Hema Sop

1 DAVAO MEDICAL SCHOOL FOUNDATION, INC.
2 DR. A. GAHOL AVENUE, BAJADA, BRGY. 19 – B, DAVAO CITY

3 DMSF HOSPITAL
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5 UNIT
6 D EPARTMENT P ROCEDURES M ANUAL
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Prepared by: Approval Date:
ERIKA MINA P. CELESTE, RMT (ASCPi) ________________________________

Hematology Section Head
Reviewed by: Effective Date:
AGATHA LAARNI C. LACUNA, RN ________________________________

ANCILLARY DIRECTOR
Manual No. ANC- ____ -M01

RANDY IAN J. ESPINOSA
QUALITY MANAGEMENT REPRESENTATIVE Version No. 1.0
Recommended by:
OSCAR P. GRAGEDA, MD, FPSP

Chief Pathologist
VICTOR D. ESPINO, MD, FPUA, FPCS

CHIEF OPERATIONS OFFICER
OLIVER G. VICTORIANO, DBA

CHIEF OPERATIONS OFFICER
Approved by:
ATTY. ALBERTO RAFAEL L. APORTADERA

PRESIDENT
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13 This Procedures Manual is contributed by the following Laboratory Personnel:

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15 ERIKA MINA P. CELESTE

16 Hematology Section Head
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1 ANCILLARY – LABORATORY – SECTION
2 DEPARTMENT PROCEDURES MANUAL
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20 TABLE OF CONTENTS
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Chapter Page
1 UNIT OVERVIEW 1
 Unit Vision and Mission 2
 Description of Key Personnel 2
2 GENERAL POLICIES FOR SECTION 21

 Quality Management 23
 Transport of Specimen 26
3 GENERAL STANDARD OPERATING PROCEDURES

 General Policy
 Communication
 Telephone Courtesy
 Endorsement
 Routine Activities During Shifts
 Duties and Roles of MedTech
 Duties and Roles of Laboratory Aide
4 LABORATORY PROCEDURES
 Blood Collection
 Handling and Storage
 Equipment
 Procedures
 Proper Identification of Patients
 Extraction
 Releasing of Results
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 Specimen and Records Retention

 Critical Values
 Workflow of Hematology Section
 Safety Measures
 NEQAS
5 REFERENCES
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23 CHAPTER 1
24 HEMATOLOGY SECTION OVERVIEW
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26  Hematology Vision and Mission

27  Description of Key Personnel
28  Hematology Section Organizational Structure
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Supersedes: Previous Procedures Manual of the Hematology Section
Approval Date:
Effective Date:
Version No.: 1.0
Authored by: Recommended by:
ERIKA MINA P. CELESTE, RMT (ASCPi) OLIVER G. VICTORIANO, DBA

Section Head Chief Operations Officer
Authored by: Approved by:
Reviewed by: Approved by:
AGATHA LAARNI C. LACUNA, RN ATTY. ALBERTO RAFAEL APORTADERA

Ancillary Directors President
RANDY IAN J. ESPINOSA, PTRP

Quality Management Representative
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35 Hematology Unit Overview

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38 Hematology encompasses the study of blood cells and coagulation. Included in its concerns are
39 analyses of the concentration, structure, and function of cells in blood; their precursors in the bone
40 marrow; chemical constituents of plasma or serum intimately linked with blood cell structure and
41 function; and function of platelet and proteins involved in blood coagulation. Increasingly,
42 molecular biological techniques enable the detection of genetic mutations underlying the altered
43 structure and function of cells and proteins that result in hematologic disease.
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45
46 VISION:
47 Trusted laboratory partner-empowering health, impacting lives, living our core values, faith in God,
48 Integrity, respect and excellence.
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50 MISSION:
51 Provide innovative, timely and quality clinical hematology services to our patients and the
52 community we serve.
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54 LOCATION:
55
56 The Hematology Section unit is located inside the laboratory department at hospital ground floor.
57
58 I. Definition of Terms:
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60 1. Blood constitutes 6 to 8% of the total body weight and consists of blood cells
61 suspended in fluid called plasma. The three main types of blood cells are the red
62 blood cells (erythrocytes), white blood cells (leukocytes), and platelets
63 (thrombocytes). The fluid plasma forms 45 to 60% of the total blood volume; the
64 red blood cells occupy most of the remaining volume. White blood cells and
65 platelets, although functionally essential, occupy a relatively small proportion of the
66 total blood mass. The proportion of cells and plasma is regulated and is kept
67 relatively constant.
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69 2. Coagulation is a chemical process whereby plasma proteins interact to convert
70 the large, soluble plasma protein molecule fibrinogen into the stable, insoluble gel
71 called fibrin. The active compound is the enzyme thrombin, which preferentially
72 converts fibrinogen into fibrin. There is a delicate balance between coagulation and
73 maintaining blood in a liquid state. Imbalance in one direction can lead to excessive
74 bleeding, whereas in the other it may lead to thrombosis.
75
76 3. Automation is a procedure in which a machine or instrument is used to
77 determine complete blood count, differential count, coagulation tests, hemoglobin
78 and hematocrit determination test and platelet count.
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Chapter 1: Section Overview| 2

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81 4. Manual Procedure is done when determining estimated platelet count and
82 differential cell count using peripheral blood smears that are stained and observed
83 under the microscope in an oil immersion objective field.
84
85 DESCRIPTION OF KEY PERSONNEL
87 I. SECTION HEAD
88 1. BASIC FUNCTION
89 Under the direct supervision of the Chief Medical Technologist, performs various laboratory
90 tests using microscopic techniques, computer-controlled analyzers, specialized automated
91 instruments and equipment following detailed instructions to provide data or information
92 for use in diagnosis, treatment, and monitoring of diseases.
93
94 2. PRINCIPAL FUNCTIONS AND RESPONSIBILITIES:

95
96 1. Verifies or records identity of patients.

97 2. Receives samples from healthcare personnel and laboratory customers in a manner that
98 ensures the samples are kept in a clear “chain of custody” to ensure reliability of test results.
99 3. Verifies the integrity of sample, and sees to it that proper transport and preservation of
100 specimen is followed.
101 4. Performs complete blood count, blood typing, differential cell count, erythrocyte
102 sedimentation rate, prothrombin time, activated partial thromboplastin time and
103 reticulocyte count.
104 5. Performs venipuncture and finger prick extraction on out-patients and in-patients of varied
105 ages in approved collection sites.
106 6. Prepares machines to be used in running tests for hematology and maintains proper
107 functioning of equipment.
108 7. Process specimens including receiving, sorting and accessioning.
109 8. Follows SOP when processing specimens for analyses in the section.
110 9. Prepares standard solutions and reagents needed for testing following standardized formula.
111 10. Prepares peripheral blood smears, bone marrow aspirates and malarial smears.
112 11. Ensures that quality control testing and verification is completed within the section.
113 12. Checks hematology storage refrigerators for level of reagents.
114 13. Acts as rotating medical technologist and performs procedures such as phlebotomy as
115 required or needed.
116 14. Ensures that results are accurate and timely.
117 15. Monitors and records average census of blood processed each month in hematology
118 department.
119 16. Responsible in hematology section orientation and training of new staff.
120 17. Provides reports during monthly unit meetings regarding the hematology section.
121 18. Documents all results of laboratory tests in hematology and accounts them in logbooks for
122 daily, monthly and quarterly reports and submits copies to other hospital departments as
123 required.

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124 19. Maintaining laboratory quality assurance and safety standards by attending and
125 participating in National Quality Assessments.
126 20. Observes safe laboratory practice.
127 21. Checks inventory of supplies and reagents and ensures that adequate supplies are on hand at
128 all times in the assigned section/s.
129 22. Discard all expired reagents or unusable supplies in the section.
130 23. Checks expiry dates and quality of reagents.
131 24. Documents incidents and problems and take appropriate actions and follow-up with staff.
132 25. Relays laboratory results to physicians as the need arises.
133 26. Collaborate in the practice of new policies and procedures.
134 27. Solves section service problems in an innovative manner and/or reports the said problems
135 to corresponding agencies concerned. Trouble shoots problems for malfunctioning
136 machines and refers to supervisor/ engineer for major repairs.
137 28. Prepares and facilitates sending out of specimens to the reference laboratory.
138 29. Attend and participate in conventions and seminars for updates and improvements in the
139 assigned area.
140 30. Courteously responds to telephone calls.
141 31. Observes cleanliness and orderliness to ensure the accuracy of laboratory results and help
142 protect workers from possible contamination or infection of disease inside the laboratory.
143 32. Secures all information from results gathered be kept confidential.
144 33. Shares in the vision of the institution, demonstrates its value and workplace ethics, supports
145 and is sensitive to its mission.
146 34. Does other duties as may be assigned from time to time.
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148
149 3. PROBLEM-SOLVING
150 Solves section service problems in an innovative manner and/or reports the said problems
151 to corresponding agencies concerned. Troubleshoots problems for malfunctioning
152 machines and refers to supervisor/engineer for major repairs/problems.
153
154 4. KEY ORGANIZATIONAL RELATIONSHIPS

155 Reports to: - Chief Medical Technologist, Assistant Chief Medical Technologist
156 Supervises: - Section Heads, Rotating Medical Technologists
157 Coordinates: - Attending Physician, Nurses on Duty
158
159 5. QUALIFICATION GUIDE

160 Education: A graduate and licensed Medical Technologist by the Professional
161 Regulation Commission
162 Experience: At least 2 years or more experience in an approved hospital based
163 laboratory.
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166 Skills: With formal laboratory training for a certain period of time, in charge of major
167 sections and performs responsibly.
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169
170 6. WORKING CONDITION

171 - Always work indoors in laboratories or offices.
172 - Always wear protective gloves, masks, or glasses when handling chemicals.
173 - Are often exposed to contaminants or hazardous conditions while handling
174 chemicals. There is some possibility of acquiring moderate injuries. However,
175 risk is reduced by following safety procedures and protocols.
176 - Works within several feet with other personnel inside the laboratory.
177 - They often share the same work space with other Medical Technologists.
178
179 II. MEDICAL TECHNOLOGY STAFF

180 1. BASIC FUNCTION
181 Under the direct supervision of the Chief Medical Technologist, performs various laboratory
182 tests using microscopic techniques, computer-controlled analyzers, specialized automated
183 instruments and equipment following detailed instructions to provide data or information
184 for use in diagnosis, treatment, and monitoring of diseases. Performs other related
185 functions.
186
187 2. PRINCIPAL FUNCTIONS AND RESPONSIBILITIES:
188 1. Verifies or records identity of patients.
189 2. Receives samples from healthcare personnel and laboratory customers in a
190 manner that ensures the samples are kept in a clear “chain of custody” to ensure
191 reliability of test results.
192 3. Verifies the integrity of sample, and sees to it that proper transport and
193 preservation specimen is followed.
194 4. Performs complete blood count, blood typing, differential cell count, erythrocyte
195 sedimentation rate, prothrombin time, activated partial thromboplastin time and
196 reticulocyte count.
197 5. Performs venipuncture and finger prick extraction on out-patients and in-patients
198 of varied ages in approved sites.
199 6. Prepares machines to be used in running tests for hematology and maintains
200 proper functioning of equipment.
201 7. Process specimens including receiving, sorting and accessioning.
202 8. Follows SOP when processing specimens for analyses in the section.
203 9 Prepares standard solutions and reagents needed for testing following
204 formula.

