Laboratory Information and Courses from MediaLab, Inc.

The Silent Carrier form of alpha thalassemia results from one alpha chain loci deletion. Individuals who are silent carriers show no clinical disease and demonstrate normal results during routine laboratory testing. This form of alpha thalassemia is usually discovered upon family studies.

Alba MA. Clinical Immunohematology Laboratory Manual. Albuquerque, NM: UNM Health Sciences Center; 2008.Brecher MF, Leger RM, Linden JV, Roseff SD, eds. Technical Manual 15th ed. Bethesda, Md. AABB; 2005.Harmening DM. Modern Blood Banking and Transfusion Practices. 5th ed. Philadelphia, Pa: F.A. Davis Company; 2005.

Burtis CA, Ashwood ER. Tietz Textbook of Clinical Chemistry 2nd ed. WB Saunders; 1994.Doig, K. Rodak's Diagnostic Hematology. 3rd ed. WB Saunders Co; 2007.Harmening DM. Clinical Hematology and Fundamentals of Hemostatis. 5th ed. FA Davis; 2008Hoffman R, Benz EJ Jr., Shattil SJ, Furie B, Cohen HJ, Silberstein LE. Hematology Basic Principles and Practice, 2nd ed. Churchill Livingstone; 1995.McKenzie SB. Textbook of Hematology, 2nd ed. Williams and Wilkins; 1996.Miale JB, Laboratory Medicine Hematology, 6th ed. Mosby; 1982.Stiene-Martin EA, Lotspeich-Steininger CA, Koepke JA, Clinical Hematology Principles, Procedures, Correlations, 2nd ed. Lippincott; 1998.

The laboratory findings in this case represent classic findings seen in beta thalassemia minor including: erythrocytosis, decreased hemoglobin, normal hematocrit, normal RDW, and the presence of codocytes (target cells). This patient does have a mild anemia, but some patients with beta thalassemia minor have no anemia. Hemoglobin electrophoresis confirms this diagnosis, showing an increased Hb A2 level and decreased Hb A.In addition, the slightly increased iron and slightly decreased TIBC contradict a suspicion of iron deficiency. These chemistry results are typical for beta thalassemia, even though the red blood cells are microcytic and hypochromic.

The cerebrospinal fluid sample should be properly labeled with the tube number, patient's name and hospital number. The samples should be transported to the laboratory immediately.

Normal cerebrospinal fluid has the following characteristics:colorlessclearno clot presentspecific gravity of 1.006 - 1.008pH 7.3When the specimen is received in the laboratory, the macroscopic examination is performed immediately. The specific gravity examination may be optional in some laboratories.

In the cytospin procedure, use a high speed centrifuge to concentrate the cells on a slide in a uniform monolayer 6 mm in diameter. The monolayer distribution enhances the morphological appearance of the cells present.Allow the slides to dry in air for several minutes and then stain them with Wright-Giemsa stain. Cytospin slides may be placed in an automatic stainer, such as Hema-Tek, or stained manually.Perform a 100 or 200 cell differential and record the number of neutrophils, eosinophils, basophils, lymphocytes, monocytes, macrophages, and blasts cells.Pathologists must review any slide which has tumor cells, unidentified cells, or immature stages of cells, such as blasts.Since criteria for review may vary from one laboratory to another, be sure to check the requirements in your laboratory before reporting the differential.

Although the procedure is simple to perform, accurate results depend on careful adherence to manufacturer’s directions and adequate quality control. Normal and abnormal controls should be tested whenever a new lot of strips is opened, and at the frequency defined by the laboratory's procedure. If quality control results do not correspond to the published control values, the problem must be resolved before patient samples are tested. High levels of ascorbic acid (Vitamin C) in the urine may inhibit some reagent strip reactions, such as glucose, blood, bilirubin, nitrate and leukocyte esterase. The urine dipstick's package insert will provide information about potential interfering substances, including ascorbic acid. Intensely colored urine may make it difficult to correctly interpret color reactions on the dipstick. The affected tests should not be reported from the dipstick. It would be necessary to use an alternative method of testing if available.

False negative results occur when elements present in the urine interfere with either the enzymatic reaction or prevent the oxidation of potassium iodide. Examples of such substances include: large quantities of ketones aspirin ascorbic acid > 50 mg/dL with some reagent strips levadopa 5-hydroxyindoleacetic acid homogentisic acid sodium fluoride ( a preservative)A specific gravity higher than 1.020 may lower glucose reagent sensitivity, especially in the presence of a high urine pH. Exposing reagent strips to excess humidity may also reduce glucose reagent reactivity.Check the package insert of the reagent strips used in your laboratory for interfering substances that may affect glucose results.

Several manufacturers offer semi-automated instruments (dipstick readers) for reading reagent strips. Use of an instrument removes the subjectivity of visually interpreting color changes on reagent strips, and assures that tests will be read at the correct time. Transcription errors will also be avoided if the instrument is interfaced with the laboratory information system. The technology employed is based on the principle of reflectance, with the amount of light reflected being inversely related to the concentration of substances present. An example of reflectance is the light which is scattered after light strikes an unpolished surface. Since each component on the dipstick produces a different color reaction, the light source for each test must be at the appropriate wavelength. This is accomplished either by using filters or monochromatic light sources. The percent reflectance is determined by dividing the test reflectance by the calibration reflectance and multiplying by 100. Algorithms are used to change the results obtained into a linear relationship with concentration of analyte.

A routine reagent strip protein method, based on the principle of "protein error of indicators," produces a visible colorimetric reaction that is capable of detecting most instances of proteinuria.Traditionally, laboratories have used sulfosalicylic acid (SSA) to confirm all positive protein reagent strip results, but this practice is not as common in today's laboratories. SSA is a precipitation method that reacts with all forms of protein. However, any substance that is precipitated by acid will produce false-positive SSA results. This includes radiographic dyes, cephalosporins, penicillins, and sulfonamides. SSA may be used as a secondary protein detection method if the urine is highly alkaline (pH of 9.0 or greater) which would overwhelm the buffering capacity of the reagent on the protein reagent stick. SSA may also be used as an alternative protein detection method if the urine is highly colored so that the colorimetric reaction is masked on the reagent strip.

The product profile for Ictotest® points out that bilirubin is very light sensitive, so urine specimens should be protected from excessive light exposure and examined as quickly as possible when received in the laboratory. On standing, bilirubin, which has a goldish color, is oxidized to biliverdin, which is a green color. Many of the procedures used to detect bilirubin will not react with biliverdin, so false-negative results may occur if urine is not fresh when tested.

Record the test result that is associated with the color block that most closely matches the color of the test in the tube. Remember that the final color may not be the test result if the "pass through" phenomenon occurred. Test results should be recorded according to your laboratory's procedure. Laboratories may choose to record results as 1%, 2%, 3%, etc; 1+, 2+, 3+, etc; or 100mg/dL, 200mg/dL, 300mg/dL, etc. The result of the test in the top image is negative, and the result of the test in the bottom image, reported as a percentage, is 2%. (Note: Colors in the photograph may vary slightly from actual test colors.)

Smith KR, Fisher HC III, Hook, EW III: Prevalence of fluorescent monoclonal antibody-nonreactive Neisseria gonorrhoeae in five North American sexually transmitted disease clinics.J Clin Microbiol 34:1551-1552, 1996We compared a direct fluorescent monoclonal antibody (DFA) test with alternative enzymatic and fermention tests for identifying presumptive gonococcal isolates in a systematic sample from patients attending five sexually transmitted disease clinics in five cities.Fourteen (2.5%) of 556 isolates from three clinics were nonreactive with the DFA confirmatory reagent and reactive by both the Quad-Ferm and Rapid NH tests. The prevalence of DFA-nonreactive Neisseria gonorrhoeae isolates varies geographically and is independent of local methods for the identification of possible gonococci.On the basis of our findings, we recommend that for use in medicolegal and other instances in which a diagnosis of gonorrhea has the potential to have far-reaching effects, it is appropriate to test DFA reagent-nonreactive, oxidase-positive, gram-negative diplococci by alternative methods of gonococcal confirmation.Although the prevalence of such isolates could change, the fluorescent monoclonal antibody confirmation reagents remain useful for many clinical situations. Their ease of use and ready applicability for screening large numbers of isolates make them useful for many laboratories.

A 72- year old woman had a history of recurrent urinary tract infections over the past several months, for which she had received different regimens of antibiotics including ampicillin, trimethoprim-sulfasoxazole, and ciprofloxacin.Relapses often occurred 10 days to two weeks after cessation of therapy.The current flare up, manifest by dysuria, lower abdominal pain and cloudy urine was accompanied by shaking chills and spiking fever.A sterile mid-stream urine specimen was sent to the laboratory for culture.

Vancomycin and ampicillin resistance among Enterococcus species, particularly E. faecium have been on a steady increase.The disk diffusion screening test is used in many laboratories to detect vancomycin resistant strains. Note in the upper photograph that no zone of inhibition is seen around either the vancomycin or the ampicillin disk, indicating resistance to both drugs.Vancomycin-resistant Enterococci (VRE) have been divided into three phenotypes--Van A, Van B, and Van C.Vancomycin-resistant strains of E. faecalis and E. faecium are commonly of the Van A phenotype, demonstrating high level resistance (MIC's higher than 64 ug/mL), as illustrated by total resistance of the test strain in the E test and the VA disk, as illustrated in the lower photograph.The strain shown in the lower photograph, however, is ampicillin susceptible at the level of 1 ug/ml (see lower set of yellow arrows), indicating that this drug may be effective in treating the urinary tract infection.

Perhaps the most efficient means for detecting methicillin-resistant staphylococci in clinical laboratories is the use of the agar dilution screening test.Illustrated in the photograph is a Mueller-Hinton agar plate containing 6ug/ml of oxicillin, previously inoculated with a strain of Staphylococcus aureus. Oxacillin is used as a marker for methicillin resistance because it is more stable in the agar medium. Growth on this screening medium is presumptive for methicillin resistance.Thus, in the presence of growth, as shown here, a follow-up MIC test must be performed to determine the exact level of resistance.

The prototype history for this organism is either a still birth or a neonate with death ensuing within 2 or 3 days post-partem due to high fever, sepsis, and respiratory distress. The mother usually experienced a flu-like illness late in the third trimester of pregnancy, characterized by low-grade fever, myalgias, malaise and backache. In this case, biopsy material of brain tissue obtained at autopsy was submitted to the pathology laboratory for tissue diagnosis and fluid from the pia-arachnoid was sent to the microbiology laboratory for culture.

While the Federally Regulated CCF must be used exclusively for DOT drug screen collections, there are extenuating circumstances when another form of CCF may be used. For example, where a post-accident collection must be made and the collector does not have time to obtain a Federally Regulated CCF. In this situation, a Non-Federally Regulated CCF may be used. The collector should note in the "Remarks" section why the Non-Regulated CCF was used.The use of a Non-Regulated CCF for a Federally Regulated collection is not a reason for the laboratory to refuse to test the specimens nor the Medical Review Officer (MRO) to release the results. The use of a Non-Regulated CCF for a Federally Regulated drug screen is a "correctable flaw," which may include the collector detailing the reason for using a Non-Federally Regulated CCF in a "Memorandum for Record."

Scenario 4: The donor returns from the restroom with a sufficient specimen. It is very warm to the touch. The collector is unable to obtain a reading from the temperature strip. Collector’s response: The collector completes the collection and prepares the specimen for shipment. The collector explains the situation with a supervisor. If the supervisor concurs that an observed collection is in order, the collector next tells the donor that a new collection will be conducted under direct observation. The collector explains that because the temperature of the specimen was not within the acceptable range (90-100º F/32-38º C) there is suspicion of substitution or adulteration. A new CCF is initiated. The collector marks on the CCF that the collection is observed and notes under Remarks why it is observed. The collector also notes the control number of the suspect collection. The observed specimen along with the suspect specimen are both shipped to the laboratory in separate plastic tamper-resistant bags.

