1. Written summary of the pre-analytical, analytical and post-analytical problems encountered in the hematology section.

A. PREANALYTICAL (PREEXAMINATION)
 The pre-analytical phase comprises all the processes occurring before the sample being processed in the
laboratory. It includes specimen collection, handling and processing variables, physiological variables, and
endogenous variables. Certain preanalytical variables, namely, specimen variables can be controlled; whereas
knowledge of uncontrollable variables needs to be well understood in order to be able to separate their
effects from disease-related changes affecting laboratory results
a) Specimen obtained from the wrong patient
b) Specimen procured at the wrong time
c) Specimen collected in the wrong tube or container
d) Blood specimens collected in the wrong order
e) Incorrect labeling of specimen
f) Improper processing of specimen

B. ANALYTICAL (EXAMINATION)
 Errors in the analytical phase occur within the laboratory during the testing process and are usually attributed
to operator or instrument error.
a) Oversight of instrument flags
b) Out-of-control QC results
c) Wrong assay performed

C. POSTANALYTICAL (POSTEXAMINATION)
 The post-analytical phase is the final phase of the total testing process and involves evaluation of laboratory
test results; release of test results in a timely manner to appropriate individuals, particularly critical results;
and modification, annotation or revocation of results as necessary to support clinical decision-making.
a) Verbal reporting of results
b) Instrument: Laboratory Information System (LIS)
c) incompatibility error
d) Confusion about reference ranges
e) Failure to report critical values immediately

References:

Keohane, E. M., Smith, L. J., Walenga, J. M., Rodak, B. F., & W.B. Saunders Company. (2016). Rodak's hematology:
Clinical principles and applications. St. Louis: Elsevier/Saunders. Page 31.

Lenicek Krleza, J., Honovic, L., Vlasic Tanaskovic, J., Podolar, S., Rimac, V., & Jokic, A. (2019). Post-
analytical laboratory work: national recommendations from the Working Group for Post-analytics
on behalf of the Croatian Society of Medical Biochemistry and Laboratory
Medicine. Biochemicmedica, 29(2), 020502. https://doi.org/10.11613/BM.2019.020502

Arul, P., Pushparaj, M., Pandian, K., Chennimalai, L., Rajendran, K., Selvaraj, E., & Masilamani, S.
(2018). Prevalence and types of preanalytical error in hematology laboratory of a tertiary care
hospital in South India. Journal of laboratory physicians, 10(2), 237–240.
https://doi.org/10.4103/JLP.JLP_98_17
2. Written summary of the criteria used in accepting and rejecting a specimen in the hematology section.
A. Reasons for Specimen Rejection
 A laboratory result is only as good as the integrity of the specimen provided. Specimens are rejected for
conditions that may result in identification errors or inaccurate results.
a) Test order requisition and the tube identification do not match.
b) Tube is unlabeled, or the labeling, including patient identification number, is incorrect.
c) Specimen is hemolyzed.
d) Specimen was collected at the wrong time.
e) Specimen was collected in the wrong tube.
f) Specimen was clotted, and the test requires whole blood or plasma.
g) Specimen was contaminated with intravenous fluid.
h) Specimen is lipemic.

B. Requirements for a Quality Specimen

 Requirements for a quality specimen are as follows:
a) Patient properly identified
b) Patient properly prepared for draw
c) Specimens collected in the correct order and labeled correctly
d) Correct anticoagulants and other additives used
e) Specimens properly mixed by inversion, if required
f) Specimens not hemolyzed
g) Specimens requiring patient fasting collected in a timely manner
h) Timed specimens drawn at the correct time

Reference:

Keohane, E. M., Smith, L. J., Walenga, J. M., Rodak, B. F., & W.B. Saunders Company. (2016). Rodak's hematology:
Clinical principles and applications. St. Louis: Elsevier/Saunders. Page 31-32.
Written summary of the conditions that causes interferences on most hematology analyzers and its corrective action.