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205 10. Prepares peripheral blood smears, bone marrow aspirates and malarial
206 smears.
207 11. Ensures that quality control testing and verification is completed within the section.
208 12. Checks hematology storage refrigerators for level of reagents.
209 13. Acts as rotating medical technologist and performs procedures such as
210 phlebotomy, chemistry, bacteriology, clinical microscopy as required or needed.
211 14. Ensures that results are accurate and timely.
212 15. Monitors and records average census of blood processed each month in
213 hematology department.
214 16. Responsible in hematology section orientation and training of new staff.
215 17. Provides reports during monthly unit meeting regarding the hematology section.
216 18. Documents all results of laboratory tests in hematology and accounts them in
217 logbooks for daily, monthly and quarterly reports and submits copies to
218 other hospital departments as required.
219 19. Maintaining laboratory quality assurance and safety standards by attending and
220 participating in National Quality Assessments.
221 21. Checks inventory of supplies and reagents and ensures that adequate supplies
222 are on hand at all times in the assigned section/s.
223 22. Discard all expired reagents or unusable supplies in the section.
224 23. Checks expiry dates and quality of reagents.
225 24. Documents incidents and problems and take appropriate actions and follow-up
226 with staff.
227 25. Relays laboratory results to physicians as the need arises.
228 26. Collaborate in the practice of new policies and procedures.
229 27. Solves section service problems in an innovative manner and/or reports the said
230 problems to corresponding agencies concerned. Trouble shoots problems
231 for malfunctioning machines and refers to supervisor/ engineer for major
232 repairs.
233 28. Prepares and facilitates sending out of specimens to the reference laboratory.
234 29. Attend and participate in conventions and seminars for updates and improvements
235 in the assigned area.
236 30. Courteously responds to telephone calls.
237 31. Observes cleanliness and orderliness to ensure the accuracy of laboratory
238 results and help protect workers from possible contamination or infection of
239 disease inside the laboratory.
240 32. Secures all information from results gathered be kept confidential.
241 33. Shares in the vision of the institution, demonstrates its value and workplace
242 ethics, support and is sensitive to its mission.
243 34. Does other duties as may be assigned from time to time.
244
245
246

248 Reports to: - Chief Medical Technologist, Assistant Chief Medical Technologist
249 Supervises: - Section Heads, Rotating Medical Technologists
250 Coordinates: - Attending Physician, Nurses on duty.
251

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253 Education: A graduate and licensed Medical Technologist by the Professional
254 Regulation Commission
255 Experience: At least 2 years or more experience in an approved hospital based
256 laboratory.
257
258
259 Skills: With formal laboratory training for a certain period of time, in charge of major
260 sections and performs responsibly.
261
262
264 - Always work indoors in laboratories or offices.
265 - Always wear protective gloves, masks, or glasses when handling chemicals.
266 - Are often exposed to contaminants or hazardous conditions while handling
267 chemicals. There is some possibility of acquiring moderate injuries. However,
268 risk is reduced by following safety procedures and protocols.
269 - Works within several feet with other personnel inside the laboratory.
270 - They often share the same work space with other Medical Technologists.
271
272 III. LABORATORY AIDE

273
274 1. PRINCIPAL FUNCTIONS AND RESPONSIBILITIES

275 1.1 Receive and check approved laboratory specimen from patient or nurse on duty.
276 1.2 Record all laboratory request forms received in a designated logbook
277 1.3 Assists in the release of final results to the patient or wards promptly.
278 1.4 Clean and disinfect the laboratory area and wash all used glassware.
279 1.5 Help the Chief Medical Technologist in the procurement of laboratory reagents and
280 supplies.
281 1.6 In charge of stock room arrangement and cleanliness.
282 1.7 Moderate supervision under Standard Operating Procedure.
283 1.8 No supervision responsibility required.
284 1.9 Share in DMSF vision, mission and goals demonstrated, its values and
285 workplace ethics.
286 1.10 Adhere to and follow the DMSF policies, procedures and compliance program.
287 1.11 Authorized specimen collector and encoder for Drug Testing.
288 1.12 Assists in the preparation and helps facilitate in sending out of specimens to the
289 reference laboratory.
290 1.13 Maintains a friendly, respectful and professional environment for all patients.
291 1.14 Maintains confidentiality of its customers and secures all information from results
292 gathered be kept confidential.

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293 1.15 Shares in the vision of the institution, demonstrates its value and workplace
294 ethics, supports and be sensitive to its mission.
295 1.16 Does other duties as may be assigned from time to time.
296

298 Reports to: Chief Medical Technologist
299 Asst. Chief Medical Technologist
300 Rotating Medical technologists
301 Supervises: None
302 Coordinates: Chief Medical Technologist
303 Asst. Chief Medical technologist
304 Rotating Medical Technologists
305

307 3.1 High school or college graduate or its equivalent
308 3.2 With health care service background and experience
309 3.3 Knowledge on basic laboratory principles and ability to follow laboratory
310 procedures and policies.
311 3.4 Have knowledge of basic laboratory principles and ability to operate autoclave and
312 other laboratory machines and equipment, likewise ability to work with other
313 people.
314
316 4.1. Always work indoors in laboratories or offices.
317 4.2 Always wear protective gloves, masks, or glasses when handling chemicals.
318 4.3 Are often exposed to contaminants or hazardous conditions while handling
319 chemicals. There is some possibility of acquiring moderate injuries. However, risk is
320 reduced by following safety procedures and protocols.
321 4.4 Work within several feet of others in the laboratory.
322 4.5 They often share the same work space with other Medical Technologists.
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337 CHAPTER 2
338 GENERAL POLICIES FOR HEMATOLOGY SECTION
339
Approval
Date:
Effective
Date:
Version No.: 1.0
Erika Mina P. Celeste, RMT (ASCPi) OLIVER G. VICTORIANO, DBA

340
AGATHA LAARNI C. LACUNA, RN ATTY. ALBERTO RAFAEL L. APORTADERA

Ancillary Director President

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348 Quality Management

349
350 Quality Assurance (QA)

351 Quality Assurance is encountered in the pre-analytic, analytic and post–analytic phase
352 of laboratory testing. It monitors quality performance starting from the ordering of a
353 laboratory determination to its reporting, interpretation of result and the application to
354 patient care. It also involves in total quality control which requires constant attention of
355 all involved with the processed system.
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357 Quality Control (QC)
358
359 It is concerned with the analytical phase of QA. It monitors the overall reliability of
360 laboratory results in terms of accuracy and precision.
361 External QC – monitors primarily the accuracy of laboratory tests.
362 Internal QC – primarily monitors the day-to-day performance of laboratory tests namely
363 precision, result of control specimen and result of patient specimen.
364
365 Objectives of Quality Control:
366  To provide a continuous record of precision and indications of technologist’s
367 analytical skills.
368  To give easy warning, trends and shift in control results so that remedial
369 action may be taken before serious loss of precision occur.
370  To permit valid judgment on the accuracy of results by monitoring precision
371 and permitting continuous comparison of assay values on “known” sera with
372 stated levels.
373  To facilitate comparison between different techniques for the assay of a
374 constituent and to derive a justifiable choice between methods.
375  To monitor the performance of equipment especially of an automated one.
376  To accumulate a body of information about laboratory performance with
377 which the challenges of external monitoring organization can be met.
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381
382
383 CONSIDERATION OF CHOOSING A CONTROL SOLUTION

384
385 Quality control specimens are used in the laboratory to ensure that patient testing is
386 performed within acceptable limits of variation. In Hematology, both commercially prepared
387 and within laboratory prepared specimens may be used. In a large busy laboratory, a Q.C.
388 specimen may be run every hour, whereas in a smaller operation, quality control testing may
389 be performed once every 8-hour shift. However, any time a change can occur in a procedure
390 that may affect test results (e.g., new reagents or change of instrument tubing or lamp), a Q.C.
391 specimen should be run.
392
393 Objectives of Quality Control
394 1. To provide a continuous record of precision and indications of technologist’s analytical
395 skills.
396 2. To give easy warning, trends and shift in control results so that remedial action may be
397 taken before serious loss of precision occur.
398 3. To permit valid judgment on the accuracy of results by monitoring precision and
399 permitting continuous comparison of assay values on “known” sera with stated levels.
400 4. Facilitate comparison between different techniques for the assay of a constituent and to
401 derive a justifiable choice between methods.
402 5. To monitor the performance of equipment especially of an automated one.
403 6. To accumulate a body of information about laboratory performance with which the
404 challenges of external monitoring organization can be met.
405
406
407 Selection of Quality Specimen
408 1. Should behave like the real specimen.
409 2. Should be available in sufficient quantity to last a minimum of one year.
410 3. Should be stable over a period of one year.
411 4. Should be available in convenient vial volume.
412 5. Should be minimal in concentration and composition from vial to vial.
413 6. Should include clinically normal, high and low abnormal ranges.
414 7. Should preferably be lyophilized and require reconstitution before use.
415
416 Proper Preparation of Quality Control Specimen