Scenario 5: The collector notices that the urine the donor just handed to her has a very strong smell like that of a cleaning product such as bleach. Collector’s response: The collector completes the collection in the usual manner and prepares the specimen for shipment. The collector explains the situation to a supervisor. If the supervisor concurs that an observed specimen should be collected, the collector explains to the donor that because of the strong, unusual smell, the first specimen is suspect for adulteration and that a directly observed collection will be done. A new CCF is initiated. The collector marks on the CCF that the collection is observed and notes under Remarks why it is observed. The collector also notes the control number of the suspect collection. The observed specimen along with the suspect specimen are both shipped to the laboratory in separate plastic tamper-resistant bags. In addition to an unusual smell, other indications of adulteration might be an unusual color that cannot be explained by medication, particles or debris in the urine, and a heavy or thick foam that is inconsistent with urine.

Electrophoresis is the migration or separation of charged particles or solutes of a liquid solution in an electrical field. Conventional electrophoresis is tedious and time consuming. Electrophoresis automation and newer electrophoresis techniques have revitalized the utilization of electrophoresis in today's clinical laboratories. Molecular diagnostic analysis using electrophoresis and research in proteomics have also contributed to this revitalization.

Clinical Chemistry Concepts and Applications. Shauna C. Anderson and Susan Cockayne. Long Grove, Illinois: Waveland Press, Inc, 2003.Clinical Laboratory Instrumentation and Automation Principles, Applications, and Selection. Kory M. Ward, Craig A. Lehmann, Alan M. Leiken. Philadelphia: WB Saunders Company, 1994.Laboratory Instrumentation, 4th Edition. Mary C. Haven, Gregory A. Tetrault, Jerald R. Schenken, eds. New York: Van Nostrand Reinhold, 1995.Molecular Diagnostics Fundamentals, Methods, and Clinical Applications. Lela Buckingham and Maribeth L. Flaws. Philadelphia: FA Davis Company, 2007.Principles of Gel Electrophoresis. Available at http://www.vivo.colostate.edu/hbooks/genetics/biotech/gels/principles.html accessed 9/29/08.Tietz Textbook of Clinical Chemistry and Molecular Diagnostics, 4th Edition. Carl A. Burtis, Edward R. Ashwood, David E. Burns, eds. Philadelphia: Elsevier Saunders, 2005.

An agarose gel electrophoresis first separates the proteins in a serum sample. Antiserum against the protein of interest is spread directly on the gel. The protein of interest precipitates in the gel matrix. After a wash step to remove other proteins, the precipitated protein is stained. This method is qualitative and is used to identify proteins found in multiple myeloma.Below is the immunofixation electrophoresis gel from a serum sample analyzed on SPIFE 3000, Helena Laboratories. After electrophoresis, the precipitated proteins are stained with Acid Violet, a stain developed and used by Helena Laboratories. The SP lane represents a routine serum protein electrophoresis of this specimen. On the next three protein separations, antiserum against IgG, IgA, and IgM were applied to the G, A, M lanes respectively. Antiserum to kappa light chain was added to the next protein separation and antiserum to lambda light chain to the last protein separation.

We have listed the 'classic' cardiovascular risk markers as LDL-C, HDL-C and triglycerides. But there are many more cardiovascular risk markers as well as cardiovascular risk factors. A cardiovascular risk factor is a condition (not a laboratory analyte) that is associated with an increased risk of developing cardiovascular disease. Examples include: Age Gender (males are at increased risk) Heredity Hypertension Cigarette Smoking Obesity Diabetes StressThere are also negative risk factors, factors which decrease a person's risk of cardiovascular disease. Examples include: Optimal HDL-C concentration Exercise Estrogen Moderate alcohol intakeThis course will not focus on cardiovascular risk factors. Instead we will focus on newer, emerging cardiovascular risk markers. There are well over twenty well-studied cardiovascular risk markers; in this course we will focus on some of the more established markers and the ones which are becoming more commonly measured in the clinical laboratory. These include apolipoprotein A1/apolipoprotein B100, Lp(a), oxidized LDL, LpPLA2, hsCRP and lipoprotein particle size and concentration.It is important to remember that the association between a cardiovascular risk marker and actually having or developing cardiovascular disease is a statistical one. The fact that a patient has a particular risk marker which is abnormal simply increases the probability of developing cardiovascular disease, it does not mean that he or she is certain to develop cardiovascular disease. Conversely, if an individual does not have a particular cardiovascular risk marker present it does not guarantee protection against cardiovascular disease. We must always remember that some percentage of individuals who have heart attacks or strokes will not have abnormal risk markers present.

In this course we have described some emerging cardiovascular risk markers. It is important to note that there are many more markers, some of which appear robust and which may have clinical value. Examples of other risk markers that are emerging but were not discussed are listed in the table to the right.An important question that should always be asked is "how many risk markers do we need?" With so many risk markers available, the laboratory needs to research which markers are truly the strongest and most valuable for the patient demographic the facility deals with most and which markers physicians will order and utilize.

Atherosclerosis. U.S. Department of Health & Human Services National Institutes of Health. Available at http://www.nhlbi.nih.gov/health/dci/Diseases/Atherosclerosis/Atherosclerosis_WhatIs.htmlAccessed June 23, 2009.Daniels LB, Barrett-Connor E, Sarno M, Laughlin GA,Bettencourt R, Wolfert RL. Lipoprotein-associated phospholipase A2 (Lp-PLA2) independently predicts incident coronary heart disease (CHD) in an apparently healthy older population: The Rancho Bernardo study. J Am Coll Cardiol. 2008;51:913-919.Executive Summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001; 285:2486-2497. Frostegard, J, Wu R, Lemne C, Thulin T, Witztum JL and de Faire U. Circulating oxidized low-density lipoprotein is increased in hypertension, Clin Sci 2003; 105, 615.Garza CA, Montoir VM, McConnell JP, et al. Association between lipoprotein-associated phospholipase A2 and cardiovascular disease: a systematic review. Mayo Clin Proc. 2007;82(2):159-165.Interpretive Handbook, (MC0440rev0407) Mayo Clinic, Rochester MN;2007. Maksimowicz-McKinnon K, Bhatt DL, Calabrese LH: Recent advances in vascular inflammation: C-reactive protein and other inflammatory biomarkers. Curr Opin Rheumatol. 2004;16:18-24.Mora S, Szklo M, Otvos JD, et al. LDL particle subclasses, LDL particle size, and carotid atherosclerosis in the multi-ethnic study of atherosclerosis. Atherosclerosis. 2007;192:211-217.NACB Laboratory Medicine Practice Guidelines. Emerging biomarkers of cardiovascular disease and stroke. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines. 2006.PLACtest animation, diaDexus. http://www.plactest.com/laboratorians/action.php Accessed June 23, 2009.Rifai N, Warnick GR. Lipids, lipoproteins, apolipoproteins, and other cardiovascular risk factors. In: Burtis CA, Ashwood ER. Bruns DE. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. 4th ed. St. Louis, MO: Elsevier Saunders: 2006; chap. 26.Ridker PM, Rifai N, Rose L, et al. Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med. 2002;347:1557-1565.Sniderman AD. Differential response of cholesterol and particle measures of atherogenic lipoproteins to LDL-lowering therapy: Implications for clinical practice. J Clin Lipidol 2008;2:36-42.Tsimikas, S, Brilakis ES, Miller ER, et al. Oxidized phospholipids, Lp(a) lipoprotein, and coronary artery disease, N Engl J Med: 2005;353:46.Tsimikas S, Bergmark C, Beyer RW, et al. Temporal increases in plasma markers of oxidized low-density lipoprotein strongly reflect the presence of acute coronary syndromes. J Am Coll Cardiol. 2003; 41: 360.Tsimikas, S, Lau HK, Han KR, et al. Percutaneous coronary intervention results in acute increases in oxidized phospholipids and lipoprotein(a): Short-term and long-term immunologic responses to oxidized low-density lipoprotein. Circulation. 2004;109, 3164.Tsimikas S, Witztum JL, Miller ER, Sasiela WJ, et al. High-dose atorvastatin reduces total plasma levels of oxidized phospholipids and immune complexes present on apolipoprotein B-100 in patients with acute coronary syndromes in the MIRACL trial, Circulation: 2004;110, 1406. Walldius G, Jungner I, Holme I, et al. High apolipoprotein B, low apolipoprotein A-I, and improvement in the prediction of fatal myocardial infarction (AMORIS study): a prospective study. Lancet. 2001;358:2026-2033.Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364:937-952.

This program has provided some basic information about emergency situations that can occur in a laboratory.However, it is not a substitute for a hands-on first aid course, such as those that may be given at a local community center.The more you know about first aid, the more prepared you will be to act calmly and effectively in emergency situations, possibly saving lives.

Specimen rejection criteria established by your laboratory should be followed at all times, as improperly collected or processed coagulation specimens could adversely affect patient results. Generally speaking, hemolyzed specimens should not be used in coagulation testing because ADP liberated from lysed red blood cells can interfere with a number of coagulation tests, especially those involving platelet assessment. Grossly lipemic specimens may cause erroneous results or a clot may not be detected if a photo-optical coagulation system is used. An alternative method that is not affected by lipemia, such as an electromechanical method, may be required One way to avoid a grossly lipemic specimen is to ask the patient to fast prior to specimen collection.

The INR component of the laboratory result is a calculated value that is used by the clinician to monitor anticoagulant therapy and adjust dosage as dictated by clinical status. An INR of 2.0 - 3.0 is often desired as the therapeutic range. The following formula is used by the clinical laboratory to derive an INR value. The INR must be adjusted for every new lot of PT reagent. INR= (PT of patient/PT of geometric mean of the normal population)ISI The International Sensitivity Index, or ISI value, is provided by the reagent manufacturer as the relative sensitivity of the reagent itself. The INR is used to standardize PT results, and in turn, anticoagulant therapy, across laboratory instrumentation, methodologies, and locale. Be sure to frequently check that ISI values match those of the lot currently in use as erroneous results may otherwise occur .

Molecular diagnostics have begun to play an integral part in clinical laboratory diagnostic testing. Traditionally, molecular diagnostics have been utilized in three major clinical areas: Infectious diseases Genetics Tumor markers These molecular based diagnostic tests, while historically reserved for specialty/reference labs, have recently seen expansion of their utility within the scope of routine clinical laboratories. Molecular based diagnostics can be utilized by small labs as well as large ones, and can be found in virtually every department of the clinical laboratory.

Many clinical laboratories utilize reference laboratories for molecular methodology testing. Transport and shipping of biological specimens must follow laws and regulations governing these types of specimens. Consult your laboratory’s accrediting agency and reference lab for specific polices and procedures.

Molecular methodologies can be useful in the detection of a variety of diseases that are important public health issues such as:Chlamydia trachomatis (CT) Neisseria gonorrhoeae (GC)Human papillomavirus (HPV)Human Immunodeficiency Virus (HIV)Herpes Simplex Virus (HSV)Cytomegalovirus (CMV)In many clinical laboratories, traditional methods have been replaced by molecular methodologies because testing can occur for several pathogens in a single specimen. This is termed multiplex testing.