Reference:

Keohane, E. M., Smith, L. J., Walenga, J. M., Rodak, B. F., & W.B. Saunders Company. (2016). Rodak's hematology:
Clinical principles and applications. St. Louis: Elsevier/Saunders. Page 226.
 Written summary of the phlebotomy procedure from the patient identification to the patient aftercare which includes
the important information such as the order of draw, ideal and other puncture site for difficult cases, specimen
handling and storage and waste disposal.
Venipuncture Procedure
 The phlebotomist uses standard precautions, which include washing hands and applying gloves at the beginning of the
procedure and removing gloves and washing hands at the end of the procedure. The Clinical and Laboratory Standards Institute
(CLSI) recommends the following steps:
1. Prepare the accession (test request) order.
2. Greet the patient and identify the patient by having the patient verbally state his or her full name and confirm with the
patient’s unique identification number, address, and/or birth date. Ensure the same information is on the request form.
3. Sanitize hands.
4. Verify that any dietary restrictions have been met (e.g., fasting, if appropriate) and check for latex sensitivity.
5. Assemble supplies and appropriate tubes for the requested tests. Verify paperwork and tube selection.
6. Reassure and position the patient.
7. If necessary to help locate a vein, request that the patient clench his or her fist.
8. Apply the tourniquet and select an appropriate venipuncture site, giving priority to the median cubital or median vein.
Ensure the tourniquet is on for no longer that 1 minute.
9. Put on gloves.
10. Cleanse the venipuncture site with 70% isopropyl alcohol using concentric circles from the inside to outside. Allow skin to
air-dry.
11. Inspect the equipment and needle tip for burrs and bends.
12. Perform the venipuncture by anchoring the vein with the thumb 1 to 2 inches below the site and inserting the needle,
bevel up, with an angle less than 30 degrees between the needle and the skin. Collect tubes using the correct order of
draw, and invert each tube containing any additive immediately after collection. CLSI recommends a particular order of
draw when collecting blood in multiple tubes from a single venipuncture.9 Its purpose is to avoid possible test result error
because of cross-contamination from tube additives. The recommended order of draw is as
follows:
a) Blood culture tube (yellow stopper)
b) Coagulation tube (light blue stopper)
c) Serum tube with or without clot activator or gel (red, gold, red-gray marbled, orange, or yellow-gray
stopper)
d) Heparin tube (green or light green stopper)
e) EDTA tube (lavender or pink stopper)
f) Sodium fluoride tube with or without EDTA or oxalate (gray stopper)
13. Release and remove the tourniquet as soon as blood flow is established or after no longer than 1 minute.
14. Ensure that the patient’s hand is open.
15. Place gauze lightly over the puncture site without pressing down.
16. After the last tube has been released from the back of the multisample needle, remove the needle and activate the safety
device according to the manufacturer’s directions.
17. Apply direct pressure to the puncture site using a clean gauze pad.
18. Bandage the venipuncture site after checking to ensure that bleeding has stopped.
19. If a syringe has been used, fill the evacuated tubes using a syringe transfer device.
20. Dispose of the puncture equipment and other biohazardous waste.
21. Label the tubes with the correct information. The minimal amount of information that must be on each tube is as follows:
a) Patient’s full name
b) Patient’s unique identification number
c) Date of collection
d) Time of collection (military time)
e) Collector’s initials or code number
Note: Compare the labeled tube with the patient’s identification bracelet or have the patient verify that the
information on the labeled tube is correct whenever possible.

Reference:

Keohane, E. M., Smith, L. J., Walenga, J. M., Rodak, B. F., & W.B. Saunders Company. (2016). Rodak's hematology:
Clinical principles and applications. St. Louis: Elsevier/Saunders. Page 25.
 Written summary of summary on how the Blood Indices are computed, its reference ranges and interpretation, and the
different diseases/disorders that are associated with it.

Formulas:

Reference ranges and interpretation, and the different diseases/disorders that are associated with it:

MCV (fL) MCHC (g/dL) Red Blood Cell Morphology Found in

Iron deficiency anemia, anemia of inflammation,
<80 <32 Microcytic; hypochromic thalassemia, Hb E disease and trait, sideroblastic
anemia
Hemolytic anemia, myelophthisic anemia, bone marrow
80 – 100 32 – 36 Normocytic; normochromic
failure, chronic renal disease
Megaloblastic anemia, chronic liver disease, bone
>100 32 – 36 Macrocytic; normochromic marrow failure, myelodysplastic
syndrome

Reference:

Keohane, E. M., Smith, L. J., Walenga, J. M., Rodak, B. F., & W.B. Saunders Company. (2016). Rodak's hematology:
Clinical principles and applications. St. Louis: Elsevier/Saunders. Page 196.