417 1. Lyophilized sample should be reconstituted and handle with good quantitative technique.
418 2. Allow the lyophilized Q.C. sample to dissolve completely before use.
419 3. Aliquot it by 300-500ul to avoid deterioration and contamination then labeled with number
420 and date of reconstitution and freeze in -25 to -15C (only one freezing session)
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423
424
425 Precision
426 1. Standard Deviation
427 It is the measurement of dispersion of the values around the mean in a
428 normal or Gaussian distribution.
429 2. Precision monitoring technique
430 Levey – Jennings Q.C. chart
431
432 a. The control results are plotted on the ordinate (Y-axis) versus time on
433 the abscissa (X-axis)
434 b. The mean value of the control is indicated by solid line while the
435 control limit usually ±2SD around the mean are indicated by
436 interrupted or dotted lines.
437 c. Random error shows a wider range of scatter of the points on the
438 control chart, while systemic error can be seen when the points drift
439 or shift on one side of the central solid line.
440
441 QC chart must be updated monthly.
442
443 3. Stains
444  Commercially prepared slide for hematology or slide of normal
445 patient must be available.
446  Change stains every Monday morning or if needed, to have a reliable
447 blood smear.
448
449 4. Hematology Control must be run every day then record the result in designated
450 logbook for documentation.
451
452 5. Coagulation control must be run every day then record the result in designated
453 logbook for documentation
454
455 6. Slides storage of hematology slides are placed in a box and is labeled by month.
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467 TRANSPORT OF SPECIMEN
468
469 1. Use appropriate anticoagulant upon blood extraction.
470 2. Prevent biochemical exposure, contamination of specimen and decomposition of its
471 constituents.
472 3. Specimen must be received by reference laboratory as soon as possible.
473 4. Specimen proper storage and transport must be followed.
474
475
476 REAGENTS AND EQUIPMENTS
477
478 Proper handling and manipulation of machine is strictly observed. Calibration of

479 instruments must be scheduled at least once or twice a year and preventive
480 maintenance must be done regularly by company engineer. For operation of
481 automated machines please refer to manual given by the Sales Representative of each
482 corresponding machine.
483
484
485 REAGENTS PROTOCOL

486 A. Reagent kits must always be accompanied with their respective reagent
487 standard.
488 B. All reagents must be BFAD approved and passed the quality assurance test.
489 C. Always take note of the opening of each reagent kit.
490 D. Always run control specimen daily.
491 E. Normal range of control and normal value of patients must be posted for
492 guidance.
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502
503
504
505
506 CHAPTER 3
507 GENERAL STANDARD OPERATING PROCEDURES
508
509  General Policy

510  Communication
511  Telephone Courtesy
512  Endorsement
513  Routine Activities During Shifts
514  Duties and Roles of Medical Technologist
515  Duties and Roles of Laboratory Aide
516
Approval Date:
Effective Date:
Version No.: 1.0

AGATHA LAARNI C. LACUNA, RN ATTY. ALBERTO RAFAEL L. APORTADERA


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517
518
519
520 GENERAL POLICY

521 The healthcare professional/ provider assigned in any clinical area station must practice the
522 following:
523 1.Must be courteous at all times especially to the hospital staff, personnel, doctors, heads,
524 patients and watchers
525 2.Must respect their superiors and co-staff.
526 3.Must be polite in answering phone calls.
527 4.Must follow and observe the policies imposed by the hospital and stations/departments.
528 5.Must attend meetings set by the station head and or any hospital meetings or gatherings
529 scheduled.
530 6.Must follow and observe the memorandum released by the hospital and other departments.
531 7.Ladies’ hair should be tied up and no hair color or highlighted hair. Must wear light make-
532 up to look neat and presentable.
533 8.Gentlemen should be following the standard of haircut for health care provider. Must look
534 tidy and neat at all times. No piercing is allowed.
535 9.Wearing proper, prescribed uniform during duty hours as follows:
536 9.1 Medical Technologist
537 9.1.1 Prescribed uniform
538 9.1.2 Prescribed uniform with white undershirt without prints (for male nurses)
539 9.1.3 White socks
540 9.1.4 Closed shoes
541 9.1.5 Employee ID
542 9.2 Laboratory Aides
543 9.2.1 Prescribed uniform (scrub suit)
544 9.2.2 White socks
545 9.2.3 Closed shoes
546 9.2.4 Employee ID

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547 10. Must come at least 30 minutes before the endorsement time. PUNCTUALITY is strictly
548 implemented in every station. Medical Technologist must report on time to receive
549 endorsement.
550 I.1 Proper endorsement must be made before going off duty. All special
551 endorsements must be read first before endorsement proper starts.
552 I.2 Everybody must pay attention to the endorsement process.
553 I.3 In crashing out laboratory and other procedures, the staff concerned must never
554 forget to indicate the date it was taken, served or done.
555 I.4 The outgoing staff must leave the department in good order. All necessary
556 endorsements should be well received and clarified by the incoming shift.
557
558 COMMUNICATION
559
560 1.Silence must be maintained at all times in all areas.

561 2.Communication must be made in low voices and not be heard within the hearing distance of
562 the patient.
563 3.Extra silence must be maintained and observed during night shift at all times.
564 4.Medical Technologists must not argue in front of the patient.
565 5.Complaints from the patient and or the public must be referred to the immediate superior
566 as soon as possible. This is to promote early resolution to the issue raised in the area.
567 Thus, improving and maintaining the quality of care to be rendered to the patient.
568 6.Laboratory personnel must always remember their responsibility and must maintain
569 confidentiality of all patient information and any privilege communication. This refers
570 not only to the information found in the laboratory result but also to whatever is
571 learned or seen by them while attending and taking good care of the patient.
572 7.While on duty and within hospital premises, employees are prohibited from gossiping or
573 engaging in rumor mongering.
574
575
576 TELEPHONE COURTESY

577 1.Answer the phone in a low and accommodating tone of voice.
578 2.Answer call promptly after the first ring, if possible.

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579 3.Identify yourself. If you are the caller; give your name and that of your department or unit. If
580 you are answering the phone, give your name and department/unit.
581 4.Try placing and receiving your own calls.
582 5.If you ask someone to place a call for you, make sure that you are ready for the information
583 that you wanted to relay on the line.
584 6.Plan on what you are going to say and how to say it before dialing any number.
585 7.List down frequently called numbers; when in doubt refer to your telephone directory.
586 8.Keep pad and pencil handy. Jot down necessary details of the message received accurately.
587 9.When the person called is not available, give the caller a definite time when to call again or
588 offer to take the message and relay promptly.
589 10. Leave message or information when leaving your office or desk. Have someone nearby
590 answer your phone during your absence.
591 11. Offer help to the caller if the call is not intended for you or your department. If your
592 phone is connected to another department try to connect the caller to the department
593 where he/she intends to call.
594 12. If you must leave the line during a conversation, explain to the caller that you are going
595 to get facts on the information the caller wanted to secure. Explain this to the caller
596 thoroughly and explicitly. Advise the caller to call you back or offer to call him back.
597 13. When screening calls or asking identifying calls, avoid using terms that might create a
598 negative impression on the one who receives the call. Be polite and courteous in
599 answering a phone call.
600 14. During a lengthy explanation by the caller, indicate your presence on the line by using
601 verbal expression such as “certainly”, “of course”, “yes, I understand”.
602 15. Be polite in receiving a wrong number call, you can answer back by telling the other line
603 such as “I’m sorry you dialed the wrong number”, “You are calling DMSF Hospital?” In
604 that way, you even advertised your hospital to the caller.
605 16. Finally, end the conversation politely. Don’t forget uttering the word “thank you” and
606 “goodbye”. Place the receiver gently.
607
608
609 ENDORSEMENT
610 Endorsement is an oral report given by the outgoing shift of Medical Technologist to incoming shift
611 of Medical Technologist on the significant evaluation of each patient’s laboratory procedure. It also

60 _______Version 1.0
612 involves the transfer of responsibilities from one shift to another for the purpose of achieving
613 continuity of patient care.
614
615
616
617 LABORATORY ROUNDS

618 1.The following should be observed/done by the staff during rounds:
619 1.1 Introduce self who will render test or procedure to the patient.
620 1.2 Address patient by name and observe courtesy.
621 1.3 Informs patient of any test, procedures and checks/validates if preparations have
622 been followed.
623 1.4 Accepts expression of complaint and assures patient that the complaint will be
624 attended to and will return to address any change necessary, if possible
625
626 ROUTINE ACTIVITIES DURING SHIFTS

627 1. Morning shift (7AM-3PM)
628  Endorsement will be done from the evening shift, patient details as well as the
629 physical upkeep of the machine and the working area
630  Routine analysis both manual and automated will start, after maintenance and
631 Internal Quality Control.
632
633 2. Afternoon Shift (3PM-11PM)
634  Endorsement will be done from the morning shift, patient details as well the
635 physical upkeep of the machine and the working area
636  Routine analysis will start.
637
638 3. Evening Shift (11PM-7AM)
639  Endorsement will be done from afternoon shift, patient details as well as
640 physical upkeep of the machine and the working area.
641  Daily Maintenance of the machine is performed once a day (at 12 midnight).
642 This includes shut down of the machine, Background checking, and running of
643 Quality Controls.
644  Once the results are displayed, record the result in the designated quality
645 control logbook. If there are flaggings (highlighted in red), reanalyze and rerun
646 the control material. If the problem persists, contact a senior or a service
647 engineer.
648  Record the results of the QC in the designated logbook.
649  Routine analysis will start.

63 _______Version 1.0
650
651
652
653 CHAPTER 4
654 LABORATORY PROCEDURES
655 657
656 658
659
Approval Date:
Effective Date:
Version No.: 1.0

AGATHA LAARNI C. LACUNA,RN ATTY. ALBERTO RAFAEL L. APORTADERA


660
661
662
663
664

66 _______Version 1.0
665
666
667
668
669 COLLECTION AND DISPOSAL OF SPECIMEN POLICIES

670
671 I. Blood Collection

672
673 1.1 Obtaining blood from a finger
674
675
676 Preparing the finger
677
678  The finger is cleansed with a gauze pad which has been moistened with 70%
679 alcohol or some similar antiseptic.
680  It is then dried so that the blood will form a round drop.
681
682 Puncturing the finger
683
684  The tip of the finger is punctured with a sterile lancet or pricker.
685  The puncture is made by grasping the finger firmly and making a quick
686 deliberate stab.
687  Since a deep puncture is less painful than a superficial puncture, it is best to go
688 deep enough the first time and avoid puncturing the patient a second time.
689
690 Eliminating the first drop
691
692  The first drop of blood may contain tissue juices.
693  Also the first drop may be contaminated with extraneous materials which
694 have been clinging to the surface of the skin.
695  When blood contains tissue juices and foreign particles, it is not a true
696 representative sample of the patient’s blood.
697  Therefore, the first drop of blood is always wiped away.
698
699 Withdrawing the blood
700
701  Gentle pressure is applied. If necessary, drops of blood are taken for the
702 desired examination.
703  Heavy pressure should be avoided because it may cause the flow of tissue
704
705