Hereditary hemochromatosis (HH) is a disorder of iron regulation that results in excessive dietary iron absorption through the gastrointestinal tract. Over time, the resultant iron overload and its deposition in tissue may lead to widespread organ damage, a variety of chronic disorders, and even death. Although it is a genetic disorder, clinical symptoms most typically become apparent in middle aged adults. Iron overload occurs in a variety of hereditary and acquired forms, known as iron storage diseases. HH is the most common cause of inherited iron overload. (1) Due to lack of awareness, HH often goes undetected or unrecognized by health care providers. Early detection to prevent the serious complications associated with iron overload has important consequences for reducing morbidity and mortality. Laboratory tests that assess iron levels and molecular assays for genetic mutatations are essential for both its detection and diagnosis.

Hereditary hemochromatosis (HH) is frequently discovered only during management of associated illness or routine health evaluations. It has been estimated that only a small percentage of all affected persons are actually diagnosed. Individuals with HH may be symptomatic for several years prior to diagnosis and may have consulted multiple health care providers.Under-diagnosis of HH is thought to occur due to:• Lack of specificity of early signs and symptoms• Asymptomatic status of some patients until damage to organs and tissues has occurred• Confusion with liver disease due to other causes• Insufficient awareness and knowledge of HHEarly identification of persons with HH is essential to prevent serious and irreversible complications associated with severe iron overload. A classic triad of skin hyperpigmentation (bronzing), type 2 diabetes, and hepatic cirrhosis has long been recognized as evidence of advanced iron overload. However, persons with HH may present with a much wider variety of signs and symptoms, particularly if they are seen before significant iron accumulation has occurred. Age of presentation and disease severity are highly variable. A diagnosis of HH is based on laboratory evidence of iron overload, genetic mutations associated with HH, and presence of clinical signs and symptoms consistent with HH.(10)

The diagnosis of hereditary hemochromatosis (HH) is made through a combination of laboratory tests and medical evaluation of a patient's signs and symptoms. Iron overload is identified by tests that evaluate iron metabolism, while molecular assays are needed to document mutations in the HFE gene or others such as hepcidin, hemojuvelin, or transferrin receptor. Individuals with documented iron overload who exhibit signs and symptoms consistent with HH and who possess HFE or other mutations are considered to have HH. Other causes of secondary iron overload may need to be ruled out.An example of a testing algorithm is shown.

DNA tests for HFE mutations associated with hereditary hemochromatosis (HH) are available in some clinical laboratories and reference laboratories. Testing for the presence of the C282Y is essential, although most labs also test for H63D and S65C mutations. Molecular testing is most appropriate for confirmatory testing of symptomatic individuals with altered iron studies (increased TS and SF), in pre-symptomatic individuals (increased TS, normal SF and liver function tests), and in family members of individuals diagnosed with HH. The use of genetic tests alone for routine screening of asymptomatic persons is not recommended for several reasons. A positive test indicating the presence of HFE mutations does not guarantee that an individual will develop clinically significant iron overload or predict severity of symptoms. A negative result (no HFE mutations present) does not rule out a diagnosis of iron overload because of genetic heterogeneity. Compared to biochemical analyses for iron, molecular assays are expensive. Finally, molecular testing may result in the diagnosis of a genetic disease, thus opening up the possibility for discrimination in health insurance coverage. Using molecular methods, DNA is extracted from leukocytes in whole blood samples or from buccal cells and analyzed for specific HFE mutations using polymerase chain reaction (PCR) with melt curve analysis. Currently there are no FDA-cleared products for HFE testing, and testing laboratories are using "home brew" reagents. This situation is expected to change as manufacturers submit products for FDA approval.

The privacy regulations give covered entities permission to use and disclose PHI for treatment, payment, and health care operations (TPO), without obtaining specific authorization.A covered entity may disclose PHI to other covered entities such as reference laboratories, and homecare services, which are providing services to the primary covered entity.The service that the other covered entity is providing must fall within treatment, payment or health care operations (TPO).If the service being provided does not fall within TPO, an authorization is generally required.An authorization form must state the specific disclosures of PHI to be made, what the information will be used for, and must be signed and dated by the patient.

You will have many opportunities to avoid disclosing protected health information. Here is one simple example: Your best friend asks you to look up her mother's laboratory results. Knowing the HIPAA privacy regulation and your own departmental policies and procedures, you do not disclose the protected health information which she is requesting. You politely tell your friend that your are not allowed to give her the laboratory results.

Prevention of HIV exposure is the best line of defense to prevent occupational transmission of HIV as there is no vaccine available to develop specific immunity and the postexposure prophylaxis is toxic. Following appropriate workplace practices in the laboratory focus on preventing needlesticks or other sharps injuries and exposure of mucous membranes and abraded skin to HIV-infected blood or body fluids.

They are easily available.Biological pathogens can be obtained from nature, hospital  laboratories, university research facilities, etc.They can be hard to detect.Small quantities can have potentially deadly or incapacitating effects on a susceptible population.They can be used covertly.They can be spread throughout large areas by natural convection, air or water currents. They can be easily spread.Ventilation systems in buildings is one way biological agents may be spread. In addition, transportation facilities could become part of the dissemination system by carrying biological agents far from their initial source.

The LRN is a multilevel system designed to link frontline clinical microbiology laboratories and hospitals and other institutions to state and local public health laboratories in supporting advanced capacity public health, military, veterinary, agricultural, water and food testing laboratories at the federal level. Laboratories within the LRN are divided into 3 levels: Sentinel Labs, Reference Labs, and National Labs.

At the highest level are the “national” laboratories. Examples would include those operated by CDC, the United States Army Medical Research Institute for Infectious Diseases, and the Naval Medical Research Center. These laboratories have very unique resources to handle highly infectious agents and the ability to identify specific agent strains.

Level 3 laboratories are responsible for: Working with hospitals and private laboratories in their jurisdiction Knowing how to properly collect and ship clinical specimens Ensuring that specimens, which can be used as evidence in a criminal investigation, are properly handled and that chain-of-custody procedures are followed Being familiar with chemical agents and how they can affect health and well-being Training on anticipated clinical sample flow and shipping regulations Working to develop a coordinated response plan for their respective state and jurisdiction

At present, 5 laboratories participate in Level 1 activities. At this level, technical personnel are trained to detect exposure to an expanded number of chemicals in human blood and urine. This includes all Level 3 and 2 laboratory analyses, plus analyses for mustard agents, nerve agents, and other toxic chemicals.

Recent events, including the terrorist attacks on September 11, 2001 and the subsequent bioterrorist releases of anthrax, have been a harsh awakening that the nation’s workplaces could be terrorist targets.Traditionally laboratory safety guidelines have emphasized use of optimal work practices, appropriate containment equipment, well-designed facilities, and administrative controls to minimize risks of unintentional infection or injury for laboratory workers. Today, in addition to the above, laboratories must make a risk and threat assessment, secure data and electronic technology systems, plus develop policies regarding specimen accountability, facility security, and emergency response.The next few pages will cover a number of things that you can do to assist in making your laboratory more risk free to a terrorist attack and some things you can do in case that security is breached. You too have a role in the security of your workplace!

In some laboratories the anticoagulated sample is used to prepare concentrated smears. Placing the fluid in a Wintrobe tube and centrifuging it separates the sample into four layers:fat and perivascular cellsplasmabuffy layer - myeloid and nucleated erythroid cellserythrocytesThe volume of each layer is measured using the scale on the Wintrobe tube and then the percentage of each layer is calculated. Next the plasma is removed and a smear is made from the buffy coat and top of the red cell layer. Either the manual push method or cytospin technique may be used to make the smears. They may be stained with a variety of cytochemical stains. Concentrated smears are used to examine cell morphology and demonstrate the presence of abnormal cells when the marrow is hypocellular. The smears cannot be used for differential counts or evaluation of cellularity.

Quality control procedures may include the following: monitoring variables within the laboratory, like water quality, glassware calibration, and instrument calibration, that may affect results defining protocols for performing quality control for each test procedure participating in proficiency testing programs graphing quality control results performing daily and periodic analysis of quality control data and charts troubleshooting quality control errors documenting quality control errors, including the steps taken to resolve the problem and verification of success performing routine maintenance of laboratory instruments keeping records

Internal quality control is set up within a laboratory to monitor and ensure the reliability of test results from that laboratory.The primary tool for internal quality control is called a control. A control is a specimen with a predetermined range of result values, called control values, that is processed in the same manner as a patient sample. Control samples are processed with each series or run of patient samples.If the result of a test on a control sample is different from its known value, this indicates a problem in the equipment or the methods being used.

To ensure reliability of results, many other factors besides controls are monitored. These include: water quality analytic balance calibration glassware calibration centrifuge calibration thermometer calibration electric power stability heating bath temperatures refrigerator temperatures freezer temperatures expiration of reagents, standards, and controls instrument maintenance procedure manuals, including written step-by-step procedures of all tests performed by laboratory method selection, based on local population and clinician needs normal range verification based on the local population technical competencies of laboratory staff members

External quality control is performed to ensure the reliability of test results between different laboratories. It is also required by CLIA for laboratory accreditation. External quality control is generally accomplished through proficiency testing (PT). In proficiency testing, simulated patient samples are sent out to laboratories for testing. The CLIA standards for handling proficiency testing specimens are as follows: PT samples must be tested with the laboratory's regular patient load. PT samples must be tested the same number of times that patients' samples are tested routinely. Laboratories participating in PT programs must not engage in interlaboratory comparison of PT sample results. Laboratories may not send PT samples to another laboratory for analysis. Laboratories must document all steps of processing for PT samples. PT is required for only the primary method used for testing of analytes in patients' samples during the period covered by the PT event.In return for their participation, the laboratory will receive the following information: results for each analyte sample mean result for each analyte standard deviation of results by the comparative method number of laboratories using the same method standard deviation index (SDI) lower and upper limits of acceptability of resultsPT results that are between the lower and upper limits of acceptability are considered satisfactory. For chemistry, 80% of samples must test within the acceptable range for the PT to be considered successful. External quality control serves several purposes, including: providing a check on internal quality control detecting errors in a lab's methods providing a comparison of testing methods, which is useful in selecting new methods

Both the employer and the employee should share the responsibility for assessing and improving ergonomics in the laboratory. A three-step ergonomic program includes: Finding the hazard Determining what improvements / changes should be made Taking action to improve the workplaceEmployers should: Provide ergonomics education Provide ergonomically designed tools and equipment Allow frequent stretch breaks If possible, adjust work schedules to prevent employees from performing repetitious tasks for prolonged periods of time. As an employee, you should evaluate the ergonomic practices in your work area.Employees should: Understand the risk of injury Apply ergonomic principles to the performance of tasks Look for ergonomic hazards and improve the workplace whenever possible Recognize and report early signs of musculoskeletal disorders (MSDs)

Centers for Disease Control and Prevention. Laboratory ergonomics. Available at: http://www.cdc.gov/od/ohs/Ergonomics/labergo.htm. Accessed July 6, 2009.Cornell University. CUErgo. Available at: http://ergo.human.cornell.edu/ Accessed July 6, 2009.National Institute for Occupational Safety and Health. Ergonomics and musculoskeletal disorders. Available at: http://www.cdc.gov/niosh/topics/ergonomics/ Accessed July 6, 2009.UCLA Ergonomics. Musculoskeletal disorders: Anatomy of an injury. Available at: http://ergonomics.ucla.edu/MSD_Anatomy.html. Accessed July 6, 2009.US Department of Labor. Healthcare wide hazards module: Ergonomics. Available at: http://www.osha.gov/SLTC/etools/hospital/hazards/ergo/ergo.html Accessed July 6, 2009.

