Procedures Information and Courses from MediaLab, Inc.

Burtis, CA. & Ashwood, ER. Tietz Textbook of Clinical Chemistry 2nd ed. W. B. Saunders. 1994.Harmening, DM. Clinical Hematology and Fundamentals of Hemostatis 5th ed., F.A. Davis, 2008Lotspeich-Steininger, Stiene-Martin and Koepke, Clinical Hematology Principles, Procedures, Correlations, Lippincott 1992McKenzie, SB., Textbook of Hematology 2nd ed., Williams and Wilkins 1996.Miale, JB, Laboratory Medicine Hematology 6th ed., Mosby 1982.Nouwens, J and Spahn, M. Hemoglobin H Disease: A self-instructional unit 3rd ed., Educational Materials for Health Professionals, Inc. 1991.Doig, K. Rodak's Diagnostic Hematology 3rd ed. W.B.Sunders Co., 2007.

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.

Spinal fluid samples are either clear or turbid. Some sources use the following rating system for turbid CSF specimens: 0 = crystal clear fluid 1+ = faintly cloudy, smoky, or hazy 2+ = turbidity clearly visible but newsprint read easily through tube 3+ = newsprint not easily read through tube 4+ = newsprint cannot be seen through the tubeTurbidity may be caused by leukocytes, erythrocytes, fungi, bacteria, amoebae, contrast media, or aspiration of epidural fat during puncture.200 leukocytes/mm3 will cause slight turbidity (1+); increased numbers of WBCs will cause increased turbidity. At least 400 erythrocytes/mm3 are needed to produce 1+ turbidity.Occasionally CSF will have an oily appearance due to the presence of substances remaining in the CSF after radiologic (x-ray) procedures have been performed.

Use a fresh, well-mixed uncentrifuged urine. Hold the reagent strip by the opposite end from the test areas and dip the stick into the specimen so that all test areas are immersed in the specimen. Remove the stick immediately. Prolonged immersion in the sample may wash out the test reagents. Hold strip in a horizontal position and run the edge of the strip against the rim of the urine container or touch the long edge of the strip to absorbent toweling to remove excess urine (do not blot the strip). Maintain the strip in a horizontal position to prevent mixing of reagent chemicals. Observe the reagent pads at the specified time periods. Color changes that occur after the stated maximum read time are not valid. Hold the strip close to the chart and compare the colors to read the results. A good light source facilitates accurate reading. Quality control procedures should be performed with each new lot of reagent strips and as often as required by the laboratory's procedure

Semiquantitative tests are used in some laboratories to confirm the presence of protein in the specimen when the result is positive on the urine dipstick. Tests that are used for confirmation include: sulfosalicylic acid (SSA); heat and acetic acid; nitric acid ring test; and Roberts' Ring Test. Any one of these procedures may be used for confirmation of the presence of protein. A protein dipstick result that is greater than a trace may be an indication of proteinuria.

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.

“Ketone bodies” is a generic term which refers to acetoacetic acid (diacetic acid), acetone, and beta-hydroxybutyric acid. Screening procedures used to detect ketonuria do not react with all ketone bodies. Since all three of the ketone bodies will be present in the urine and are equally significant, it is sufficient to detect an increase in any one or two of the ketone bodies. Most procedures, including Acetest®, measures acetoacetic acid and acetone but not beta-hydroxybutyric acid.

Many people involved in the clinical laboratory sciences need to be familiar with basic statistics for a variety of reasons.  These reasons include: performing quality control, and interpreting of results of instrument testing determining suitability of different methods or instruments for the same task understanding how acceptable laboratory procedures and methods are established determining ranges for clinical tests of normal, healthy individuals understanding clinical trials and new methods presented in journals and articles performing those trials and research projects yourself

If a plaque ruptures it will expose sub-endothelial tissue to blood cells and in so doing stimulate the formation of a clot. The clot is the body's attempt to seal off the crack but the clot itself can cause further obstruction to blood flow. This sudden increase in the blockage caused by the raised ruptured plaque and associated clot can transform a mild blockage into a critical one within a matter of hours. If it occurs within the blood vessels of the heart, the decrease in blood flow leads to severe and prolonged chest pain known as unstable angina. Such a patient is at obvious risk for a myocardial infarct should the blockage become any worse.Atherosclerosis typically begins in early adolescence, and is found in most major arteries but since it is asymptomatic during the early half of life we need cardiovascualr risk markers to help assess patient risk. If an at-risk patient is identified early, the hope is that medication, lifestyle changes or medical procedures can be used to avert a serious cardiovascular event. So, although the vast majority of us have some degree of atherosclerosis, risk markers can help identify those among us who are in more imminent danger or who have increased risk of an adverse cardiovascular event.