69 _______Version 1.0
706
707
708
709
710
711
712 Preventing further bleeding
713
714  When the desired amount of blood has been obtained, an antiseptic/cotton
715 pad is placed on the puncture.
716  The patient is then instructed to apply pressure to the wound until bleeding
717 has ceased.
718
719 1.2 Obtaining the blood from vein
720  Preparing the needle and syringe
721  Applying the tourniquet
722 a. It is desirable to enlarge the veins of the forearm so that they may
723 become more prominent. This is accomplished by allowing blood to
724 enter the arm by way of the arteries and blocking its return via the
725 veins.
726 b. A tourniquet placed above the bend in the elbow serves the purpose.
727 c. The patient is instructed to clench his fist as this aid in building up
728 the pressure.
729  Selecting the vein
730 a. The most prominent vein is usually chosen.
731 b. If the veins are not visible, opening and closing the hand may help to
732 bring them out.
733 c. Quite often, the veins cannot be seen, but may be felt.
734 d. They will then reveal themselves as elastic tubes beneath the surface
735 of the skin.
736  Applying antiseptic
737 a. At the proposed site of the injection, an antiseptic solution is applied
738 with a piece of cotton or gauze pad.
739  Inserting the needle
740 a. Many veins have the tendency to roll over when stuck with a needle,
741 therefore must be held in position.
742 b. The needle is then held in line with the vein and inserted at
743 approximately a 25-degree angle.
744 c. The bevel of the needle should be up to facilitate easier passage of
745 the needle.
746 d. Precaution should be taken against pumping air into the vein. A few
747 cubic centimeters of air pumped into the vein could cause death.
748  Withdrawing the blood
749 a. When the needle enters the vein, the plunger is pulled slowly back
750 and the desired amount of blood is drawn into the syringe.
751 b. Should the blood start to enter into the syringe and cease, the needle
752 may have slipped out of the vein, or gone through it.
753 c. If it has gone through, it should be slowly withdrawn until it is once
754 again in the blood stream.

72 _______Version 1.0
755  Releasing the tourniquet

756 a. Before the needle is withdrawn, the pressure must be released,
757 otherwise, the blood will continue to flow from the hole made by the
758 needle.
759 b. The pressure is removed by first instructing the patient to open his
760 clenched fist and then releasing the tourniquet.
761  Withdrawing the needle
762 a. After the tourniquet is released, the needle is withdrawn.
763 b. As the needle is withdrawn, the antiseptic pad is applied to the
764 puncture.
765
766
767  Preventing the bleeding
768 a. In order to prevent bleeding, the patient is instructed to apply
769 pressure to the antiseptic pad covering the punctured site.
770
771 1.3 Obtaining blood from an infant
772
773  If only a few drops are needed for examination, the blood may be obtained by
774 puncturing the heel or big toe.
775  If several cubic centimeters are required, the blood may be obtained by making a
776 venipuncture on the scalp or neck.
777 (Should be performed by a physician or an expert technician).
778
779
780 1.4 Procedure for obtaining blood from the external jugular vein:
781  Wrap the infant in a small sheet to prevent movement of arms and legs.
782  Place the infant on the edge of a table or bed so that the head just hang over the
783 edge.
784  Pin the sheet holding the baby to the table or bed.
785  Turn the baby’s head to one side and locate the external jugular vein. If the baby
786 cries or can be induced to cry, the external jugular vein becomes quite prominent.
787  Sterilize the area.
788  Attach the sterile needle to a syringe.
789  Hold the skin taut, insert the needle and withdraw the blood.
790  Withdraw a needle and place a piece of cotton moistened with alcohol on the site of
791 puncture. Apply gentle pressure until the bleeding has ceased.
792
793 Note: In obtaining blood from an infant, it is always a good policy to double check
794 the wound and make certain that the bleeding has ceased before leaving the
795 ward or room.
796
797 II. HANDLING AND STORAGE OF SPECIMEN
798 1. Transfer drawn blood to corresponding tubes with appropriate anticoagulant while
799 taking precaution to avoid hemolysis of blood sample.
800 2. Label the tube with the complete name of patient, initials of the phlebotomist and date
801 of extraction.

75 _______Version 1.0
802 3. In cases of delay in examination, blood sample must be refrigerated.

803 4. After processing the test, save the remaining sample for at least 7days.
804 5. In cases of abnormal cells observed during microscopy, save the smears with proper
805 labels.
806
807
808
809 II EQUIPMENTS
810
811
812 A. SYSMEX CA-600
813
814 Reagents:
815 Sysmex Actin FSL
816 Sysmex Calcium Clean I
817 Sysmex Calcium Clean II
818 Sysmex Calcium Chloride
819 Sysmex Ci-Trol
820 Sysmex Thromborel S
821
822
823 B. SYSMEX XN-550
824
825 Reagents:
826 Sysmex Cellpack DCL
827 Sysmex E-check control
828 Sysmex Fluorocell WDF
829 Sysmex Lysercell WDF
830 Sysmex Sulfolyser
831
832
833 C. ABX PENTRA XL 80
834 ABX Basolyse
835 ABX Cleaner
836 ABX Diluent
837 ABX Eosinofix
838 ABX Lysebio
839
840
841
842
843 SYSMEX CA-600
844
845 The Sysmex Automated Blood Coagulation Analyzer CA-600 series is a
846 compact fully automated instrument capable of 5-parameter random analysis
847 for in-vitro diagnostic use. This instrument incorporates latest technologies as
848 represented by microcomputers, thus enabling analysis of multiple
849 parameters with increased flexibility of PT, APTT, Fibrinogen, Thrombin Time
850 (Coagulation Method).

78 _______Version 1.0
851
852 In addition, it has a number of functions including preferential processing of
853 STAT samples and a built-in quality control function. Moreover, it allows
854 analyzed data to be displayed and printed out together with reaction curves,
855 thus making it possible to obtain a highly reliable analysis result.
856
857
858
859 Procedure for running of sample of PT and APTT:
860
861 With completion of analysis preparation and registration of tests (PT and
862 APTT), the instrument is now ready to start analysis:
863
864 1. Check the system status display of the instrument. Make sure that the Root
865 Menu screen displays “Ready”.
866 2. Press (Start) key.
867 The screen confirming the first tube’s initial position will appear.
868 3. Press CONTINUE key or FIRST TUBE key.
869 CONTINUE key: Starts with the reaction tube that follows the last used tube in
870 the previous analysis.
871 FIRST TUBE key: Start with the upper extreme-right tube in the right-hand
872 reaction tube rack.
873 4. When all analyses are over, the alarm sounds.
874
875 APTT MIXING with One Hour Incubation
876
877 Procedure:
878
879 1. Mix 50ul patient’s sample and 50ul control
880 2. Get 10ul from mixed sample and control.
881 3. Mix and incubate for 1 hour (or as doctor’s preference) at dry incubate
882 (blood bank Inc.)
883 4. Run as APTT
884 5. Wait for the result.
885
886
887
888 PT MIXING
889
890 1. Mix 100ul patient’s sample and 100ul control
891 2. Get 100ul from mixed sample and control.
892 3. Add 200ul neoplastine Reagent.
893 4. Wait for the result.
894
895 SYSMEX XN-550
896 Sysmex XN 550 is an automated hematology analyzer for in vitro diagnostic use in
897 screening patient population found in clinical laboratories. This instrument enables
898 quantitative, identification, and existence ratio analysis of tangible components of blood and
899 body fluid (red blood cells, white blood cells, platelets and other cells) by means of electrical
900 impedance, laser light scattering and fluorescent labeling.

81 _______Version 1.0
901
902 Procedures:
903
904 For Sampler Mode:
905
906 1. Set Sampler mode on the machine
907 2. Click on the sampler icon on the menu screen.
908 3. Enter the necessary parameters as prompted by the dialog box:
909 -Sample Number
910 -Rack Number
911 -Analysis start position
912 4. Click OK- The main unit READY LED changes to green, and location of start position will
913 highlight on the screen.
914 5. Open the Sample drawer/cover.
915 6. Set the samples in the Sampler rack as shown in the diagram. Make sure that the barcode
916 part of the barcode sticker is placed on the top portion/near the cap of the tube.
917 7. Close the Sampler drawer then Press start switch (blue button).
918
919 For Manual Mode:
920
921 1. Set Manual mode on the machine
922 2. Click on the manual icon on the menu screen
923 3. Scan the barcode/Data input
924 4. Click OK - The main unit READY LED changes to green, and system changes to Manual
925 Aspiration Ready Status.
926 5. Open the Sample cover.
927 6. Gently invert sample 8 times, remove the cap, then fit the tube into the corresponding
928 adapter/position.
929 7. When the start switch is pressed, the sample position goes back inside the instrument and
930 the READY LED flashes green, indicating the sample is being aspirated.
931 8. When sample aspiration is complete, the buzzer beeps and the READY LED goes out.
932
933
934 ABX Pentra XL80
935 Pentra XL 80 system is a fully automated hematology analyzer used for in vitro diagnostic
936 testing of whole blood specimens..
937
938
939 Measurement and Computations:
940
941 - Impedance for WBC, platelets, RBC, basophils.
942 - Photometry for hemoglobin
943 - Impedance and light scattering for lymphocytes, monocytes,
944 neutrophils, and eosinophils.
945 - Computation from stored data that was directly measured for hematocrit, MCV, MCH,
946 MCHC, RDW, MPV, PCT, and PDW.
947
948
949 Procedures:
950

84 _______Version 1.0
951 For Autoloader:

952
953 1. Press the Worklist icon.
954 2. Enter rack number.
955 3. Enter patient’s name and details.
956 4. Click the check icon.
957 5. Put the rack with corresponding blood sample on the left side of the machine.
958 6. Press the Start rack icon.
959 7. Wait for the results.
960
961
962
963 For STAT mode:
964
965 1. Press STAT mode icon.
966 2. Enter patient’s name.
967 3. Click the check icon.
968 4. Put the sample on the correct tube holder.
969 5. Wait for the instructions to appear.
970 6. Push the tube holder.
971 7. Wait for the results.
972
973
974
975
976
977 IV. PROCEDURES
978
979
980
981 1. Complete Blood Count (CBC) the importance of CBC cannot be underestimated. It
982 is a screening procedure that is helpful in the diagnosis of many diseases. It is one indicator of
983 the body’s ability to fight disease, used to monitor the effects of drug and radiation therapy,
984 and it may be employed as an indicator of the patient’s progress in certain diseases such as
985 infection or anemia.
986
987
988 The CBC comprises of the following:
989
990
991 White blood cell count - Having a higher or lower number of WBCs than normal may
992 indicate an underlying condition. A WBC count can detect hidden infections within your body and
993 alert doctors to undiagnosed medical conditions, such as autoimmune diseases, immune
994 deficiencies, and blood disorders.
995 Hemoglobin determination - measures the amount of hemoglobin in your blood.