The primary goal of ergonomics is the prevention of musculoskeletal disorders (MSDs). There are many potential causes of MSDs. Injury can occur from a single event (strain, sprain, slip, or fall) or result from build-up of tissue damage from many small injuries. An MSD can develop over time if a motion is repeated consistently so that the constant trauma causes damage to a muscle, tendon, bone, or bursa of a joint. Force, vibration, or maintenance of an awkward position for a prolonged period of time can cause MSDs.Some specific causes of MSDs that are related to laboratory tasks are: Prolonged use of a keyboard or mouse Prolonged sitting at a microscope Pipetting Screwing and unscrewing vial caps Standing at a laboratory instrument for a prolonged period of time Lack of rest - intensive hours at the workstation with few breaks Sustained awkward position

As a clinical laboratory worker, your role is vital in the health care process. You provide information to doctors, nurses, and healthcare organizations that is vital to proper patient care. Because your role is so important, you must be properly qualified, trained, and licensed for your position. You must also keep up with the latest laboratory techniques and developments by fulfilling continuing education requirements; and you are bound by a code of ethics, which ensures that patient results are accurate, reliable, and free from error and bias.

To practice as a clinical laboratory scientist in the state of Florida, you must have an appropriate Florida license. Without a license, you cannot conduct clinical laboratory examinations or report test results. You do not need a Florida license to work in: Laboratories run by the federal government. Labs that perform only waived testing. Labs run exclusively for research and teaching purposes that do not report patient results.These laboratories may have other licensing and training requirements.

Effective date March 17, 2008All applicants for a Director license must meet the qualifications for a high complexity laboratory director that are defined in 42 CFR 493.1443 as published on October 1, 2007.A licensed physician may direct a clinical laboratory without a separate laboratory director's license if he / she is certified in clinical pathology by the American Board of Pathology (ABP) or the American Osteopathic Board of Pathology (AOBP); is board-certified in the pertinent laboratory speciality; and/or has four years of pertinent clinical laboratory experience (post-graduate) with two years experience in the speciality that will he/she will direct.A non-physician may obtain a director's license for a specialty area if he / she: Holds an earned doctoral degree in a chemical, biological, or clinical laboratory science Is certified in the pertinent laboratory specialty by an approved national board A director can oversee up to five laboratories.

A supervisor is the laboratory director's designee for monitoring compliance with all applicable regulations of the board and the department. Other duties include: Performing the duties of a technologist, if needed, in the specialty area(s) where licensure is held Assigning direct supervision responsibilities to licensed technologists if needed, while ensuring that direct supervision of technicians is properly performed. Evaluating technologists' and technicians' competency in running tests and reporting results Being available to all personnel to answer questions and resolve problems Providing day-to-day supervision of test performance, including on-site direct supervision of testing that is performed by technicians Ensuring that quality control is performed and corrective action taken if necessary Ensuring that no patient testing is reported until corrective action has been taken and the test system is properly functioning Providing orientation to all testing personnel Implementing a quality maintenance program

Technicians perform laboratory testing under direct and general supervision, as required by the test and the conditions of the technician's license. Other duties include:Performing tests only as authorized by the director and the technician's licensed specialty.Following the laboratory's procedure for specimen handling and running testsParticipating in proficiency testing and demonstrating that proficiency samples are tested in the same manner as patient samplesFollowing quality control and instrument calibration policiesDocumenting corrective action taken when results exceed the laboratory's acceptable performance valuesIdentifying potential problems with tests or report resultsNotifying a technologist or supervisor if results are outside the laboratory's acceptable performance levels

Offering or taking a bribe, kickback, bonus, commission, or inducement is against the rules of the Board and against the law. Many companies give away small promotional items, such as pens or note pads, to promote their products. This is legal, but be cautious about accepting more valuable items. This could be seen as a bribe. All of the following are serious violations of Board, state, and federal rules:Participating in any commissions, bonuses, kickbacks, inducements, or split-fee arrangements from physicians, health care providers, suppliers, hospitals, nursing homes, other clinical laboratories, pharmacies, and other facilities.Exploiting or influencing a patient for financial gain, including promoting, selling, or withholding services, drugs, or referrals.

Laboratory professionals can learn about medical errors and prevention by maintaining their awareness of laboratory-related news and events. They can read print and online news sources, magazines, and professional journals to stay informed. They can also learn what is happening through televised and other media reports. Staying up to date about current trends and progress in error prevention enables professional to learn from mistakes and prevent new ones.

Laboratory discussion meetings help to prevent medical errors. The staff can meet periodically to discuss recent averted adverse events and ones that might have been averted.Discussion should not be about blame. Privacy must be protected, so real names should not be identified. Management can provide guidelines for discussion and analysis.A suggested format for discussion:1. Briefly describe each adverse event.2. Identify its possible causes.3. Discuss relevant guidelines.4. Suggest possible preventive actions.Discussion can include actions that do and do not work to prevent medical errors.

Medical errors are possible at any phase of patient care. Preanalytic medical errors begin with the patient and the places he or she receives medical care--the bedside, chair-side, hospital, clinic-- wherever the patient is located. The possibility for these errors continues through the ordering processes for medical tests or procedures. Preanalytic medical errors also happen with the systems, processes, and procedures involved in the collection of test samples from patients. These medical errors occur during the time before the laboratory is directly involved in assaying and analyzing test samples. Examples of preanalytic medical errors: Wrong patient Wrong test Wrong timing Wrong collection procedure Wrong tube, container, additive

Errors also occur after analyses are completed and reported. Postanalytic errors begin with the medical professionals who receive test results, and they include interpretation of the results. These errors can occur at--the bedside, chair-side, hospital, clinic-- wherever the patient and the medical professional are located. The possibility for postanalytic medical error continues through diagnosis and treatment procedures and processes. These medical errors occur during the time after the laboratory reports test results. Examples: Wrong test value associated with patient Wrong test interpretation Wrong diagnosis Wrong treatmentLaboratory professionals might believe they are not associated with postanalytic medical errors, but they can be. One deadly example is fatal hemolytic transfusion reaction involving laboratory error.

The government believes that fraud, abuse and waste exist in the healthcare industry today because of cases it has settled and prosecuted.All healthcare providers, including laboratories, make billing errors.The Office of Inspector General (OIG) believes that honest members of the healthcare community can police themselves if they receive guidance.The OIG has published Compliance Program Guidance documents for health care providers, including laboratories.

Element 7: The laboratory has a duty to respond to problems it detects either through its auditing or monitoring system or as reported by employees.It is required to take corrective action and review policies and procedures to ensure the problem does not occur again.It is required to discipline or retrain employees if necessary.The laboratory will report problems to appropriate government agencies and return any money to which it is not entitled.

Element 2: The laboratory has appointed a Compliance Officer (CO) and a Compliance Committee to serve as the focal point for all compliance activities and decision making.The CO and any member of the compliance committee is accessible to all employees in the laboratory.

Element 4: The laboratory has established a system of communication so that employees can and are encouraged to report problems and suspect activities they might observe or discover, without fear of retribution, including an anonymous option.The anonymous system instructions are posted throughout the laboratory.

Social Security Act: Medicare and Medicaid laws are in this act. Medicare rules and regulations come under this act. Antikickback laws: Provide criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit or receive money or favors for referrals of tests or services that will be paid for by the Medicare or Medicaid programs. False Claims Act: Provides criminal penalties for knowingly or willingly filing a false claim to a government program. Self Referral (Stark) laws and regulations: Identify financial relationships that have the potential to result in directed referral to one or both of the individuals or entities involved. Prohibit the referral of patients or tests between related entities unless certain conditions are met. Health Insurance Portability and Accountability Act (HIPAA) Prohibits health care providers and payers from improper or inappropriate use of a patient's confidential health information Requires health care providers to insure that a patient's confidential information is kept secure Provides for standardized electronic formats for all health care transactions

Billing: Highest risk activity a laboratory has. All laboratory activities contribute to the billing process. Many of the risk areas included in this program are components of the billing function. Medical necessity: Medicare is only allowed, by law, to pay for tests that are reasonable and necessary for the diagnosis and treatment of disease. Medical necessity is an underlying principle of the Medicare program. Tests performed for screening or routine exams are not considered medically necessary by the Medicare program.

Advance Beneficiary Notices (ABNs) allow laboratories to bill Medicare patients directly for specific tests that are not covered by Medicare. A laboratory cannot bill a Medicare Beneficiary for a laboratory test unless it notifies the patient in writing that Medicare is not going to pay for the test. This notice is called an ABN. The beneficiary can choose not have the test performed if they do not want to pay for it. Laboratories cannot make all Medicare beneficiaries sign ABNs. The ABN must contain the specific name of the test. The ABN must give a specific reason the laboratory thinks payment for the test will be denied. The beneficiary should sign the ABN and be given a copy.

Requisitions must be designed to ensure that ordering physicians can choose tests that are medically necessary for their patients. Requisitions should contain reminders about Medicare rules of medical necessity and list the contents of panels and profiles. Requisitions must provide a place for the physician to include diagnosis (ICD9-CM) codes. Physicians should be encouraged to use only the requisitions supplied by the laboratory to order tests. Ambiguous or unclear test orders When the orders for a test are not absolutely clear, the laboratory must contact the ordering physician to clarify the orders before performing and billing for the test. The laboratory cannot guess at the order. The laboratory cannot perform and bill for tests that are not specifically ordered. The laboratory cannot change a physician order without contacting the physician. In any case where specimen integrity or patient care will be compromised by a delay in testing follow the policies the laboratory has established for such cases.

Panels and Profiles: It is not against the law for a laboratory to allow the use of panels, profiles and custom panels. The laboratory must ensure that the ordering doctor knows what tests are included in a panel or profile and what CPT codes will be billed to the Medicare program. The laboratory notifies doctors about panels and profiles through a written notice and the requisition. Employees should not permit the order of any panel or profile not authorized by the laboratory.

It is against the law to offer or ask for money or favors to get a physician to order tests from a laboratory. This is known as an "inducement" or a "kickback." Laboratories should only give supplies to a physician for the drawing, processing, storing or transporting of specimens to the laboratory. The laboratory cannot provide supplies physicians use for their own purposes. The laboratory must monitor the amount of supplies provided to ensure that it matches the number of tests sent to the laboratory. The lab cannot give free tests except in the event of laboratory error. The lab cannot give free education to clients unless it is about the laboratory's services or policies. The lab cannot give excessive or expensive gifts or entertainment to physicians The lab can give discounts but the price must be above cost and at "fair market value."

The laboratory's couriers may not transport items except those related to the testing services offered by the laboratory. Couriers must follow all OSHA standards for the handling and transport of specimens. The laboratory is responsible for all tests it refers to other laboratories. Laboratory should not change CPT codes supplied by a reference laboratory without contacting the reference laboratory. The laboratory is responsible for all tests it bills to Medicare/Medicaid even if the test was performed by a reference laboratory.

Laboratories must not induce physicians to order unnecessary tests through their marketing or education activities: They must monitor the use of laboratory services by their clients. They must correct any situation where something they did caused an unnecessary increase in test utilization. Cost Reports Hospitals laboratories must ensure that information used in hospital Medicare cost reports is accurate and includes only those costs which are appropriate. Laboratories must follow all CLIA and OSHA regulations: failure to do so may result in a False Claims Act violation.

Medical necessity means that Medicare is not allowed by law to pay for any tests that are not necessary for diagnosis or treatment of disease.A laboratory may not submit a claim to Medicare or other government payers for any test it knows is not medically necessary except in certain cases: When the patient has signed an advance notice. When a patient has requested the lab to submit such a claim for a determination by Medicare. Medicare does not pay for screening tests or tests that are ordered in the absence of signs or symptoms.Billing department employees are responsible to follow all policies and procedures related to the submission of claims to reduce erroneous billings.