Specimen collection and handling in molecular based methodologies will differ based on the target of interest and the specific testing protocol. Each individual procedure will require specific specimen collection and handling procedures. It is imperative that the collection and handling instructions are followed to decrease the possibility of introducing interfering substances.

Some global specimen collection and handling issues to consider include: Specimens that contain nucleated cells will be of interest in DNA methodologies while specimens lacking nucleated cells are more useful in RNA methodologies. rRNA is more stable than mRNA, which is labile and sensitive to contamination. DNA is relatively stable and can be obtained from nonviable sources. Serum or plasma obtained by standard routine venipuncture procedures can be used as long as proper site selection and decontamination occur. Standard anticoagulants such as Ethylenediaminetetraacetic Acid (EDTA) and Acid Citrate Dextrose (ACD) can be used; however avoid the use of heparin as an anticoagulant as it interferes with some polymerase chain reaction (PCR) methodologies. When using fluorescence, fasting serum or whole blood specimens should be used to decrease the interference by lipids.

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.

Unsaturated iron binding capacity (UIBC) may also be used as a marker for altered iron metabolism. UIBC represents the portion of iron binding sites on transferrin that are not occupied by iron. Therefore, a low UIBC indicates that transferrin is highly saturated with iron, a finding consistent with hereditary hemochromatosis (HH). HH may be suspected when the UIBC is less than 143 micrograms/dL, a criterion suggested by the results of one study.(5)UIBC may be a lower cost alternative to the more complex transferrin saturation (TS). UIBC and SI are both fully automated procedures that are available on widely used laboratory instruments. The TIBC can be calculated by adding UIBC and SI, resulting in a value for TIBC that can be used for determining TS: TS = SI/(SI + UIBC) X 100

Administrative Safeguards include the policies, and procedures that your facility uses to manage and protect ePHI. Although there are probably many such policies and procedures at your institution, a few examples might include: Active review and audits of IS activity. Employee confidentiality agreements. Employee security clearance policies and procedures. Employee disciplinary policies. Data backup and disaster recovery plans

Standard Internet email provides no security for PHI. Many facilities would choose not to allow transmission of PHI via email at all. Some facilities may allow transmission of PHI via secure encrypted email, or as password protected email attachments. You must of course comply with your facilities' policies and procedures regarding any use or disclosure of email for PHI.

Access to computer systems must be password protected. Please read and understand the password recommendations below, but remember, you must follow your own facility's specific password policies and procedures. Keep passwords secret; do not share them with others.Memorize passwords to avoid having to write them down.Create strong passwords which:Are at least 7 characters long.Are not dictionary words or easily recognizable proper nouns.Include upper and lower case letters, numbers, and special characters.Change passwords regularly. Never select "remember my password" if prompted by Windows to do so.

Fax Machines may be used to transmit PHI, provided that you are in compliance with your own institution's policies and procedures. To minimize the risk of misdirected faxes: Preprogram fax machines with frequently used destination numbers. Double check accuracy when faxing to numbers which are not preprogrammed. Always include a Confidentiality Statement on the cover page. Check transmittal confirmation after each fax, to ensure that the information was sent to the correct number. Do not leave the original report on the fax machine. Report fax errors to your supervisor or other designated person.

The remainder of this course will cover what you need to know about the: HIPAA Privacy Regulation, and HIPAA Security Regulation.You will, of course, also need to understand and follow your own institution's privacy and security policies and procedures.

Gloves must be worn: when there is a reasonable chance of exposure to blood, other infectious body fluids, mucous membranes, or nonintact skin. during vascular access procedures, including phlebotomy. when handling contaminated items or surfaces.Wear only flat rings under gloves as large rings may tear gloves.Replace gloves: Between patient contacts If they are damaged or contaminated Before leaving the work area. Wash hands after removing gloves.Never wash disposable gloves.

