Improper phlebotomy practice is among one of the most important, and more so, overlooked issues in laboratory medicine. Lab practices involving phlebotomy are critical for diagnostic purposes as erroneous results from incorrect collection can result in potentially life threatening misdiagnoses or treatment routes. This pre-analytical error can result in misleading hyperkalemia and hypocalcemia illustrated in otherwise healthy patients. Improper order of draw can incur costs for both the patient and healthcare facility. Preventative measures must be employed to reduce such adverse events from reoccurring as this singular error can lead to a domino effect of continuous error if not recognized and investigated.