996 Hemoglobin is a protein in your red blood cells that carries oxygen to your body's organs and
997 tissues, and transports carbon dioxide from your organs and tissues back to your lungs. If a
998 hemoglobin test reveals that your hemoglobin level is lower than normal, it means you have a low

87 _______Version 1.0
999 red blood cell count (anemia). Anemia can have many different causes, including vitamin
1000 deficiencies, bleeding and chronic diseases. If a hemoglobin test shows a higher than normal level,
1001 there are several potential causes such as having a blood disorder called polycythemia vera, living
1002 at a high altitude location, smoking and dehydration.
1003 Differential count - A differential blood count gives the relative percentage of each type of
1004 white blood cell mainly Neutrophils, Lymphocytes, Monocytes, Eosinophils and Basophils. It also
1005 helps to reveal abnormal white blood cell populations (eg. blasts, immature granulocytes, and
1006 circulating lymphoma cells in the peripheral blood).
1007
1008 Hematocrit - test measures the proportion of red blood cells in your blood. Red blood cells
1009 carry oxygen throughout your body. Having too few or too many red blood cells can be a sign of
1010 certain diseases.
1011
1012 Red blood cell count - also called erythrocytes, are cells that circulate in the blood and
1013 carry oxygen throughout the body. The RBC count totals the number of red blood cells that are
1014 present in your sample of blood. It is one test among several that is included in a complete blood
1015 count (CBC) and is often used in the general evaluation of a person's health.
1016
1017 Red blood cell indices (MCV,MCH,MCHC) - Mean corpuscular volume (MCV), mean
1018 corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were
1019 first introduced by Wintrobe in 1929 to define the size (MCV) and hemoglobin content (MCH,
1020 MCHC) of red blood cells. Termed red cell indices, these values are useful in elucidating the etiology
1021 of anemias. Red cell indices can be calculated if the values of hemoglobin, hematocrit (packed cell
1022 volume), and red blood cell count are known.
1023
1024
1025 Bleeding Time is a screening test for detecting disorders of platelet function and von Willebrand’s
1026 disease, and is directly affected by the platelet count and the ability of platelets to form a plug. The
1027 thickness and vascularity of the skin and the ability of the blood vessels to constrict and retract may
1028 also affect test results. The coagulation mechanism, however, does not influence the bleeding time
1029 unless there is a severe deficiency present.
1030
1031 Procedure:
1032
1033 1. Make a finger puncture (deeply enough to ensure a free flow of blood).
1034 2. Record the time.
1035 3. At 30 second interval, remove the drops of blood with a filter paper.
1036 4. When blood ceases to flow, record the time.
1037
1038 Normal Value: 1 – 3 minutes
1039
1040 Clotting Time is the time elapsed between the placing of the drops of blood on the slide and the
1041 observance of fibrin thread. It is the time when the clot is formed firmly on the slide.
1042
1043 Procedure:
1044
1045 1. Make a finger puncture (deeply enough to ensure a free flow of blood).
1046 2. Wipe away the first two drops of blood.

90 _______Version 1.0
1047 3. Place several drops of blood on the slide, start to note the time.
1048 4. At 15 second interval, draw the lancet through a drop of blood.
1049 5. When the lancet picks up fibrin threads and drags them along, record
1050 time.
1051
1052 Normal Value: 2 – 5 minutes
1053
1054
1055 Prothrombin Time (PT) is a useful screening procedure for the extrinsic coagulation mechanism
1056 including the common pathway. The PT will also be prolonged when the fibrinogen concentration is
1057 less than 80 mg/dl and in cases of dysfibrinogenemia. The PT is frequently used to follow the
1058 course of oral anticoagulant therapy.
1059
1060 note: Centrifuge citrated tube with patient’s blood for 15 minutes.
1061
1062
1063 Activated Partial Thromboplastin Time (APTT) is a most useful procedure for routine
1064 screening of coagulation disorders in the intrinsic system, for detecting the presence of circulating
1065 anticoagulants, and for monitoring heparin therapy.
1066
1067 note: Centrifuge citrated tube with patient’s blood for 15 minutes.
1068
1069
1070
1071
1072
1073 Erythrocyte Sedimentation Rate (ESR) is a nonspecific measurement used to detect and
1074 monitor an inflammatory response to tissue injury in which there is a change in the plasma
1075 concentration of several proteins. This procedure, very simply, consists of allowing a specific
1076 amount of blood to sit in a vertical position for a period of time. The distance, in millimeters, that
1077 the red cells fall during this time period is the erythrocyte sedimentation rate and is reported in
1078 mm/hr.
1079
1080 Procedure:
1081 1. Get materials for a venipuncture. Make a venipuncture and collect 2ml of
1082 blood.
1083
1084 2. Mix by inverting the tube 3-4 times.
1085
1086 3. Insert the pipette through the pierceable stopper. The blood will
1087 automatically rise to zero.
1088
1089 4. It is absolutely essential that the pipette makes firm contact with the bottom
1090 of the tube.
1091
1092 5. Place the tube with pipette in the rack provided. Let it stand for 1 hour.
1093
1094 6. In exactly 1 hour, record the number of mm the cells have fallen.
1095

93 _______Version 1.0
1096 Normal Value

1097 Male: 0 - 10 mm/hr
1098 Female: 0 -20 mm/hr
1099
1100
1101 Reticulocyte Count is an important diagnostic tool. It reflects the amount of effective red blood
1102 cell production taking place in the bone marrow. A decreased reticulocyte count is found in aplastic
1103 anemia and in conditions in which the bone marrow is not producing red blood cells. Increased
1104 reticulocyte counts are found in hemolytic anemia, individuals with iron deficiency anemia
1105 receiving iron therapy, thalassemia, sideroblastic anemia, and in acute and chronic blood loss.
1106
1107
1108
1109 A. Test Tube Method ( Kobe)
1110
1111 Procedure:
1112 1. The test tube is pre-dosed with 50 ul staining solution. 50 ul whole
1113 blood, or 50 ul capillary blood from EDTA tube is added to this staining
1114 solution.
1115 2. Then the tube is closed with the attached stopper and mixed gently.
1116 3. Approximately 20-30 minutes after test insertion it is mixed again and
1117 then the smear can be made.
1118 4. It has to dry and to be counted within 1 hour.
1119
1120
1121
1122 Computation:
1123
1124
1125 # of reticulocytes seen x 100 = %
1126 1,000 erythrocytes
1127
1128
1129 Normal Values: Adults - 1% to 2%
1130 Infants - 4% to 8%
1131
1132
1133
1134 Blood Smear for Malaria Parasite (BSMP)
1135
1136
1137
1138 A. Preparation for blood smears for malaria
1139
1140
1141 Procedure:
1142
1143 1. Before extracting blood, ask first the patient’s for details (Name, Age,
1144 History of travel and Address)

96 _______Version 1.0
1145
1146 2. Clean the 3rd and 4th finger from the thumb with alcohol swab, using
1147 firm strokes to remove the dirt and grease from the finger. Air-dry the
1148 finger. Use sterile lancet, puncture the ball of the patient’s finger. Apply
1149 gentle pressure to the finger to express the first drop of blood and
1150 wipe it with dry cotton.
1151
1152 3. Apply gentle pressure to the finger then collect 3 small drops of
1153 blood on one side of a clean slide and 1 small drop next to the 3 drops,
1154 leaving some space between the thick and thin smears to be made.
1155 Handle clean slides only by edges. Wipe the remaining blood away
1156 from the patient’s finger with dry, clean cotton.
1157
1158 4. Make a thin smear first. Place slide on flat surface, firm surface.
1159 Bring down a second slide(spreader) on the 1 small drop at an angle of
1160 45 degrees, allow the blood to run along its edge.
1161
1162 5. Firmly push the angled slide away from the blood towards the end
1163 of the slide.
1164
1165 6. After spreading the thin smear, make a thick smear. With the corner
1166 of the second slide, quickly join the drops of blood, and spread them in
1167 a circular motion until it is about the size of a centavo coin. The
1168 thickness should be such that it is just possible to see newsprint
1169 through it.
1170
1171 7. Using a lead pencil, label the smear with name or number of the
1172 patient and date on the thick portion of the thin film. Air dry slide on a
1173 flat, level position, protected from insects, dust and extreme heat.
1174
1175 8. Fix the thin smear with methanol by using dropper or by dipping it
1176 in the solution for a few seconds. Airs dry the smear. Do not fix the
1177 thick smear.
1178
1179 9. Stain thick and thick smears with Giemsa or Wright’s stain for 10-15
1180 minutes then wash under running tap water.
1181
1182 (10% Giemsa stain preparation: 1 part + 9 parts distilled water)
1183
1184 10. Air dry smears in a vertical position then examine under oil
1185 immersion.
1186
1187 Computation in THICK FILM:
1188
1189 a) If > 100 parasite: count up to 200 WBC
1190
1191 number of parasites counted x 8000
1192 200 WBC
1193
1194 b) If < 100 parasite: count up to 500 WBC

99 _______Version 1.0
1195
1196 number of parasites counted x 8000
1197 500 WBC
1198
1199
1200 Computation in THIN FILM:
1201
1202 Number of parasites x 5,000,000
1203 20 fields x 250 RBCs
1204
1205 Reporting:
1206
1207 NMPS - NO MALARIAL PARASITE SEEN
1208
1209
1210 P. falciparum
1211 -Trophozoites only F
1212 -Trophozoites and gametocytes F+g
1213 -gametocytes only Fg
1214
1215
1216 P. vivax
1217 -any/ all stages seen V
1218
1219 P. malariae
1220 -any/all stages seen M
1221
1222 Mixed infection VFg, FM, VMFg
1223
1224
1225
1226 PERIPHERAL BLOOD SMEARS and SAVE SMEARS:
1227
1228 Procedure:
1229
1230 1. Collection of specimens through prick method.
1231 2. Proper smearing and labelling of smears. Make at least 3 to 4 smears.
1232 3. Ask the patient or Nurse if the reader of the smear is Pathologist or Hematologist.
1233 4. Stain the slides in Wright’s stain properly.
1234 5. Air dry the slides.
1235 6. Make a slide pouch and include the following details: (Name, Age, Sex, Room and
1236 Accommodation, prepared by, verified by, Recorded by and Reader of the smear.)
1237 7. The slides should be verified by another MedTech
1238 8. Record the details in PBS logbook located in Histopathology area.
1239 9. Place the slides in unread area if the reader is pathologist.
1240 10. Contact the designated Hematologist if they are the preferred reader then place the smears on
1241 slide storage in Hematology Section.
1242
1243