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

Bone marrow samples are obtained from the patient by a physician. The technologist is responsible for examining the sample macroscopically to ensure that it is adequate, making slides on the unanticoagulated sample and processing the remaining portions of the sample as required for procedures ordered.

Quality control procedures are performed in a clinical laboratory to ensure that patients' results are reliable. Reliability refers both to accuracy (how close a test is, on average, to patients' true results) and precision (the consistency of tests performed at different times).

An internal quality control program must monitor results both in the normal range and in the abnormal range. For each test, there is one control in the normal range and one or two abnormal controls. Abnormal controls may be in the unhealthy but physiologically possible range, or outside what is physiologically possible, or both. Testing in many ranges ensures that the procedures are accurate for a wide range of patient results. Controls are run at least as often as specified by the instrument manufacturer. Controls should also be run whenever there is concern about the quality of results or stability of the testing system, or if the results of previous controls were not acceptable.If a problem is discovered, the samples in previous runs of the instrument may also have been affected. Once the problem(s) are corrected, it may be necessary to go back and re-run previous samples working in reverse order, until the retested results match the original results.

A record keeping system is a vital component of an internal quality control program. Record keeping systems include: instrument maintenance logs calibration logs temperature logs water quality logs quality control results quality control chartsEach log includes: date time name of employee performing check or maintenance results description of maintenance performed problem description problem solving and verification stepsThe record keeping system can be used to: monitor compliance with quality control procedures train employees in problem detection and problem solving help prevent instrument breakdowns evaluate service personnel performance identify topics for continuing education programs help ensure reliable patient results

Clinical laboratory personnel licenses are divided into four types: director, supervisor, technologist, and technician. Each type has different roles, responsibilities, qualifications, and continuing education requirements. When you apply for a license, you must apply for one of these four types. All licensed clinical laboratory personnel are permitted to collect, process, store, and ship specimens and perform manual pretesting procedures. Clinical laboratory personnel qualified as director (either physician director or licensed director), supervisor, technologist, or technician can perform testing within the specialty(ies) for which they are licensed. Each license is valid for one or more specialties. Directors, supervisors, and technologists are permitted to interpret and report test results.

Specialists in immunohematology perform all testing prior to blood transfusions and work to prevent transfusion infections. They also investigate any post-transfusion reactions. This specialty includes all lab procedures performed in the specialty of histocompatibility. Specialists in clinical chemistry analyze body fluids such as blood, urine, and spinal fluid to determine the chemical makeup, including the amount of carbohydrates, proteins, enzymes, and trace elements. The special covers urine microscopics and chemical evaluation of the liver, kidneys, lungs, heart, and other vital organ systems. This specialty also covers all testing performed in the specialties of radioassay and blood gas analysis. Specialists in blood banking can perform all immunohematology testing as well as testing from the specialties of clinical chemistry, hematology and serology/immunology that relates to donor blood. Clinical laboratory personnel who are licensed in the specialties of immunohematology, clinical chemistry, hematology, and serology / immunology may perform all tests in the blood banking specialty.

Licensed clinical laboratory personnel are required to follow all laws and rules of the Board, orders of the Board relating to disciplinary action, and must be truthful and helpful in the event of an investigation. The following are violations of Board rules:Violating a previous Board order relating to disciplinary action.Misrepresenting or hiding facts during licensing, renewal, or disciplinary procedures.Interfering with investigations into disciplinary violations.

System designers sometimes fail to analyze the purposes of medical systems and how best to achieve them. Instead, they revert to traditional ways of doing things. These failures of analysis account for many medical errors. An example is the tendency to encourage reliance on rote memory for performing procedures instead of manuals, job aids, checklists, and computerized protocols.

