Order of Draw Explained: Clearing Out Any Confusion

Phlebotomy is not just about drawing blood. It also covers proper care and handling
of the specimen that will be used for laboratory testing or analysis. It is vital that
the samples are not contaminated or tainted in any way, and should be handled in
such a way that quality and accuracy of the analysis is not compromised. Special
considerations must also be applied when collecting indwelling catheter line draw
and blood cultures. This is where the order of draw becomes necessary.

To avoid cross-contamination of additives between tubes, blood must be drawn in a

specific order. The procedure is the same for all types of tubes or instruments used.
It is vital that the order is followed not only to avoid contamination, but also to
ensure accuracy of test results. Because the smallest error could mean that the
patient might not receive the most appropriate care and treatment for his specific
case.

Who determines the order of draw?

Formerly known as the National Commission of Clinical Laboratory Standards

(NCCLS), the Clinical Laboratory Standards Institute (CLSI) (http://clsi.org/) approves
and publishes the order of draw. Since the procedure can change if new research
indicates probable inaccuracy in a test result, it is important that health care and
testing facilities use the most recent order of draw. The latest update is the H3-A6
from November 2007 that is also used by several laboratory accreditation agencies,
including The Joint Commission and the College of American Pathologist.

What is the recommended order?

The same order is used for glass and plastic venous blood collection tubes,
evacuated system and a syringe. There used to be a separate order for blood
collected using a syringe, but it has been rendered obsolete as research showed
there was no reason to use a different order.

Before getting to the order of draw, familiarizing certain acronyms will make the
entire process simpler and easier to understand.

SPS Sodium polyanethole sulfonate

SST Serum Separator Tube

EDTA ethylenediaminetetraacetic acid

FDP Fibrin degradation products

Order of Draw as Recommended by CLSI (http://96.36.117.186/NewsLetter.pdf)

order of draw 2

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Yellow SPS (Blood culture)

Blood cultures are used in microbiology. The additive it uses is a broth mixture that
is intended to preserve the quality of microorganisms.

Light Blue Sodium Citrate

Coagulation tubes have light blue-colored stopper and a sodium citrate additive. It
is used for coagulation tests, requiring full draw.

Plain Red No Additive

This is commonly used for routine venipuncture and does not require any additive.

Plastic Red Clot Activator

Tubes with plastic red stoppers contain a clot activator. It causes blood clots and
help in separating the serum by centrifugation. This process is often used in blood
bank (cross-match), chemistry, immunology and serology.

Gold, Red/Gray SST/Gel w/Clot Activator

Serum separator tube (SST) does not have any additive but a clot activator that will
separate blood from the serum by centrifugation. This draw is used in chemistry,
immunology and serology.

Green Heparin-Lithium or Sodium

Tubes with green tops have lithium heparin anticoagulant.

Lavender, Purple, Tall Pink EDTA

The EDTA anticoagulant in tubes with lavender or purple stopper helps remove
calcium by forming calcium salts. This draw is often used in blood bank cross-
matching and hematology.

Gray Sodium Fluoride, Potassium Oxalate

Tubes with gray-colored stopper contain sodium fluoride or potassium oxalate

additives, which acts as an Antiglycolytic agent that helps preserve glucose for up
to five days. This requires full draw, as the opposite may cause hemolysis.

Aside from these, there is a tube with royal blue top that contains FDP. The draw is
used when there is an order to test deep vein thrombosis or blood clot in a deep
vein, pulmonary embolism, stroke and other blood clotting disorders. If a patient
shows any symptom related to the condition, royal blue draw will be requested.

Order of Draw for Skin Puncture

Skin puncture specimens have to be collected according to a certain order as

recommended by CLSI, which is as follows:

Lavender (EDTA) micro-collection tube

Plasma additive micro-collection tubes, such as green (lithium heparin) light green
(lithium heparin with gel), gray (sodium fluoride and potassium oxalate)

Serum micro-collection tubes, such as red (no additive), gold (clot activator and gel)

This is to ensure that specimens requiring anticoagulants are drawn first. Whenever
clot appears in a micro-collection tube with a lavender stopper/shield, the specimen
will be rejected. An added precaution is to never use iodine or Betadine solutions to
cleanse the skin before collecting blood samples to prevent possible interference of
test results, especially in the analysis of potassium, glucose, and total protein.

Why must the order of draw be followed accordingly?

As already mentioned, this is done to avoid cross-contamination and unreliable test

results. How can this happen?

A tube with EDTA, for example, is rich in potassium and can cause an increase in
potassium levels. Therefore, if a test for potassium is required, the tubes used must
be those that are placed before those that contain EDTA. The same thing is true
when a coagulation test need to be performed. Since tubes with clot activators can
interfere with the results, tubes with light blue stopper or shield must be used
before those that have red/gray stopper, gray/yellow stopper, gold shield, red shield
and orange shield tubes.

Blood culture tubes are usually at the top of the order of draw to avoid
contamination of the blood collected. This is because bacteria from non-sterile tube
stoppers or shields may result in bacteria growth, which will show in the test result
as a blood infection. This is why blood culture bottles or SPS tubes with yellow
stopper must be collected first before any other tubes.

How do you remember the order of draw?

Considering the number of colored stoppers or shields to remember, mistakes are

bound to happen. Since there is no room for error in phlebotomy, it is crucial that
you memorize the order in the easiest way possible. A very helpful mnemonics has
been developed Sally brings really good grease and leaves the gravy.
Sally Sterile