102 _______Version 1.0
1244
1245
1246
1247
1248
1249 Blood Typing (ABO and Rh)
1250
1251
1252 A. Tube Method
1253
1254 Procedure:
1255 1. Fresh drawn sample from the patient into EDTA anticoagulant tube.
1256 2. Label each tube with letters A, B, D for forward typing and KAC, KBC
1257 for reverse typing.
1258 3. Prepare for 5% red cell suspension (NSS + red cell until cherry
1259 red is attained)
1260
1261 Cell/Forward typing:
1262 a. Place 1 drop of 5% patient’s red cell suspension in tubes labeled
1263 A, B, D.
1264 b. Add 1 drop of anti-A sera in tube A
1265 c. Add 1 drop of anti-B sera in tube B
1266 d. Add 1 drop of anti-D in tube D.
1267
1268 Backward /Reverse typing:
1269 a. Place 2 drops each to tubes labeled KAC, KBC of patient’s
1270 serum/plasma
1271 b. Add 1 drop of Known A Cell to tube KAC
1272 c. Add 1 drop of Known B Cell to tube KBC
1273
1274 4. Mix and centrifuge for 45 seconds.
1275 5. Read results and confirm it with another Med Tech on duty to validate
1276 blood typing result.
1277
1278 6. Record results in blood typing worksheet according to grades of
1279 agglutination.
1280
1281 7. The performing Med Tech will sign in the blood typing worksheet
1282 countersigned by the med tech that validated the blood typing result.
1283
1284
1285
1286
1287
1288
1289

105 _______Version 1.0
1290
1291
1292
1293
1294
1295 Interpretation and Manner of Reporting:
1296
1297 Presence of agglutination: + (positive) - (negative)
1298
1299
1300
Forward Typing Reverse
Typing
Anti-A Anti-B Known A Cell Known B Cell
Blood Type
A + - - +
B - + + -
O - - + +
AB + + - -
1301
1302
1303 PROPER IDENTIFICATION OF PATIENTS
1304
1305 Proper identification of patients must be followed. This can be ensured with proper labeling
1306 of specimen. These labels must contain the following information:
1307 Patient Name
1308 Age
1309 Sex
1310 Room Number
1311 Date and Time of Collection.
1312
1313 Information on the label and information on the request form should coincide. The type of
1314 specimen (urine, stool, semen and other body fluids) must also be written on the label. The
1315 test to be done must be indicated on the request form.
1316
1317 To ensure proper identification of patients the following must be strictly followed by the
1318 phlebotomist:
1319
1320 1. Check if patient identification tag matches with the electronic request encoded by the
1321 nurse on duty.
1322 2. Ask and let the conscious patient say his/her full name before blood
1323 extraction.
1324 3. Check the identity of unconscious patients from NOD or watcher prior to extraction.
1325 4. If identity is unknown assign a temporary identification.
1326 5. In situations where it is not feasible for a patient to have an identification bracelet
1327 on their person, for example burn patients, the phlebotomist will obtain the identification
1328 of the patient from the attending nurse or prior to blood collection.

108 _______Version 1.0
1329 6. Pediatric patients must be identified by their parent/guardian.

1330
1331
1332
1333
1334 EXTRACTION
1335 BLOOD COLLECTION GUIDELINES

1336 1. The phlebotomist (blood collector) will collect blood samples ordered by the
1337 physician provided the sample can be collected in an evacuated tube, microtainer
1338 or syringe.
1339 - A family member or authorized person is allowed to accompany the patient/client
1340 during extraction of blood, if and when requested.
1341
1342 2. All requests for blood examinations must be paid or approved by billing section/
1343 cashier/ pharmacy before any examination will be carried out.
1344 3. The phlebotomist is limited to drawing from approved blood collection sites (see Site
1345 Selection for Blood Collection).
1346 4. Clean the venipuncture site with 70% alcohol or 1% iodine.
1347 5. Apply tourniquet several inches above the puncture site.
1348 6. Never leave the tourniquet longer than one minute.
1349 7. The needle as it enters the skin should be positioned at approximately 15 degrees to
1350 the site with the bevel up.
1351 8. After withdrawing the needle, a ball of cotton secured with a plaster is placed over
1352 the wound to stop the bleeding.
1353 9. Check the condition of the patient before he/she leaves the extraction area.
1354 10. Syringes and needles must be used only once. Dispose the used syringe and
1355 needle in a thick plastic container with hypochlorite and disinfectant.
1356
1357 11. Transfer drawn blood to appropriate tubes taking precaution to avoid hemolysis of
1358 blood sample.
1359 12. Label the tube with complete name of patient, date of extraction, initial or other
1360 identifier of the phlebotomist.
1361
1362 RELEASING OF RESULTS

1363 TURN AROUND TIME OF RELEASING OF RESULTS
1364
1365 STAT PROCEDURE:
1366 30 MINUTES:
1367 CBC
1368 BLOOD TYPING
1369 CLOTTING TIME AND BLEEDING TIME
1370
1371 1 HOUR:
1372 PROTIME

111 _______Version 1.0
1373 APTT
1374 ESR
1375
1376
1377 TAT PROCEDURE: 1 HOUR- 2 HOURS: ALL TESTS
1378
1379
1380
1381 SPECIMEN AND RECORDS RETENTION

1382
MATERIAL/RECORD PERIOD OF RETENTION
Quality Control Records 2 years
Daily Maintenance Charts 1 year
Raw data and Requisitions 2 years
Worksheet/Reports 2 years
SPECIMENS
Coagulation Plasma 48 hours
EDTA blood 48 hours
Peripheral Blood Smears (Normal) 7 days
Peripheral Blood Smears (Abnormal) 1 year
Slides Indefinitely
1383
1384
1385 CRITICAL VALUES
1386
NAME OF TEST LOW HIGH
Platelet Count <100x109/L >500x 109/L
Hemoglobin Count < 80 g/dL
WBC < 2.0 x 109/L
Prothrombin Time > 14 seconds
INR >6.0
1387
1388

114 _______Version 1.0
1389
1390
1391
1392
1393
Laboratory Specimen Schedule Releasing of Other

Procedure Container of official result Information
and Running
Patient of the
Preparation tests
Hematology
CBC
CBC/Platelet
Platelet Count Whole Blood Within 1-2
Platelet/ (WB), Daily hours
Hematocrit 2 ml,
Hemoglobin (Hgb) lavender top
tube, NPP 1.STAT Request and
Hgb/Hct
result will be
RBC
prioritized.
WBC
Differential Count
WBC & Differential
Ct.
Whole Blood Daily After 2 hours
ESR <2 ml NPP
2. Hemolyzed
WB 3-5 specimen may
BSMP drops, direct Daily Within 2 Days interfere with the
smear, NPP result.
WB, 2 ml
Reticulocyte Ct. lavender top Daily
tube, NPP
Clotting & Bleeding WB, NPP
Time (CT/BT) Daily
Protime WB, 2 ml Within 1-2
APTT blue top Daily hours
tube, NPP
Whole Blood
(WB),
Blood Typing 2 ml, Daily
lavender top
tube, NPP
1395 Legend: NPO (no food and water intake), NPP (no patient preparation), WB (whole blood)
1396

117 _______Version 1.0
1397
1398
1399
1400
1401
1402 WORKFLOW IN HEMATOLOGY SECTION

1403
PRE ANALYTICAL
Receiving of Test Request

Identifying the patient and extraction of blood
Pass the sample to the section for testing
ANALYTICAL
Identifying the patient and patient’s sample

Processing the sample by request
(CBC, BLOOD TYPING, PT, APTT ETC)
Double checking of results
Verification of results by other Medtechs
POST ANALYTICAL
Releasing of results of it’s designated

turn around time.
1404
1405
1406
1407

120 _______Version 1.0
1408
1409
1410
1411
1412
1413
1414
1415
1416 SAFETY MEASURES IN HEMATOLOGY SECTION
1417
1418 I. SAFETY IN THE LABORATORY
1419
1420 Personnel working in the laboratory maybe exposed to risks from various chemicals,
1421 infectious materials, fire hazard, gas leak, etc. The environment is also at risk of being
1422 contaminated by hazardous materials used and wastes generated in the laboratory.
1423
1424
1425
1426 II. PSYCHOLOGICAL SAFETY
1427
1428 Safety begins with the recognition of hazards and it is achieved through the application of
1429 common sense, a safety focused attitude, good personal behavior, good housekeeping in all
1430 laboratory works and storage area and the continual practice of laboratory techniques.
1431
1432 The following are preventive measures and practices of personnel in the laboratory to lessen
1433 the unnecessary exposure to health and safety risks.
1434
1435 1. Annual safety review
1436 2. Safety drill
1437 3. General Consciousness
1438 4. Appropriate orientation to safety rules
1439 5. Safe work environment
1440
1441 III. SAFETY AWARENESS FOR LABORATORY PERSONNEL
1442
1443 1. Label all storage areas, refrigerators, etc., appropriately, and keep all
1444 chemicals in properly labeled containers.
1445 2. Date all bottles/ reagents when received and when opened.
1446 3. Note special storage conditions.
1447 4. Post warning signs for unusual hazards such as flammable materials,
1448 biohazards or other special problems.
1449
1450 Blood and body fluids are considered potentially infected with blood borne pathogens. Safety
1451 awareness is meant to minimize exposures to laboratory personnel skin, eyes, mucous
1452 membrane or parental contact with blood or other potentially infectious materials.
1453
1454
1455

123 _______Version 1.0
1456
1457
1458
1459
1460
1461 IV. Precautions include:
1462 Appropriate barriers such as gloves, gown, masks and goggles must be worn by the Medical
1463 Technologist to prevent skin, eye exposure when contact with blood or other body fluids of
1464 patients. Laboratory personnel must have hepatitis B vaccination upon hiring.
1465
1466 Universal precautions to be followed by laboratory personnel:
1467 1. Wearing of gloves when performing phlebotomy especially when the medical technologist
1468 has open wounds.
1469 2. Hand washing after removal of gloves or after any contact with, blood or body fluid in
1470 between patients is a must. Hand washing area must be accessible for collection and
1471 processing of specimen.
1472 3. Washing and reusing of gloves between patients is discouraged because microorganisms
1473 that adhere to gloves are difficult to remove
1474 4. Laboratory gown must be removed before leaving the laboratory area.
1475 5. Eating, drinking, smoking, applying heavy cosmetics or touching contact lenses is strictly
1476 prohibited in the laboratory work area.
1477
1478
1479
1480 V. Personal Safety
1481
1482 1. Safety goggles should be worn in the laboratory when handling blood and other body fluids
1483 to protect the eyes from chemical and other body fluids splash.
1484 2. Laboratory coat should be worn in the laboratory.
1485 3. The lab coat is designed to protect the clothing and skin from chemicals and other body
1486 fluids that may be spilled or splashed.
1487 4. Appropriate closed-toed shoes should be worn in the laboratory.
1488 5. Never pipette anything by mouth in the laboratory.
1489 6. Never store food in a refrigerator where hazardous and infectious materials are stored.
1490 7. Wash hands as soon as possible after removing protective gloves.
1491 8. Wash hands before leaving the laboratory.
1492
1493
1494
1495
1496 VI. Disinfectants used by laboratory
1497
1498 17.6.1 Heat sterilization – 2500 °C for 15 minutes
1499 17.6.2 10% Lysol
1500 17.6.3. 10% hypochlorite