ICD-9CM (International Classification of Disease, 9th Edition, Clinical Modification) codes are used for the classification of disease and conditions and for describing signs, symptoms and medical circumstances.These codes are used to indicate the medical necessity of a particular test.ICD-9 codes can only be supplied by the ordering physician or a representative of that physician. "Code steering" means to steer or direct a physician to supply an ICD-9 code that is payable. ICD-9 codes cannot be used from a previous laboratory order. If a physician supplies a narrative description instead of an ICD-9 code the laboratory must accurately translate that code using only certified coders.It is against the law to use the wrong ICD-9 code for the purpose of causing or increasing payment for a test.

It is important that billing department employees are clear and accurate when communicating with physician office personnel and patients. Never guess at the answer to a question; ask if you are unsure. Do not speculate or express personal opinions. When requesting diagnosis information from the physician office staff be careful to not lead them to give a billable code: The code must come from the patient's medical record. There is an incentive program for patients to find and report fraud and abuse by health care providers, including laboratories, so: Billing department employees must accurately state laboratory policies and procedures, or forward the call to a supervisor to avoid misstatements and misunderstandings.

The laboratory should not offer or provide free testing to any individual in a position to make or control referral for laboratory services: The laboratory may write off charges only when laboratory errors in billing or testing occur. Sales and marketing personnel cannot offer free testing in any form unless approved by the compliance officer. Free testing for indigent patients must be approved by the compliance officer. Sales and marketing personnel cannot offer or give anything of value to a customer or potential customer beyond the usual promotional items. If a client solicits a questionable or illegal item or special consideration, it should be reported to the sales manager or compliance officer.

Laboratories may only lease space from physicians who refer Medicare patients to them under certain circumstances: There must be a written lease for at least one year. Lease price must be at "fair market value." All leases must be reviewed by legal counsel to ensure compliance with antikickback and Stark laws.When leasing or renting equipment to a physician or from a physician the same basic rules apply as for space.If the laboratory is located in a hospital, the relationship between the hospital and a physician who refers to the lab may have antikickback or Stark implications.

Never use sign and symptom information received from a patient for laboratory billing purposes.Never use ICD-9 codes from previous visits for a new visit even if the request is for the same test and the patient assures you that it is for the same reason. (Standing orders are an exception.)ICD-9 codes should be requested when setting up standing orders and will then apply to all subsequent visits. It is not necessary in this case to get a new ICD-9 code for each visit.If the patient refuses to sign an ABN but demands to have the test done: Have the fact that they were given notice (ABN) witnessed by a second person. (By phone if you are located in single-person drawing site). Ensure that documentation is complete.

When communicating directly with patients concerning their laboratory tests or orders be careful not to discuss the following: Why a test has been ordered by a physician. What the test might indicate or what the test results mean. Any opinions about their doctor. Any information about internal laboratory issues. Refer the patient to their doctor for information about the tests and the results.If the laboratory provides any printed information about tests that are designed for patients, give the patient that information.

The setting is automated chemistry department, night shift, busy core laboratory for a hospital based outreach laboratory. A medical technologist who operates the automated chemistry analyzer on third shift encounters short samples a couple of times a night. When this happens, he runs as many of the ordered tests as he can and fills in the blank results with a comment indicating that a short sample occurred. As far as he knows there isn't a policy that addresses this problem directly.The test reports out with the results and the comments. The technologist does not have to change the physician order in any way and is providing the maximum results that can be reported for the specimen in a timely fashion. This is done as a matter of patient care and quality service. There has not ever been a complaint about this practice as far as he knows. Are there any additional steps this technologist should be taking?Correct Answer: The technologist should follow the procedures that the laboratory has in place for testing and billing samples for which there is no order or for ambiguous orders. If the policies do not seem to address his particular situation, he thinks there should be a separate policy to cover this situation or has a question about it, he should talk to his supervisor or to the laboratory compliance officerDiscussion: This choice addresses the problem in the most complete manner, in that the employee fulfills his responsibility to take action when he thinks there is a problem.

The setting is the cafeteria in a hospital or the lounge in an independent laboratory. Two employees from different departments are old friends are having lunch together. A billing clerk and a medical technologist are friends and are having lunch together. The billing clerk mentions that she saw a bill go through the system for one of her coworkers for a biopsy. She asks the medical technologist if she has the necessary security level access to see pathology test results because she is concerned about the welfare of the coworker. The medical technologist does have the necessary security clearance to see the results. She should:Correct Answer: Refuse to look up the results for the clerk and remind the clerk that it is a violation of compliance policies to do so, or to ask another to do so. Remind her of the requirement for each employee to report any violations of policy. Discussion: The Medical technologist has a responsibility to report violations of compliance policies and the friend has put her in a difficult position. For that reason, it is not enough to just refuse the clerk's request. If the medical technologist does not take the responsibility to inform the employee of the policy then there is a possibility that the employee would ask some other employee to do it for her.

The Client Services department which is a crowded room divided into cubicles which contain desks separated only by thin moveable dividers. Lots of activity, phones ringing, multiple conversations going on at once etc. A client service representative receives a call from a large client office that she speaks with every day for a variety of reasons. Today the client is requesting the laboratory to write off the charges for a test that the office person ordered incorrectly by mistake even though the laboratory has already done the test and reported the results back to the office. Since this service representative works with this office frequently she believes that this is a rare request. Actions that the client service representative may take are:Correct Answer: Refuse to write off the charges for the test and inform the client that it could be considered an inducement if the laboratory does that, which would make both the laboratory and the office liable should it ever come to light. Offer whatever billing options are available according to lab policies. or Refuse to write off the charges and explain to the client that approval must be obtained from the department manager or the laboratory compliance officer before any action can be taken because writing the test off could be considered an inducement.Discussion: The primary reason is that the test is not written off simply because the client asks for it to be done. Tests should never be written off by the laboratory automatically. There should always be an approval process involved or a policy that strictly forbids any write off except in the case an error on the part of the laboratory where documentation exists to support it.

A courier is making a routine stop in a client's office and is approached by the office manager with whom he is very friendly because he has been going to this office for years. The office manager asks the courier if Dr. John Smith is a regular stop on his route and the courier answers yes. She then asks the courier if he would do her a little favor since he stops at Dr Smiths office regularly anyway and drop off an x-ray for her so she won't have to call a courier service. The courier knows that this is a big account for the laboratory and customer service is a high priority for the laboratory. This courier should:Correct Answer: Refuse to do it for the customer and explain to the customer that the laboratory has a policy that says he must only provide courier services related to laboratory.Discussion: Even though this is a single incident, by doing this favor the courier is giving the office manager license to ask these kinds of favors in the future. Since the provision of this free courier service is a form of inducement or kickback to the client, both the client and the laboratory would be involved if the such a practice were to go on regularly and be discovered by the government or by the laboratory. Hiding the incident and asking the office manager to conspire with him to do this will only make it worse for the employee and would lead to serious discipline action up to termination. The courier's best course of action, for the protection of his friend the office manager and himself, the physician practice and the laboratory is to not do this and explain the reason to the office manager so she is aware of the consequences of asking this favor.

Busy hospital laboratory in a 350 bed urban hospital that provides laboratory testing for the hospital and for the hospital's outreach testing laboratory. A medical technologist in the microbiology department receives a call from a friend who works in a laboratory in a physician office. The physician is not a regular client of the laboratory currently but uses another laboratory for most of their work. The microbiologist knows that the sales department would like to get this account. The friend explains to her that she is doing a quality control check on her in-office microbiology testing and her regular laboratory will do it but is going to charge her for it. She asks the microbiologist if she will do it for free since it is quality control, not Medicare and is not going to be billed to anyone.She tells the microbiologist that she would like to use the hospital lab for everything but her doctor insists on using the competitor. She indicates that the favor might help get the doctor to try the hospital laboratory for other tests. The microbiologist should:Correct Answer: Explain to her friend that if the hospital does the tests for no charge on the promise of other referrals, both the physician office and the hospital could be liable for violations of the antikickback statute.Discussion: The antikickback statute is implicated in this scenario because the free testing is solicited on the condition that other referrals may occur as a result of providing the favor. In fact, the solicitation itself is a violation of the law. The fact that Medicare patients are not specifically mentioned in the scenario is not sufficient to remove the risk. The technologist should also report the incident to the Compliance Officer and seek advise about what documentation, if any, should be kept concerning the incident.

The company also carries certain responsibilities: The laboratory has a responsibility to communicate to all its employees its compliance policies, procedures, standards of conduct and the consequences of non-compliance. All employees must be able to understand the policies and standards. The laboratory has a responsibility to act on reported problems and suspect activities. The laboratory must resolve problems and ensure they don't recur. The laboratory must take appropriate and fair disciplinary actions against all involved. The laboratory must report to the appropriate government agency when necessary. The laboratory must promptly return money received from the government to which it is not entitled. The laboratory must audit its policies and procedures to ensure they are being followed and that they work.

Laboratory administration has these responsibilities: Communicate compliance policies, procedures, standards of conduct to all employees and the consequences of non-compliance. Act on reported problems and suspect activities. Resolve problems and ensure they don't recur. Take appropriate and fair disciplinary actions against all involved. Report to the appropriate government agency when necessary. Promptly return money received from the government to which the laboratory is not entitled. Audit the laboratory's policies and procedures to ensure they are being followed and that they work.

All healthcare providers, including laboratories, could potentially submit erroneous claims for Medicare reimbursement. These billing errors can trigger an investigation. The creation of a voluntary compliance program, using the guidelines provided by the Office of Inspector General (OIG), can assist healthcare institutions and laboratories to audit themselves, thereby preventing submission of erroneous claims and a possible fraud and abuse investigation.

The laboratory has written and distributed to all affected employees, standards, policies, and procedures that instruct employees in the proper legal and ethical conduct expected in all areas of business the laboratory conducts. These policies must be adhered to by all employees regardless of status or position in the company.

The laboratory has established a comprehensive training and education program about the laws and regulations that govern the laboratory and the standards, policies and procedures of the compliance program. Mandatory for all employees regardless of status or position in the company. There is additional training for those employees who work in higher compliance risk areas of the laboratory such as billing, marketing, and sales. This interactive software is a component of that training program.

The laboratory monitors and regularly audits compliance activities, policies, and procedures to ensure they are being followed. If a problem is detected through the audit or monitoring process, it should be reported to the appropriate supervisor, manager or the CO.

The laboratory can only perform tests that are ordered by individuals authorized to order tests. If an employee knows that a test has been ordered by someone other then an authorized individual, the employee should report it to their supervisor or the compliance officer (CO). The laboratory must have a system in place to detect tests that are not performed due to a laboratory error and stop or credit the billing for these tests. The laboratory cannot bill for tests that are not performed. An employee who is aware that a test has been canceled or has not been performed for some reason must follow the policies and procedures associated with correcting the billing. Release of test results by phone, fax and other non-routine methods Employees should release test results only to the clinical person who is authorized to receive the test results (i.e., the ordering physician). Never release test results to another physician or entity unless authorized by the ordering physician in writing. Never release the results of a test to a patient unless authorized in writing by the ordering physician.

Panels and Profiles: It is not against the law for a laboratory to allow the use of panels, profiles and custom panels. However, all applicable CPT codes must be included. The laboratory must ensure that the ordering doctor knows what tests are included in a panel or profile and what CPT codes will be billed to the Medicare program. The laboratory notifies doctors about panels and profiles through a written notice and the requisition. Employees should not permit the order of any panel or profile not authorized by the laboratory.