Medical errors also occur in the analytic processes and systems of patient care. Analytic errors begin with problems in the transportation of medical samples for testing. These occur between the patient's location and the testing facility. They happen during the time between specimen collection and arrival in the testing facility. The possibility for analytic medical error continues through the analytic processes and procedures of medical testing. Analytic medical error also includes systems, processes, and procedures involved in the transmission and reporting of test results. These medical errors occur during the time the laboratory is directly involved in receiving, analyzing, and reporting test samples. Examples: Wrong transport storage or temperature Delay in transport Sample mixup during transport Acceptance of unacceptable samples that are insufficient, hemolyzed, or clotted Centrifugation, mixing, and other test sample preparation errors Wrong test procedures Test control errors Sample mixup during testing Outdated reagents Wrong reagents Test result mixup Transcription errors Data reporting process errors Result report delays

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.

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.

Element 6: 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.

All tests must have a written order on file. Any verbal orders for tests including tests added on to a specimen already in the lab, must be followed up by a request for a written order. Employee who receives a verbal or add-on order must follow procedures to ensure that a follow-up written order is requested. It is against Medicare regulations to bill extra for calculated test results. Only appropriate tests actually performed may be billed. It is against the law to bill for the same tests or services twice (duplicate billing). It is against the law to bill for quality control tests or tests performed multiple times to check or verify the results.

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.

Secure sensitive and confidential documents and materials.Follow all security procedures and never give your password or other codes to any other employee.Be aware of aberrant behavior and excessive questioning about billing or other compliance risk areas.Stay current on compliance policies and procedures, laws and regulations.Don't guess at an employee's questions. If you don't know for sure, find out before answering.Report any suspect activity by an employee to the compliance officer.

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.

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.

Every employee must understand that the standards, policies and procedures associated with the compliance program must be adhered to at all times. An employee will be disciplined up to termination for violations. An employee can be disciplined or terminated for failing to report a problem or suspect activity. All employees are screened prior to being hired for previous actions against them by any law enforcement or government agency regarding any health care prosecution or exclusion from the Medicare or Medicaid program. Adherence to the compliance program's policies and procedures will be a component of every employee's annual evaluation and performance review.

In developing an effective compliance program, the OIG has identified these seven fundamental elements: Implementing written policies, procedures and standards of conduct Designating a compliance officer and compliance committee Conducting effective training and education Developing effective lines of communication Enforcing standards through well-publicized disciplinary guidelines Conducting internal monitoring and auditing Responding promptly to detected offenses and developing corrective action An example of a Voluntary Compliance Program based on these seven fundamental elements follows on the next several pages.

All tests must have a written order on file. Any verbal orders for tests, including tests added on to a specimen already in the lab, must be followed up by a request for a written order. Employee who receives a verbal or add-on order must follow procedures to ensure that a follow-up written order is requested. It is against Medicare regulations to bill extra for calculated test results. Only appropriate tests actually performed may be billed. It is against the law to bill for the same tests or services twice (duplicate billing). It is against the law to bill for quality control tests or tests performed multiple times to check or verify the results.

Documentation of compliance activities is the responsibility of all employees. All forms must be completed and properly filed. All procedures must be followed and properly documented. If documentation of compliance activities cannot be established during an audit or investigation, the government will assume that the compliance program is not being followed.

Body fluids most likely to transmit HBV are: Blood Semen Vaginal Secretions Pleural Fluid Peritoneal Fluid Pericardial Fluid Cerebrospinal Fluid Synovial Fluid Amniotic Fluid Blood contaminated saliva in dental procedures Any fluid visibly contaminated with blood Sweat uncontaminated by blood is not considered infectious.

Your employer has a responsibility to educate you about chemical hazards, and safety procedures.

This is the most important section of all. It provides information on how the chemical could affect you. Is it a carcinogen? How can it enter your body? What are the signs and symptoms of overexposure to the chemical? What first aid procedures should be used in case of an accident?

In case of a spill first, dike up the formaldehyde with absorbent pillows.Then dispose of these pillows in a sealed, formaldehyde-labeled container.Your supervisor will show you the location of these emergency spill clean-up materials or discuss alternative procedures.

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.

