen contamination in the UK. Ann. Clin. Biochem. 2019;56:219–227. doi: 10.1177/0004563218812500. [PubMed] [CrossRef] [Google Scholar]

11. Davidson D.F. Effects of contamination of blood specimens with liquid potassium-EDTA anticoagulant. Ann. Clin. Biochem. 2002;39:273–280. doi: 10.1258/0004563021901973. [PubMed] [CrossRef] [Google Scholar]

12. Jacobsen R. Addressing “order of draw” in comparative calcium levels. MLO Med. Lab. Obs. 2001;33:6. [Google Scholar]

13. Keppel M.H., Auer S., Lippi G., Von Meyer A., Cornes M., Felder T.K., Oberkofler H., Mrazek C., Haschke-Becher E., Cadamuro J. Heparin and citrate additive carryover during blood collection. Clin. Chem. Lab. Med. 2019;57:1888–1896. doi: 10.1515/cclm-2019-0433. [PubMed] [CrossRef] [Google Scholar]

14. Sulaiman R.A., Cornes M.P., Whitehead S.J., Othonos N., Ford C., Gama R. Effect of order of draw of blood samples during phlebotomy on routine biochemistry results. J. Clin. Pathol. 2011;64:1019–1020. doi: 10.1136/jclinpath-2011-200206. [PubMed] [CrossRef] [Google Scholar]

15. Cornes M.P., Davidson F., Darwin L., Gay C., Redpath M., Waldron J.L., Ford C., Gama R. Multi-centre observational study of spurious hyperkalaemia due to EDTA contamination. Clin. Lab. 2010;56:597–599. [PubMed] [Google Scholar]

16. Cornes M., Van Dongen-Lases E., Grankvist K., Ibarz M., Kristensen G., Lippi G., Nybo M., Simundic A.M., Working Group for Preanalytical Phase (WG-PRE), European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Order of blood draw: Opinion Paper by the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE) Clin. Chem. Lab. Med. 2017;55:27–31. doi: 10.1515/cclm-2016-0426. [PubMed] [CrossRef] [Google Scholar]

17. Moher D., Liberati A., Tetzlaff J., Altman D.G., PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med. 2009;6:e1000097. doi: 10.1371/journal.pmed.1000097. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

18. Critical Appraisal Skills Programme CASP Cohort Study Checklist. [(accessed on 12 August 2020)]; Available online: https://casp-uk.net/casp-tools-checklists/

19. Asif U., Whitehead S.J., Ford C., Gama R. Preanalytical potassium EDTA sample contamination: Open versus closed phlebotomy systems. Ann. Clin. Biochem. 2019;56:711–714. doi: 10.1177/0004563219878463. [PubMed] [CrossRef] [Google Scholar]

20. Indevuyst C., Schuermans W., Bailleul E., Meeus P. The order of draw: Much ado about nothing? Int. J. Lab. Hematol. 2015;37:50–55. doi: 10.1111/ijlh.12230. [PubMed] [CrossRef] [Google Scholar]

21. Cornes M.R., Sulaiman R.A., Whitehead S.J., Othonos N., Ford C., Gama R. Incorrect order of draw of blood samples does not cause potassium EDTA sample contamination. Br. J. Biomed. Sci. 2012;69:136–138. doi: 10.1080/09674845.2012.12069141. [PubMed] [CrossRef] [Google Scholar]

22. Salvagno G., Lima-Oliveira G., Brocco G., Danese E., Guidi G.C., Lippi G. The order of draw: Myth or science? Clin. Chem. Lab. Med. 2013;51:2281–2285. doi: 10.1515/cclm-2013-0412. [PubMed] [CrossRef] [Google Scholar]

23. Cadamuro J., Felder T.K., Oberkofler H., Mrazek C., Wiedemann H., Haschke-Becher E. Relevance of EDTA carryover during blood collection. Clin. Chem. Lab. Med. 2015;53:1271–1278. doi: 10.1515/cclm-2014-0944. [PubMed] [CrossRef] [Google Scholar]

24. Sharratt C.L., Gilbert C.J., Cornes M.C., Ford C., Gama R. EDTA sample contamination is common and often undetected, putting patients at unnecessary risk of harm. Int. J. Clin. Pract. 2009;63:1259–1262. doi: 10.1111/j.1742-1241.2008.01981.x. [PubMed] [CrossRef] [Google Scholar]

25. Fukugawa Y., Ohnishi H., Ishii T., Tanouchi A., Sano J., Miyawaki H., Kishino T., Ohtsuka K., Yoshino H., Watanabe T. Effect of carryover of clot activators on coagulation tests during phlebotomy. Am. J. Clin. Pathol. 2012;137:900–903. doi: 10.1309/AJCPL3LZZN9WJGZT. [PubMed] [CrossRef] [Google Scholar]

26. Cornes M.P., Ford C., Gama R. Spurious hyperkalaemia due to EDTA contamination: Common and not always easy to identify. Ann. Clin. Biochem. 2008;45:601–603. doi: 10.1258/acb.2008.007241. [PubMed] [CrossRef] [Google Scholar]