126 _______Version 1.0
1501
1502
1503
1504
1505
1506
1507 VII. Safety Equipment
1508
1509 1. The laboratory must have safety shower, wash station and fire extinguisher which must be
1510 periodically tested and inspected for proper operation.
1511
1512 2. If possible, first aid supplies must be available for the laboratory personnel.
1513
1514 3. Mechanical pipetting devices must be used for manipulating all types of liquid. Mouth
1515 pipetting is strictly prohibited.
1516
1517 4. Fume hoods should be provided for bacteriology department.
1518
1519 VIII. Biological safety
1520 1. All samples and other body fluids should be collected, transported,
1521 2. handled and processed using strict precautions.
1522 3. Gloves, gowns, goggles and face protection must be used if splash or
1523 4. splattering is likely to occur.
1524 5. Specimen should remain capped and centrifuge machine should be closed during the
1525 process, because biologic specimen could produce finely dispersed aerosol that are a risk
1526 source of infection.
1527 6. Strict implementation of proper labeling of infectious specimen must be followed.
1528 7. Biological safety cabinet should be installed in a strategic place to facilitate manipulation of
1529 infection.
1530 8. Any blood, body fluid or other potentially infectious material spills must be cleaned up and
1531 the area or equipment must be disinfected immediately.
1532
1533
1534
1535
1536 IX. Safety Measure in cleaning spill infectious materials:
1537
1538 1. Wear appropriate protective materials when cleaning.
1539 2. Use mechanical devices to pick up broken glasses.
1540 3. Absorb the spill with paper towel, gauge pack or tissue.
1541 A. Disinfect the spill site using 10% Lysol or 10% hypochlorite for 30 minutes to
1542 1 hour.
1543 B. Rinse the spill site with water.
1544 C. Dispose all materials used in appropriate biohazard container.
1545
1546 X. Safety against exposure to toxic chemicals

129 _______Version 1.0
1547 1. Laboratory must have a chemical hygiene plan.

1548 2. Maintain and update inventory periodically of all hazardous substances used in the
1549 workplace.
1550 3. Proper labeling of containers and posting of warning signs.
1551 4. Laboratory must be provided with fume hood when reagent preparation is done.
1552
1553
1554
1555 XI. Electrical Safety
1556 1. Lock out/ try out malfunction electrical or mechanical equipment and machine until
1557 serviced.
1558 2. Report to the Chief Medical Technologist / electrician any small
1559 shocks. Unplug and tag equipment until serviced.
1560 3. In case of severely shocked person who cannot let go off the instrument, unplug it without
1561 touching the person using non-conductive materials like wood.
1562
1563
1564 XII. Fire Safety
1565 1.Laboratory personnel should know the location and type of portable fire extinguisher near
1566 the work area and know how to use it.
1567 2.Purchase and store flammable reagents in the smallest quantities available.
1568 3.Do not store incompatible reagents together (e.g., acids with flammables)
1569 4.Be aware of the condition and location of the fire extinguishers.
1570
1571 XIII. Housekeeping
1572
1573 1. Eliminate safety hazards by maintaining laboratory areas in good state of order.
1574 2. Maintain clear passages to laboratory exits.
1575 3. Wipe down bench tops and other laboratory surfaces after each use with an appropriate
1576 cleaning or disinfecting agent.
1577 4. Keep laboratory floor dry at all times.
1578 5. Immediately attend to spills of chemicals or water, and notify other lab workers of potential
1579 slipping hazards.
1580
1581
1582
1583 XIV. Disposal of infectious/ hazardous specimen or materials used.
1584
1585 A. Disposal Technique
1586 1. Landfill buried
1587 2. Recycling
1588 B. Chemical wastes are those expired reagents but these are rare
1589 cases in the laboratory.
1590 a. Strong acid or base should be neutralized first before disposal.
1591 b. Solid chemical waste must be buried in landfill.
1592 c. Other liquid waste must be collected in appropriate containers

132 _______Version 1.0
1593 and segregated properly or return to the supplier.

1594 d. Blood, body fluids and pathological tissue including media agar
1595 from Bacteriology Department must be pretreated before
1596 disposal.
1597 e. Syringe, needle, and disposable plates used by Bacteriology
1598 Department must be pretreated before disposal.
1599 f. Color coded trash bins must be provided for proper disposal of waste.
1600  Black – general waste (dry noninfectious)
1601  Green – general waste (wet noninfectious)
1602  Yellow– infectious and pathologic tissue specimen
1603  Red – sharps
1604
1605 C. Categories of waste
1606 a. General waste – domestic type of waste from packing materials
1607 which is noninfectious.
1608 b. Pathologic and infectious waste – tissues, organ, blood and body
1609 fluid of human together with related swabs for culture, blood bags and
1610 infected gloves, mask and laboratory gown.
1611 c. Sharps – needle, syringe, scalpel and broken glasses.
1612 d. Chemical – solid and liquid chemical for laboratory use, cleaning,
1613 housekeeping and disinfection procedures.
1614
1615 XV. Emergency Procedures
1616
1617  Be familiar with the emergency evacuation plan.
1618  Be evacuated plan must be posted in the laboratory.
1619  Be familiar with the location, use and limitations of the safety shower, eye wash
1620 station, and spill clean-up materials, first aid kit, fire alarm and fire extinguisher.
1621  Maintain a clear path to all safety equipment at all times.
1622
1623
1624
1625
1626 XVI. Waste Disposal
1627
1628 The chemical waste produced by the machine is disposed together with the other chemical
1629 wastes as per implemented by the Hospital Waste Management Committee.
1630
1631 LABORATORY WASTE:
1632
1633 CHEMICAL WASTE
1634 a. HAZARDOUS (flammable, corrosive, carcinogenic toxic)
1635 b. NON-HAZARDOUS (Sugar, amino acids, organic and
1636 Inorganic salts)
1637
1638 METHOD OF DISPOSAL:

135 _______Version 1.0
1639  Toxic chemical waste must undergo pre-treatment process prior to disposal such as
1640 incineration or autoclaving.
1641  Non-hazardous chemical disposed directly to the sink or treated as ordinary
1642 domestic waste.
1643
1644
1645 COLOR –CODING SCHEME CONTAINERS
1646
COLOR OFF CONTAINER/BAG TYPE OF WASTE
Black Non-infectious dry waste
Green Non-infectious
Yellow Infectious ad Pathological waste
Yellow with Black band Chemical waste including those with heavy metal
Orange Radioactive waste
Red Sharps and pressured container
1647
1648
1649 PROCEDURES FOR LABORATORY CHEMICAL WASTE DISPOSAL
1650
1651 In an effort to create a more effective, cost efficient and environmentally friendly waste
1652 management system on campus, we are proposing the following procedures for the
1653 disposal of hazardous chemical laboratory waste.
1654
1655 Procedures for disposal of hazardous waste
1656
1657 Segregate materials properly. If possible, also segregate within categories. Unless the
1658 materials are used together during the course of an experiment, segregate all waste. Do
1659 not mix chemicals together in one container for convenience’s sake. We cannot stress
1660 strongly enough that different chemicals have different disposal methods.
1661
1662 Label all containers with the group name from the chemical waste category and an itemized
1663 list of the contents. For example, do not label a container simply `Corrosive Liquids'.
1664 List each chemical in the container, including all solvents used. List by full name only.
1665 Abbreviations, initials or chemical formulas are not acceptable labels.
1666
1667 Liquid dumps are intended for liquids only. Do not place glass or plastic items, such as tubes
1668 or pipettes, into solution dumps. If these items require disposal, package them
1669 separately. (Keep plastic and glass waste separate.) Any waste containing PCB's must
1670 not be placed in waste dumps. Special procedures are in place for disposal of PCB's and
1671 it is important to keep the volumes small.
1672
1673
1674 Packaging and containers:
1675

138 _______Version 1.0
1676 All waste must be appropriately packaged for the waste category. For example: corrosive
1677 waste should be stored in non-metallic containers.
1678
1679 All liquid waste must be stored in leakproof containers with a screw- top or other secure lid.
1680 Snap caps, mis-sized caps, parafilm and other loose-fitting lids are not acceptable. Solid
1681 debris must be placed in plastic bags. Do not place chemical or other non-biohazardous
1682 material in a biohazard bag. Biohazard bags are for biohazardous material only. Any
1683 waste disposed of in these bags will be treated as such. For the disposal of vials
1684 containing liquid scintillation fluid, place plastic and glass scintillation vials in separate
1685 boxes. Plastic vials can be placed loose in a cardboard box lined with a garbage bag.
1686 Glass vials should be placed in trays, then placed in a box. Attach a completed "Waste
1687 Scintillation Fluid" label (include all requested information). Please do not "hide" items
1688 for disposal in the boxes; the boxes are opened for final disposal and unexpected items
1689 can create a safety hazard to personnel.
1690
1691 Sharps (needles) must be well packaged to avoid any possibility of puncturing personnel.
1692 Used needles should be disposed of in a commercial sharps container or other suitable
1693 heavy plastic container. With the lids secured, place the containers into a cardboard
1694 box and seal with tape. Label "Sharps for disposal".
1695
1696 Importance of segregating waste:
1697
1698 It is very important that hazardous materials are segregated into the proper categories.
1699 Different hazardous waste has different disposal methods. These disposal methods are
1700 also reflective in the cost of disposal. For example, waste which has the potential for
1701 reuse or recycling, such as non-halogenated organic waste is less expensive to dispose
1702 of than waste which is destroyed in a chemical incinerator, such as halogenated organic
1703 waste. There is also a tremendous environmental advantage to reusing and recycling
1704 chemical waste. When categories are mixed, the disposal method is always for the
1705 "more hazardous" chemical. To use the above examples, when a few liters of a
1706 halogenated solvent is mixed with a drum of non-halogenated solvent, the entire
1707 volume must be considered halogenated waste. The contents of the drum, including the
1708 recyclable waste, will be destroyed in an incinerator.
1709
1710
1711 Importance of proper labelling:
1712
1713 Waste that is picked up from a lab is not sent to the final waste disposal facility in the
1714 original container. For example, a 4L bottle of waste lead solution is bulked into a 205L
1715 drum with lead solution from other labs. This is either done on-site at our campus
1716 transfer station or, in the case of larger volumes, at a waste brokers transfer station.
1717 Little on site testing is done before bulking. We depend on the labels you place on the
1718 containers. If a container is mis-labelled or incompletely labelled, that is, all the