According to federal and international regulations, all personnel who are involved in the packaging and shipping of infectious materials are required to have training in these procedures. This includes anyone who: Packages, labels, and/or marks the package Is responsible for classifying the materials Is responsible for documenting the package contents on a shipping declaration form, air waybill, etc. Transports hazardous materials by vehicle, plane, or vessel

A category A infectious substance is in a form that is capable of causing permanent disability or life-threatening or fatal disease in otherwise healthy humans or animals when exposure to it occurs. Exposure would occur if the substance were released from its protective packaging and a human or animal came into contact with it. Therefore, it is critical that a category A infectious substance does not end up in the hands of an unauthorized individual who may purposely or unknowingly release the substance from its protective packaging and endanger humans or animals. Being aware of the people that you interact with in the process of packaging and sending category A substances is vital to the safety of the transport and prevention of a health disaster. An outsider with limited access and system knowledge could constitute a threat, but be aware that insiders could also be a threat, e.g., a disgruntled employee or a person who is angry with his or her supervisor or job or the government. Anyone desiring to do harm could potentially seize the opportunity to steal a hazardous material.Follow these precautionary procedures: When you are questioned about an infectious substance that you are packaging for shipment, it is important that you know the person that is asking AND that he or she has a need to know. If you do not know the person and if you are not aware that the person needs to know about the substance that is being shipped, do not answer the questions. You could refer him or her to your supervisor. Watch for unusual behavior. Secure the package until it is picked up. Check the identification of the courier who will be picking up the package. Use an intralaboratory chain of custody procedure if the specimens are tranferred within the facility or system. Track the package once it has been sent to be sure it arrives safely. Notify the Responsible Official or federal authority if the package does not arrive at its destination.

The phlebotomist should always carefully observe the patient for clues about his mental and physical condition. In this case, the patient verbally expressed her fear of needles. In other cases, such fear may be expressed on the patient’s face or through other clues. It may help to engage apprehensive patients in conversation during the venipuncture to keep their mind off the procedure.As soon as the patient stated that she felt faint, the procedure should have been terminated. If a sitting patient faints, placing her head between her knees will help to revive her. Make sure the patient does not injure herself. Ammonium (smelling) salts, if in use at your institution, should be used cautiously, since they can be irritating. Get help from the nursing staff or a physician. Stay with the patient at least 15 minutes. The patient should not leave the area for at least 30 minutes. Make sure other appropriate institutional procedures are followed after fainting.Relevant topics:Fainting, Fainting continued

Gloves must be worn for all procedures requiring vascular access. Non-powdered latex gloves are most commonly used; Alternatives available for health-care workers allergic to latex include: Latex gloves sandwiched between 2 vinyl gloves. Latex-free glove liners.Do not use latex gloves or tourniquets when collecting blood from patients with latex allergy.

Label specimens at the bedside according to your institution’s standard procedures, or apply preprinted labels.Proper labeling is the single most critical task you are asked to perform.

Veins of small children and infants are too small for venipuncture;Safety Lancets are used to puncture the skin and collect capillary blood.Butterfly needles may be used to collect venous blood in older children.

If a patient is uncooperative or combative, request help from the nursing staff. The nursing staff will assist you in an appropriate manner according to your hospital’s procedures for patient restraint.

Phlebotomists are ethically and legally required to keep patient information confidential. Reveal patient information including medical history and results only to authorized individuals as defined by your laboratory’s policies & procedures. Do not discuss test results with patients without a written order from the ordering physician.

To review, specificity is “disease focused”. The more specific a test is, the fewer false positive results will occur. Remember that a false positive result can possibly lead to a misdiagnosis with the possible consequence of unnecessary diagnostic procedures and therapies. Sensitivity, on the other hand, is “wellness or normal focused”. The more sensitive a test is, the fewer false negative results it produces.

If stains and technique are adequate, S. aureus should be Gram positive (blue) and E. coli should be Gram negative (pink). If control slides do not react appropriately, reliable results cannot be assured for the specimen smears. Check stains and technique and prepare more control smears until proper results are achieved, then remake and stain the new direct smears. If it is impossible to prepare a new smear, the poorly stained smear may still be salvaged. Remove immersion oil from the smear using xylol. Use appropriate procedures and personal protective equipment when using xylol, since it is hazardous chemical. If the smear is underdecolorized, repeat the decolorization and counterstain steps. If the smear is overdecolorized, the slide should be stained again.

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.

Some procedures increase the potential for TB risk because they create aerosols. They include: Sputum induction and aerosol treatments Bronchoscopy Endotracheal intubation and suctioning Autopsy Microbiology processing TB specimens Surgical drainage of TB abscesses