The laboratory should not offer or provide free testing to any individual in a position to make or control referral for laboratory services: The laboratory may write off charges only when laboratory errors in billing or testing occur. Sales and marketing personnel cannot offer free testing in any form unless approved by the compliance officer. Free testing for indigent patients must be approved by the compliance officer. Sales and marketing personnel cannot offer or give anything of value to a customer or potential customer beyond the usual promotional items. If a client solicits special consideration, it should be reported to the sales manager or compliance officer.

A laboratory that receives referrals from a nursing home or Skilled Nursing Facility (SNF) should have a written agreement with that facility: The Agreement should define billing and documentation responsibilities. The facility should be responsible for determining the payment status of its patients and is liable for submitting incorrect payment information to the laboratory. Fees should be consistent with other similar customers. A laboratory that provides services to a Home Health Agency treating Medicare/Medicaid beneficiaries should have a written agreement with that agency: The Agreement should define billing and documentation responsibilities. The Agreement should place the responsibility on the Home Health Agency to establish that all patients receiving laboratory services are "homebound" as defined by Medicare. Fees should be consistent with other similar customers.

The setting is the cafeteria in a hospital or the lounge in an independent laboratory. Two employees, a billing clerk and a medical technologist, from different departments are having lunch together. The billing clerk mentions that she saw a bill go through the system for one of her coworkers for a biopsy. She asks the medical technologist if she has the necessary security level access to see pathology test results because she is concerned about the welfare of the coworker. The medical technologist does have the necessary security clearance to see the results. She should:Correct Answer: Refuse to look up the results for the clerk and remind the clerk that it is a violation of compliance policies to do so, or to ask another to do so. Discussion: The medical technologist has a responsibility to report violations of compliance policies and the friend has put her in a difficult position. For that reason, it is not enough to just refuse the clerk's request. If the medical technologist does not take the responsibility to inform the employee of the policy then there is a possibility that the employee would ask some other employee to do it for her.

The Client Services department is a crowded room divided into cubicles which contain desks separated only by thin moveable dividers. Lots of activity is present including phones ringing, multiple conversations going on at once, etc. A client service representative receives a call from a large client office that she speaks with every day for a variety of reasons. Today the client is requesting the laboratory to write off the charges for a test that the office person ordered by mistake, even though the laboratory has already done the test and reported the results back to the office. Since this service representative works with this office frequently, she believes that this is a rare request. Actions that the client service representative may take are:Correct Answers: Refuse to write off the charges for the test and inform the client that it could be considered an inducement if the laboratory does that, which would make both the laboratory and the office liable should it ever come to light. Offer whatever billing options are available according to lab policies. or Refuse to write off the charges and explain to the client that approval must be obtained from the department manager or the laboratory compliance officer before any action can be taken because writing the test off could be considered an inducement.Discussion: Tests should never be written off by the laboratory automatically. There should always be an approval process involved or a policy that strictly forbids any write off except in the case of an error on the part of the laboratory where documentation exists to support it.

A courier is making a routine stop in a client's office and is approached by the office manager with whom he is very friendly because he has been going to this office for years. The office manager asks the courier if Dr. John Smith is a regular stop on his route and the courier answers yes. She then asks the courier if he would do her a little favor since he stops at Dr Smiths office regularly anyway and drop off an x-ray for her so she won't have to call a courier service. The courier knows that this is a big account for the laboratory and customer service is a high priority for the laboratory. This courier should:Correct Answer: Refuse to do it for the customer and explain to the customer that the laboratory has a policy that says he must only provide courier services related to laboratory.Discussion: Even though this is a single incident, by doing this favor the courier is giving the office manager license to ask these kinds of favors in the future. Since the provision of this free courier service is a form of inducement or kickback to the client, both the client and the laboratory would be involved if the such a practice were to go on regularly and be discovered by the government or by the laboratory. Hiding the incident and asking the office manager to conspire with him to do this will only make it worse for the employee and would lead to serious disciplinary action up to termination.

A busy laboratory is located in a 350 bed urban hospital that provides laboratory testing for the hospital and for the hospital's outreach testing program. A medical technologist in the microbiology department receives a call from a friend who works in a laboratory in a physician office. The physician is not a regular client of the laboratory currently but uses another laboratory for most of their work. The microbiologist knows that the sales department would like to get this account. The friend explains to her that she is doing a quality control check on her in-office microbiology testing and her regular laboratory will do it but is going to charge her for it. She asks the microbiologist if she will do it for free since it is quality control, not Medicare, and is not going to be billed to anyone.She tells the microbiologist that she would like to use the hospital lab for everything but her doctor insists on using the competitor. She indicates that the favor might help get the doctor to try the hospital laboratory for other tests. How should the microbiologist respond to this request?Correct Answer: Explain to her friend that if the hospital does the tests for no charge on the promise of other referrals, both the physician office and the hospital could be liable for violations of the antikickback statute.Discussion: The antikickback statute is implicated in this scenario because the free testing is solicited on the condition that other referrals may occur as a result of providing the favor. In fact, the solicitation itself is a violation of the law. The fact that Medicare patients are not specifically mentioned in the scenario is not sufficient to remove the risk. The technologist should also report the incident to the Compliance Officer and seek advise about what documentation, if any, should be kept concerning the incident.

An Advance Beneficiary Notice (ABNs) is given to a Medicare beneficiary to inform him/her (or that person's representative) that Medicare may not provide coverage in a specific case (e.g., for a specific laboratory test). Entities who issue ABNs are known as “notifiers.” "Notifiers" can include physicians, practitioners, laboratories, and other suppliers of services that are paid under Medicare Part B. The "notifier" (e.g., the laboratory) must complete the ABN and deliver the notice to the affected beneficiary or his/her representative before providing the items or services that are the subject of the notice. The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain the original notice on file. Note: ABNs are never required in emergency or urgent care situations.

The Healthcare Common Procedure Coding System (HCPCS) and the Current Procedural Terminology (CPT) codes are used to describe specific tests or services. The amount of payment for a test is dependent on the HCPCS or CPT code. HCPCS or CPT codes should be assigned under the supervision of the laboratory technical staff. Billing department employees should never change a HCPCS or CPT code without the approval of a manager or compliance officer. If a billing department clerk notices that a particular HCPCS or CPT code is being rejected by a payer they should report it to their manager. It is against the law to use the wrong HCPCS or CPT code for the purpose of causing or increasing payment for a test.

Local Medical Review Policies (LMRPs) are published by Medicare for some laboratory tests. They are usually developed for tests that can be used for screening or diagnosis of disease. LMRPs use CPT codes to identify the tests and ICD-9 codes to determine when coverage is allowed. If an LMRP test is ordered by a physician, an ICD-9 code that is included in the LMRP must be given to the laboratory or the Medicare program will not pay for the test. It is against the law for a laboratory to change or add an ICD-9 code submitted by a physician. A laboratory should not submit a claim for an LMRP test that is not accompanied by an acceptable ICD-9 code. The Balanced Budget Act of 1997 made it illegal for physicians to order LMRP tests and not supply an ICD-9CM code with the order.

All employees have a responsibility to maintain the confidentiality of medical information. Medical information should never be discussed outside of the laboratory. Do not leave test orders or test results in areas where they can be viewed by patients. Do not discuss test results or any patient information in areas where patients can overhear the conversation. Be careful not to discuss confidential information on the telephone where patients can overhear the conversation. Employees should verify the identity of an individual requesting patient information.

Laboratories may place phlebotomists or other employees in a physician office if all of the following are done: Employee only performs laboratory related tasks. There is a written understanding given to the physician about what the employee can and cannot do. Periodic audits are done to ensure the employee is following these policies. Laboratories may place printers, computers, fax machines or other equipment or products in client offices as long as they ensure that: The physician understands the equipment belongs to the laboratory. It is used for laboratory purposes like receiving reports or ordering tests. Periodic audits are done to ensure that the client is using the equipment only for laboratory related activities.

The laboratory must ensure that its sales and marketing materials are clear and not deceptive: They should fully inform the physician about the appropriate use of laboratory tests and services. They should not be designed to induce unnecessary testing. The laboratory must have in place a document control system and record retention policy that ensures records are accessible in case of an audit or investigation. Records should be retrievable. Related documents should be linked.

Billing is the highest risk area for the laboratory because it generates the claims that are sent to Medicare and other government payers. Payment and payment errors are the focus of the OIG compliance guidance for the laboratory because of the revenue involved. Fraud and abuse is often perpetrated as a billing scheme. Nearly all laboratory functions can affect the billing of laboratory tests.

A laboratory may not bill a Medicare beneficiary for a test unless it notifies the patient in writing before the testing is done that Medicare is not going to pay for the test. This notice is called an ABN. The ABN must contain the specific name of the test and give a specific reason the laboratory thinks payment for the test will be denied. The beneficiary should sign the ABN and a copy should be sent to the laboratory and one given to the beneficiary. The billing department must have evidence that the ABN has been signed before it bills a patient. A laboratory may bill Medicare even though it knows it will not be paid when it has evidence an ABN has been signed.

In 1990 OSHA issued a Standard to replace Haz-Com specifically designed to: Meet the needs of laboratories with large varieties of chemicals. Mandate specific training for laboratory employees. This standard is called Chemical Hygiene (Standard # 1910.1450.)

Identifies any special precautions which should be taken during fire fighting procedures. This chemical is still flammable when diluted, and can be extinguished by an ABC fire extinguisher. Special fire fighting procedures included would not necessarily apply to a laboratory setting.

Laboratory safety includes a number of precautions designed to protect you and your coworkers. Remember that: eating drinking smoking applying cosmetics or lip balm are forbidden in areas where chemicals are present.

If there's a fire in the laboratory and chemicals are involved, there's a chance that some of the chemicals could react adversely with water. For that reason, the best fire extinguishers to use are ABC fire extinguishers. Using water to extinguish a chemical fire could actually fuel the blaze or cause chemicals to splatter.

Also remember to: Learn basic first aid measures. Read chemical labels. Read MSDS. Follow warnings and instructions. Use the correct protection. Practice sensible, safe work habits. Be knowledgeable about your laboratory's Chemical Hygiene Plan and the location in your laboratory of all reference materials on the hazards, safe handling, storage, and disposal of hazardous chemicals, including the location of Material Safety Data Sheets.

A ground is a conducting connection between an electrical circuit or equipment and the earth, or between an electrical circuit and some conducting body that serves in place of the earth.The purpose of a ground is to prevent the buildup of voltages that may result in a hazardous situation for the connected equipment and/or for the person operating the equipment.All electrical equipment in the laboratory that is not clearly marked as "double-insulated" must be grounded by using a three-pronged power cord.

All laboratory instruments and appliances should be checked for ground integrity and current leakage before initial use, after repair or modification, and any time a problem is suspected.Periodic checks should be made on all electrical wires. If frayed wires are found, the equipment should be immediately removed from use and repaired.Report to your supervisor any shocks or tingling received from electrical equipment.

1987 Haz-Com Standard is designed to help control employee exposure to chemicals on the job.1990 Chemical Hygiene Standard is specifically designed to meet the needs of laboratories with large varieties of chemicals, and to require specific training for laboratory employees.1992 Formaldehyde Standard is specifically for employees that work with formaldehyde. The goal was to reduce the risk of formaldehyde overexposure by establishing safe exposure limits.

Formaldehyde solution is a colorless, aqueous solution containing not less than 37% of formaldehyde or CH2O. It is usually supplied in 55 gallon drums.Formalin is a 10% formaldehyde solution that is commonly used in the laboratory.