141 _______Version 1.0
1719 contents are not listed, we may inadvertently place the waste in the wrong bulking
1720 drum. With the many hazardous combinations of chemical incompatibility possible,
1721 this could have serious implications. The result could be the release of noxious fumes,
1722 formation of more hazardous compounds, fire or even explosion.
1723
1724 It is also important when shipping hazardous waste to the disposal companies that the
1725 exact contents of the containers are known. Transportation of Dangerous Goods (TDG)
1726 regulations require that the transport of hazardous materials include detailed shipping
1727 documents. Also, although we do not test the container's contents, the waste disposal
1728 companies do extensive testing of all waste to determine the proper waste disposal
1729 method. Surprises in the containers will result in a surcharge levied onto the cost of
1730 disposal. Besides the unnecessary cost expenditure, this can also result in an
1731 embarrassing situation when it appears that we are hiding "more hazardous" waste in
1732 with other materials.
1733
1734 Chemical Waste Categories:
1735
1736 AVOID MIXING WITHIN, AS WELL AS, BETWEEN CATEGORIES. SEGREGATE WASTE
1737 WHEREVER POSSIBLE.
1738
1739 CONSULT WITH SAFETY AND ENVIRONMENTAL SERVICES BEFORE MIXING WASTE.
1740
1741 Organic waste – Phenol
1742
1743 Examples: any waste generated which contains phenol or phenol mixtures, including
1744 phenol-acid mixtures and phenol-chloroform mixtures.
1745
1746 Organic waste – Halogenated
1747
1748 Examples: any halogenated organic waste or any mixtures containing halogenated
1749 organic waste, except those containing phenol. Including chlorinated oils such as
1750 cutting oil. Examples: chloroform, 1,1,1-trichloroethane, methylene chloride
1751
1752 Organic waste – Corrosive
1753
1754 Examples: non-halogenated solvent-acid mixtures, non-halogenated organic acids such
1755 as acetic acid, trichloroacetate, acetic anhydride.
1756
1757 Organic waste - Non-halogenated plus water
1758
1759 Examples: non-halogenated solvent-water mixtures or non-halogenated solvents with
1760 greater than 20% water such as 80% ethanol.
1761

144 _______Version 1.0
1762 Organic waste - Non-halogenated

1763
1764 Examples: acetone, toluene, acetonitrile, ethyl acetate, heptane, hexane, alcohol with
1765 less than 20% water.
1766
1767 Corrosive waste – Acid
1768
1769 Examples: hydrochloric acid, sulph uric acid, nitric acid, chromic acid, hydrofluoric
1770 acid.
1771
1772 Corrosive waste - Inorganic/acid mixture
1773
1774 Examples: iron III chloride, aluminium trichloride, mercury compounds dissolved in
1775 acid, other inorganic compounds dissolved in acid.
1776
1777 Corrosive waste - Alkali
1778
1779 Examples: hydroxides, phosphates, ammonia.
1780
1781 Corrosive waste - Alkali mixture
1782
1783 Examples: compounds dissolved in hydroxides, phosphates, ammonia.
1784
1785 Waste Oil
1786
1787 Examples: used pump oil, crankcase oil, hydraulic oil. Excluding halogenated oils such
1788 as cutting oils.
1789
1790 Reactive waste
1791
1792 Examples: air and water sensitive materials such as Grignard reagent, alkaline metals,
1793 reactive halides.
1794
1795 Waste oxidizers
1796
1797 Examples: all nitrates, potassium dichromate, metal peroxides such as chromium
1798 dioxide.
1799
1800 Inorganic waste
1801
1802 Examples: heavy metal compounds and solutions such as those of mercury, lead,
1803 copper and zinc (except those dissolved in acid), other inorganic compounds not
1804 covered by another category.

147 _______Version 1.0
1805
1806 Hazardous waste –Other:
1807
1808 Examples: waste not covered by any other category. All waste in this category must be
1809 segregated. No mixtures. Does not include radioactive waste, biohazardous waste,
1810 highly hazardous waste, explosive waste or surplus chemicals.
1811
1812 Materials not covered under these procedures:
1813
1814 Radioactive waste
1815
1816 Follow procedures in place for the disposal of radioactive waste.
1817
1818 Biohazardous waste
1819
1820 Follow procedures in place for the disposal of biohazardous waste.
1821
1822 PCB waste
1823
1824 Includes any waste containing or suspected of containing PCB's. Follow procedures in
1825 place for the disposal of PCB's.
1826
1827 Explosive or other highly hazardous materials
1828
1829 Examples: peroxide formers such as aged ether, di and tri -nitro compounds, old flares,
1830 azides. These materials require special disposal. Consult the safety office for
1831 arrangements.
1832
1833 Surplus chemicals
1834
1835 Examples: any chemical which is no longer used or needed but which is still in good,
1836 usable condition. Consult the safety office for an assessment.
1837
1838
1839
1840
1841
1842
1843
1844
1845
1846
1847

150 _______Version 1.0
1848
1849
1850
1851
1852
1853
1854 NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME
1855
1856 Procedure:
1857
1858 1. National Kidney Transplant Institute National Reference Laboratory usually sends the invitation
1859 for the annual quality assurance program for Blood count during first quarter of the new year, the
1860 deadline for registration usually is April-May.
1861
1862 2. Hematology Section Head will send a letter to COO for the requisition of funds for the NEQAS of
1863 Hematology.
1864
1865 3. Once approve, fill up the registration form and encash the check to deposit in their bank account.
1866
1867 4. After depositing, send the registration form along with the original deposit slip and indicate the
1868 bank branch where the transaction was done.
1869
1870 5. NKTI usually send the NEQAS samples along with the receipt from September to November of
1871 that year.
1872
1873 6. Hematology head records the receiving of specimen and the NEQAS samples should be tested
1874 within 2 weeks after receiving.
1875
1876 7. The NEQAS sample results should be send immediately before the deadline.
1877
1878 1. The NEQAS certificate along with the results will be send to the hospital after a few months.
1879
1880
1881
1882
1883
1884
1885
1886
1887
1888
1889
1890

153 _______Version 1.0
1891
1892
1893
1894
1895 CHAPTER 5
1896 REFERENCES
1897
1898 Henry, John Bernard. Clinical Diagnosis and Management by Laboratory Methods. W.B. Saunders
1899 Company, 17th ed.,1984
1900
1901 College of American Pathologist
1902 Clinical Diagnosis and Management by Laboratory Medicine
1903
1904 Sysmex Automated Hematology Analyzer Manual
1905 SYSMEX XN – 550
1906
1907 Sysmex Automated Blood Coagulation Analyzer Manual
1908 SYSMEX CA - 600
1909
1910 ABX Diagnostic, ABX Pentra XL 80 User Manual
1911
1912
1913

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1 DAVAO MEDICAL SCHOOL FOUNDATION, INC.

2 DR. A. GAHOL AVENUE, BAJADA, BRGY. 19 – B, DAVAO CITY

ERIKA MINA P. CELESTE, RMT (ASCPi) ________________________________

Reviewed by: Effective Date:

AGATHA LAARNI C. LACUNA, RN ________________________________

Manual No. ANC- ____ -M01

OSCAR P. GRAGEDA, MD, FPSP

VICTOR D. ESPINO, MD, FPUA, FPCS

OLIVER G. VICTORIANO, DBA

ATTY. ALBERTO RAFAEL L. APORTADERA

13 This Procedures Manual is contributed by the following Laboratory Personnel:

15 ERIKA MINA P. CELESTE

2 GENERAL POLICIES FOR SECTION 21

3 GENERAL STANDARD OPERATING PROCEDURES

 Specimen and Records Retention

26  Hematology Vision and Mission

Supersedes: Previous Procedures Manual of the Hematology Section

Version No.: 1.0

Authored by: Recommended by:

ERIKA MINA P. CELESTE, RMT (ASCPi) OLIVER G. VICTORIANO, DBA

AGATHA LAARNI C. LACUNA, RN ATTY. ALBERTO RAFAEL APORTADERA

RANDY IAN J. ESPINOSA, PTRP

35 Hematology Unit Overview

Chapter 1: Section Overview| 2

85 DESCRIPTION OF KEY PERSONNEL

94 2. PRINCIPAL FUNCTIONS AND RESPONSIBILITIES:

96 1. Verifies or records identity of patients.

Chapter 1: Section Overview| 3

154 4. KEY ORGANIZATIONAL RELATIONSHIPS

159 5. QUALIFICATION GUIDE

Chapter 1: Section Overview| 4

170 6. WORKING CONDITION

179 II. MEDICAL TECHNOLOGY STAFF

Chapter 1: Section Overview| 5

247 3. KEY ORGANIZATIONAL RELATIONSHIPS

Chapter 1: Section Overview| 6

252 4. QUALIFICATION GUIDE

272 III. LABORATORY AIDE

274 1. PRINCIPAL FUNCTIONS AND RESPONSIBILITIES

Chapter 1: Section Overview| 7

297 2. KEY ORGANIZATIONAL RELATIONSHIPS

306 3. QUALIFICATION GUIDE

Chapter 1: Section Overview| 8

Supersedes: Previous Procedures Manual of the Hematology Section

Version No.: 1.0

Authored by: Recommended by:

Erika Mina P. Celeste, RMT (ASCPi) OLIVER G. VICTORIANO, DBA

AGATHA LAARNI C. LACUNA, RN ATTY. ALBERTO RAFAEL L. APORTADERA

RANDY IAN J. ESPINOSA, PTRP

Chapter 1: Section Overview| 9

348 Quality Management

350 Quality Assurance (QA)

Chapter 1: Section Overview| 10

383 CONSIDERATION OF CHOOSING A CONTROL SOLUTION

416 Proper Preparation of Quality Control Specimen

Chapter 1: Section Overview| 11

Chapter 1: Section Overview| 12

478 Proper handling and manipulation of machine is strictly observed. Calibration of

485 REAGENTS PROTOCOL

Chapter 1: Section Overview| 13

509  General Policy

Supersedes: Previous Procedures Manual of the Hematology Section

Version No.: 1.0