Your laboratory is committed to providing you with a safe working environment. It also expects you to do your part : Be a responsible member of the laboratory team. Use safe work practices.

1987 Haz-Com Standard (29 CFR 1910.1200) is designed to help control employee exposure to chemicals on the job. 1990 Chemical Hygiene Standard (29 CFR 1910.1450) is specifically designed to meet the needs of laboratories with large varieties of chemicals, and to require specific training for laboratory employees. 1992 Formaldehyde Standard (29-CFR 1910.1048) is designed specifically for employees who work with formaldehyde. The goal of this standard is to reduce the risk of formaldehyde overexposure by establishing safe exposure limits.

Smalll spills (generally less than one liter) may in most instances by handled by laboratory or other employees. However, if you experience symptoms of over-exposure during the clean up, such as burning eyes, or throat irritation, immediately leave the cleanup area and get help from your institution's Spill Response team or other designated persons.Larger spills (generally greater than 1 liter) will usually require immediate assistance from the Spill Response team or other designees. There are several ways to clean up small spills, two of which are described below:1. Dike up the formaldehyde with absorbent pillows. Then dispose of these pillows in a sealed, formaldehyde-labeled container. 2. A chemical that reacts with and neutralizes formalin such as ALDEX® may be used to treat the spill.Your supervisor will show you the location of these emergency spill clean-up materials or discuss alternative procedures. Be sure to follow your own institution's policies and procedures in regard to formalin spills.

The appropriate MSDS (Material Safety Data Sheet) for formaldehyde can be found in your laboratory's MSDS book or online. You should know where to access the MSDS and be familiar with its content. Direct any questions you may have to your supervisor.

Engineering controls must be established to reduce formalin exposure to the lowest possible level. In most cases, chemical fume hoods or/and ventilated grossing stations serve as the primary engineering controls to reduce formaldehyde vapors. Rooms in which formalin is used may also require special direct exhaust ventilation. Formaldehyde should be dispensed or used in a chemical fume hood or other appropriately ventilated and approved work area. Check your laboratory's policies and procedures to be sure you use the engineering controls provided, as well as the required personal protective equipment.

Training records must include: Employee name Most recent date trained Description of training Description, copy, or location of training materials Name and address of trainerThese records must be maintained throughout employment and 90 days thereafter, according to the US Department of Transportation (DOT). IATA and some laboratory regulatory agencies, including the College of American Pathologists (CAP), require repeat of training every two years. DOT requires training every three years. You will be able to print a certificate when you have completed this course that will certify your completion of training for packaging and shipping Division 6.2 (infectious) materials.

Laboratory specimens that are unlikely to cause disease and do not meet the criteria for category A or B substances are not subject to Division 6.2 regulations. Specimens for which the hazardous materials regulation (HMR) does not apply include human or animal samples (including, but not limited to, secreta, excreta, blood and its components, tissue and tissue fluids, and body parts) being transported for routine testing not related to the diagnosis of an infectious disease. This includes specimens that are being sent for: drug or alcohol testing cholesterol testing blood glucose level testing prostate specific antibody (PSA) testing testing to monitor kidney or liver function pregnancy testing tests for diagnosis of non-infectious diseases such as cancer biopsies

A blood specimen is collected from a patient that is suspected of having Hepatitis B. The specimen will be sent via commercial carrier (e.g., Federal Express, DHL, or UPS) to a reference laboratory for further testing. What classification should be used for appropriate packaging and labeling? Work through the Classification Decision Tree.

A blood sample, collected from an outpatient, will be sent via FedEx to a reference laboratory for cholesterol screening. What classification should be used for appropriate packaging and labeling?Work through the Classification Decision Tree.

Several things need to be considered when you are determining how to package a laboratory specimen. These considerations include: Type of specimen Solid Liquid Classification Category A Category B Exempt Size of the specimen Temperature at which the specimen must be held during shipping Will dry ice be included in the package? The specimen components Does the specimen contain a preservative, such as formalin, that may be regulated? Mode of transportation Commercial ground Passenger air Cargo air Postal service Private or contract carrier using exclusive use motor vehicle

International Civil Aviation Organization. Technical instructions for the safe transport of dangerous goods by air. Doc 9284; 2005 - 2006 ed with amendment. National Laboratory Training Network. Packaging and shipping Division 6.2 materials. Georgia Public Health Laboratory; 2008. Sentinel Laboratory Guidelines for Suspected Agents of Bioterrorism. Available at: http://www.asm.org/ASM/files/LeftMarginHeaderList/DOWNLOADFILENAME/000000001202/Packing&Shipping11-18-05.pdf Accessed on February 13, 2009.US Department of Transportation Pipeline and Hazardous Materials Safety Administration. Transporting Infectious Substances Safely. Guide to changes effective October 1, 2006. Washington, DC; 2006.

Therapeutic drug monitoring and pharmacogenomics are both pharmacy-related areas within the clinical laboratory. Although each is considered a sub-discipline within laboratory medicine, the two fields overlap significantly. In this course, we will provide an overview of each of these laboratory sub-disciplines and discuss the utility, rationale, and practice of each one.

The ultimate goal in measuring CYP450 function or identifying polymorphisms is to predict effective therapeutic doses and responses in patients.Polymorphisms are identified using molecular techniques (allele-specific PCR, restriction digests, sequencing, hybridization assays, bead-based systems, microarrays, pyrosequencing, et al).Although most clinical labs do not offer PGx testing, reference labs are beginning to market these tests. For example, one reference laboratory in the Midwest that offers CYP2D6 profiling measures about one dozen of the most common and significant mutation sites on this enzyme. This allows for detection of approximately 98% of the known CYP2D6 polymorphisms. The laboratory then generates a report which will advise the physician on the patient's drug-metabolizing status.Estimates show that 6-10% of the general population have a complete deficiency of CYP2D6, with the prevalence of mutations varying from <1% to as much as 21% within a given population.

James Brown, a phlebotomist from the laboratory went to the second floor of Memorial Hospital to draw a STAT BMP (chem-8), CBC, and PT on a patient. The patient was in critical condition so the lab results were crucial for treatment. James quickened his pace in order to speed up the result time. He collected the specimens and took them back to the lab. However, the technologist in hematology and coagulation notified him that he would need to recollect the specimen because the CBC and PT were clotted.

Poor and unsatisfactory specimens pose significant problems : They can cause misleading laboratory results.Unsatisfactory specimens must be rejected by the laboratory. The patient must then undergo another venipuncture to get a better specimen. It costs time & money to redraw the specimen.The credibility of the laboratory is reduced if too many unsatisfactory specimens are drawn.

The phlebotomist collects blood & other specimens which ultimately provide doctors and nurses with laboratory test information critical to patient care.He or she therefore plays a vital role in any health care system.

Phlebotomist positively identifies patient. Phlebotomist draws and labels blood specimen. Specimen is transported to laboratory. Specimen is accessioned and processed in lab.

As a professional phlebotomist, you have a critical role in this basic work-flow cycle. The rest of this program contains the information you need to begin training in this important profession.

Assayed controls have been analyzed by the manufacturer so that the range of values for the analytes they contain is known. Unassayed controls are unknowns. The laboratory purchasing the controls must determine the concentration of each analyte.

External quality control (also called proficiency testing or PT) evaluates a laboratory’s testing results by comparing them to those of similar laboratories. Specially prepared specimens are obtained by multiple laboratories from proficiency testing program sponsored by professional societies, such as the College of American Pathologists or the American Association of Bioanalysts. These "unknowns" are then tested by multiple laboratories, and results are returned to the proficiency testing program. For external quality control, the laboratory must use its routine testing methods.

Daily Documentation and evaluation of quality control is vital to diligently monitor sources of error. One of the most commonly used methods for documentation is the Levey-Jennings control chart (often referred to as the L-J chart). In 1931, Dr. Walter Shewhart, a scientist at the Bell Telephone Laboratories, proposed applying statistical based control charts to interpret industrial manufacturing processes. In 1950, S. Levey and E.R. Jennings suggested the use of Dr. Shewhart’s control chart in the clinical laboratory.

On April 24, 2003, the Clinical Laboratory Improvement Amendments (CLIA) Final Rules went into effect.As of that date, each laboratory that introduces a nonwaived, unmodified, FDA-cleared or approved test system must do the following before reporting patient test results: Demonstrate that it can obtain performance specifications comparable to those established by the manufacturer for the following performance characteristics: Accuracy. Precision. Reportable range of test results for the test system. Verify that the manufacturer's reference intervals (normal values) are appropriate for the laboratory's patient population.

A ten-year-old boy came to a physician's attention because of recent jaundice and icteric sclerae. The immediate laboratory work revealed: Hct 24%(normal 36%-47%), MCV 79.5 fl (normal 78-95fl),RDW 13%(normal 11.5-15.0%). His blood smear findings are reflected in these photomicrographs. Note particularly the spherocytes in the upper picture. Some resemble a half-blister with the other half of the cell containing solidly-staining hemoglobin. These are called eccentrocytes. When present, they should trigger a search for red cell hereditary G-6PD deficiency and the oxidant that triggered hemolysis. These morphological findings are only clues; specific testing for G-6PD deficiency should be performed. The blue arrows in the upper photomicrograph are directed toward solid-staining spherocytes in which the cell membrane is beaded by inclusions wrapped within the cell membrane, suggesting the remains of denatured hemoglobin. Included on the smear is a target cell, several acanthocytes, a smudge cell, and a few schistocytes. The lower photomicrograph is supravital staining of affected red blood cells, verifying the presence of Heinz bodies. This disorder was first recognized during the Korean war in 10% of black American soldiers given the antimalarial drug primiquine.

Illustrated in the photomicrograph of a peripheral smear are two populations of erythrocytes. Approximately 50% of the erythrocytes are normal size and contain a full complement of hemoglobin. The patient had received blood transfusions. The transfused red blood cells are the normocytic, normochromic red cells. Admixed are microcytic erythrocytes and larger erythrocytes, some faintly mottled or smudged, suggestive of reticulocytes. This picture represents a hemolytic process with a reticulocyte response. A similar dimorphic red cell population appears following erythropoietin therapy. It is important to recognize when a population of cells in the peripheral smear is not in context with anticipated laboratory findings and the clinical situation.

Laboratory data must be presented to clinicians in a user friendly way to promote effective decision making. Databases must be designed to provide clear information that leads quickly to the best patient care outcome. We continue learning how to collect and retrieve laboratory data from our machines, but we are not always in tune to how entry and retrieval of data is geared to and, more directly, influences patient care outcomes. Examples of blood cell abnormalities on a peripheral blood smear that may immediately direct the physician to a specific diagnosis are: (1) presence of target cells as found in thalassemia or hemoglobinopathies and target cells in liver disease, particularly with obstructive jaundice; (2) burr cells as a signal of chronic renal disease and uremia; and (3)atypical neutrophil inclusions relating to genetic disorders. Critical appraisal of such observations could add valuable clues for a diagnosis. Laboratory professionals must establish a set of principles for orderly observation of blood cell morphology, have a clear vision of the applications of their work, and understand the potential clinical implications of their reports and interpretations. Emphasis on values and relevance focuses on patient care outcomes and their dependency on prompt availability of results and contextual interpretations.

In a study on the reporting of red blood cell morphology abnormalities conducted in Ontario, Canada (Hookey L, Dexter D, Lee DH, Laboratory Hematology 7:83-88, 2001), fewer than 50% of 33 participants used the same term to describe the quantitative frequency of peripheral blood abnormalities. Seven blood smears, each containing one of several abnormal erythrocytes-- schistocytes, teardrop cells, acanthocytes, and Howell-Jolly bodies--were evaluated by 32 participants. The participants were asked to document their evaluations from a list of quantitative terms. There was a heterogeneity in the use of terms "rare," "slight," "occasional," "few," "mild", "present," "moderate," "many," and "marked." Choices of terms were subjective without points of reference. Guidelines for establishing standardized qualitative estimations of abnormal erythrocytes in the peripheral smear are presented as follows: 1+ = 2 - 4/Oil Immersion Field (OIF) 2+ = 5 - 7/OIF 3+ = 8 - 10/OIF 4+ = >10/OIF. The terms "few," "moderate," "many," and "marked" may be substituted for the 1+ - 4+ grading system, but only when their specific points of reference are universally understood in tandem with the above guidelines. A comment should be triggered if any erythrocyte abnormalities are seen in numbers >3/OIF including, but not limited to, polychromasia, basophilic stippling, nucleated RBC's, and Howell-Jolly bodies. Rouleaux or RBC agglutination are important findings and must be documented.

It is important to differentiate in vitro changes which are secondary to preparing the slide, from in vivo morphology, which is the result of the pathophysiological condition of the patient. Examining erythrocytes in the critical viewing area is extremely important in making this distinction. The determination of the clinical significance of the morphology reported is the responsibility of the physician, who must correlate the blood smear findings with the clinical diagnosis, and other laboratory parameters.

Venipuncture is the collection of blood from a vein. The person having the responsibility for the performance of the venipuncture may be a phlebotomist who is a part of the laboratory staff, or he/she may be another healthcare professional that has been trained to perform this duty. In this course, we will refer to the person performing the venipuncture as the phlebotomist.

Hidden errors are those that cannot be detected or corrected by the laboratory analyst prior to testing. Most often these errors can be prevented by the phlebotomist following correct venipuncture procedure for every procedure, every time.Hidden errors include hemoconcentration, incorrect order of draw, and (the most serious of all errors) misidentification of patient or specimens. Because these errors often are unknown, the analyst may inadvertently report erroneous patient results which could be harmful to the safety and well-being of the patient. Condition What is it? How does it happen? What is the Result? Hemoconcentration Blood pools at site of venipuncture Tourniquet is applied for a prolonged period of time Test results may be inaccurate because blood components move between blood and tissues Pouring Blood between tubes Mixing contents of two or more tubes Removing top of tube to combine contents of one tube with another Inaccurate test results due to over or under dilution or incorrect anticoagulant Clots form due to lack of mixing Patient may have to be redrawn Incorrect patient identification and incorrect specimen labeling Using the wrong name to label a specimen Failure to positively identify EVERY patient using 2 unique identifiers BEFORE beginning venipuncture Failure to label EVERY specimen in the presence of the patient Failure to concentrate fully on the task Results reported to caregiver for wrong patient Compromises patient care; may be life-threatening

Fill blood collection tubes completely (until vacuum is exhausted) to ensure the correct blood to anticoagulant ratio necessary for accurate patient results. Specimens may be rejected by the laboratory if the tube is short-filled or over-filled. To avoid short-filling of tubes, the phlebotomist must ensure that the blood flow stops completely before removing the tube from the needle. When using a winged device (butterfly) to collect blood for coagulation studies (e.g., protime, aPTT), the phlebotomist must draw a light blue top "waste" tube before attaching another light blue top tube for testing. If the air in the tubing of the winged device is not displaced into a waste tube and is drawn into the tube used for testing, the tube used for testing will short-fill. The laboratory may reject the specimen because of invalid blood to anticoagulant ratio.

Clinical and Laboratory Standards Institute (CLSI). Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays; Approved Guideline. Fourth ed. CLSI document H21-A4. NCCLS. Wayne, PA: 2003.Clinical and Laboratory Standards Institute (CLSI). Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard. Sixth ed. CLSI document H3-A6. NCCLS. Wayne, PA: 2007.Clinical and Laboratory Standards Institute (CLSI). Procedures for the Handling and Processing of Blood Specimens; Approved Guideline. Third Edition. CLSI document H18-A3. NCCLS. Wayne, PA: 2004.Ernst DJ. Applied Phlebotomy. Baltimore, MD: Lippincott Williams & Wilkins: 2005.Lowe B. Reinforcing safety sticklers. Advance for Medical Laboratory Professionals. May 2004; 16:2A-3A.The Joint Commission. Patient Safety-2009 National Patient Safety Goals. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/. Accessed July 18, 2009.

When the results on Mr. John Ready were called to the nurse, she was very surprised that the result of his CBC was normal. The nurse explained to the laboratory technologist that Mr. John Ready had a known diagnosis of lower GI bleeding. His hemoglobin had been very low for the past 24 hours because of the internal bleeding, and she thought it was very surprising that his hemoglobin had normalized so quickly without having received a blood transfusion. Mr. Ready’s doctor decided the patient should be redrawn to ensure a correct result. The nurse further questioned if the phlebotomist could possibly have drawn the wrong patient because earlier that day Mr. Ready had been moved to room 831, and room 825 was presently occupied by a patient named Walter Redding. If Julie had properly identified the patient by asking him to state his name and then checking the name and identification number on the wristband, she would have realized that the patient in 825 was the wrong patient.

Round cells in semen are of two types: immature sperm and white blood cells. To determine the percentage of white blood cells (specifically granulocytes) a special leukocyte screening test must be done. This test involves staining for the peroxidase enzyme present in the granulocytes.The 1999 WHO manual contains a protocol for doing this test (Appendix III). There is also at least one test kit on the market for this assessment (Leukoscreen: Bioscreen, Inc.).Laboratories with particular expertise in doing CBC and assessing granulocytes in stained blood smears may be able to do a differential count by this method rather than using a biochemical test for leukocyte screening.

This presentation will describe basic aspects of WHO III assessment. For information on details of some of the morphological assessments you will need to review information presented in the 1992 WHO III manual.Learning to do strict morphology assessments is more complicated than learning WHO III and generally requires that the technician take one of the many hands-on laboratory courses offered periodically around the country. Details of strict morphology assessment are presented in the 1999 WHO IV manual.

Most semen is somewhat viscous. Liquefaction should be complete before viscosity is assessed. Semen viscosity can be determined by trying to draw the specimen into a wide bore pipette. Normal semen can be dropped from a pipette in single droplets. Some laboratories report viscosity on a scale from 0-4. Others report the results as "non-viscous", "slightly viscous", "very viscous" and so forth. A specimen that is more viscous than normal after liquefaction may have reduced sperm motility. During sexual intercourse, hyperviscosity can prevent the sperm from reaching the cervix.

Other aspects of specimen collection that must be considered are the temperature of the specimen and the time needed to transport it to the laboratory.Ideally, the specimen should be collected in a room at the testing site.If on-site collection is not possible, the specimen should be kept at body temperature (37°C) from the time of collection until it arrives at the laboratory. This can be facilitated by holding the container close to the body, for example by carrying it in an inside pocket.Semen should arrive at the laboratory as soon as possible after collection, preferably within one hour.Lubricants should not be used for collection unless absolutely necessary as most lubricants are toxic to sperm. If lubricant must be used then non-toxic forms such as KY jelly or cooking oil should be the only options.

Microscopic examination of semen includes assessment of: sperm concentration percent motility percent viability cellular elements other than spermatozoa sperm morphology Sperm counting will be covered in this section. Assessment of other cellular components and of morphology will be covered in the next sections. For assessing count, motility, viability and other cellular components your laboratory will require a phase contrast microscope with 10x oculars and objectives up to 20x. For assessing morphology you will need bright field objectives up to 40x and 100x (oil immersion).

Motility of a normal semen sample is 50% or greater.Sperm motility is important because sperm must be moving in order to penetrate the cervical mucus, travel to the fallopian tube, and fertilize ova.Accurate motility evaluation requires that the temperature be standardized. Some laboratories read motility at 37°C while others routinely report motility at room temperature. The temperature of the assessment should be specified in the final report.

In addition to determining the percent motility, the laboratory must evaluate the quality of the movement. The process of rating motility may vary somewhat from one laboratory to another. Normal motile sperm should have strong forward progressive motion. Automated sperm analyzers commercially available and specifically designed to evaluate semen can add specific information about motility parameters. In addition to determining percent motility, they calculate the speed at which the sperm are swimming in microns/second.

The transfusion service laboratory (TS) instructed clinical staff to draw blood specimens for compatibility testing before transfusing any blood components or products.Once the blood samples were collected, the clinical staff immediately began transfusing the patient with the O Rh-negative blood.

The laboratory obtained post-transfusion blood specimens in order to perform a serological investigation. Pretransfusion and post-transfusion DATs were performed. Patient cells DAT CC Pretransfusion 0 2+ DAT = direct antiglobulin test with polyspecific antiglobulin serumCC = IgG sensitized RBC

The microscopic examination was traditionally performed on all urine specimens after macroscopic exam, specific gravity and chemical tests were completed. Today, many laboratories perform a urine microscopic only if preliminary evaluation indicates the need for microscopic examination. Such laboratories must have criteria determining the specimens on which a urine microscopic will be determined. The microscopic exam is often important in detecting and evaluating renal and urinary tract disorders as well as other systemic diseases.

The TST interpretation depends on the measured diameter of the induration and the clinical status of the patient.An induration of 15 or more millimeters is considered positive in all persons.An induration of 10 or more millimeters is considered positive in patients in the high risk progression groups and in mycobacteriology laboratory workers.An induration of 5 or more millimeters is considered positive in the high risk infection groups.

Biosafety level (BSL) 3 practices, safety equipment, and facility design and construction are applicable to microbiology laboratories that work with indigenous or exotic agents with a potential for respiratory transmission, and which may cause serious and potentially lethal infection. If the laboratory is propagating and manipulating cultures for M. tuberculosis, BSL 3 practices, containment equipment, and facilities are required. Nonaerosol-producing manipulations can be performed using BSL 2 practices, containment equipment, and facilities. At biosafety level 3, laboratory manipulations should be performed in a Class l or Class ll biosafety cabinet (BSC) or other physical containment device. Secondary barriers include controlled access to the laboratory and ventilation requirements that minimize the release of infectious aerosols from the laboratory. Secondary barriers should include self-closing double-door access and negative airflow into the laboratory. Exhausted air must not be recirculated.

The findings in the photograph from a peripheral blood smear would elicit a report comment of "increased platelets" of some high magnitude, such as "marked" or "4+". Estimates of platelet counts from review of a peripheral blood should be made on each smear examined. This provides a simple estimate of "high" or "low" or corroborates the value generated from an electronic cell counter. A formula for estimating platelet counts must be established in each laboratory. Following is a guideline: 5/oil power field (OPF) = 100,000/cumm; each platelet thereafter = 10,000/cumm. Thus, if an average of 10 platelets/OPF are observed, the estimated platelet count is 150,000.cumm. Such a counting scheme for platelets when clustered as in the photograph is probably not needed, as there are more than 100 platelets in the field. This translates into a platelet count of 1 million/cumm or more. This peripheral smear observation, however, would serve to corroborate an electronic platelet count of 1.2 million/ cumm.

In most clinical hematology laboratories, an initial blood count is performed by an electronic instrument. Some of these instruments also produce a differential blood count, and a platelet count. Instruments that provide a 3-part differential indicate the percentage of neutrophils, lymphocytes, and a mixed field group that includes monocytes, eosinophils, basophils, immature and atypical cells. Thus, the atypical cells shown in the photograph would be counted as mixed cells and a smear review would be needed to make an identification. Instruments providing a 5-part differential count include monocytes and eosinophils. In cases where the mixed cell count is high, or there are other indications that atypical cells may be present, a hematologist's review of the smear is indicated.