HUSM/HEMA-UPT/QP-01

RECEIPT OF SAMPLE

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY HOSPITAL UNIVERSITI SAINS MALAYSIA

Prepared by: Checked by: Approved by:

Dr. Marini Ramli Assoc. Prof. Dr. Suhair Abbas Assoc Prof. Dr Rosline Hassan

15.08.2009 01.10.2009 01.11.2009

Effective date:

01.11.2009

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM RECEIPT OF SAMPLE (HUSM/HEMA-UPT/QP-01) TITLE: TABLE OF CONTENT Page Version 2 of 7 3

PAGE

TABLE OF CONTENT

Title of Quality Procedure

Table of Content

Record of Amendment and Record of Review

Objective, Scope, Abbreviation, Definition and References

Procedure and Responsibility

Record

Flow chart Appendices i. Appendix 1 : Criteria for sample rejection ii. Appendix 2 : List of routine and coagulation tests requested through LIS iii. Appendix 3 : List of routine and coagulation tests ordered paperless

Prepared by Checked by Approved by

Dr. Marini Ramli Assoc. Prof. Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Effective Date

01.11.2009

Hakcipta Makmal Hematologi & Unit Perubatan Transfusi 2012

Sebarang cetakan dan penggunaan semula mana-mana bahagian dalam dokumen ini tidak dibenarkan

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM RECEIPT OF SAMPLE (HUSM/HEMA-UPT/QP-01) RECORD OF AMMENDMENT VERSION NO DATE DESCRIPTION OF AMMENDMENT
Amendment 1: Appendix 1 Criteria For Sample Rejection 2 05.07.2010 Amendment 2: Appendix 2 List of Routine and Coagulation Test Requested Through LIS Transform to online documentation in http://www.medic.usm.my/hematology/index.php/qp01 Amendment 3 Page 5 of 7: change procedure and responsibility Amendment 4 Appendix 2 List of Test Requested Through LIS (update Hemolisis Test and Factor Assays) Amendment 5 Appendix 1 Criteria For Sample Rejection (update No. 20 - No. 25) Amendment 1 Page 5 of 7: No. 6.1 a change procedure Amendment 2 Page 5 of 7 : No. 6.1.c.i - at least 2 identifiers required (Name and RN patient) needed by the Assessor Amendment 3 Appendix 1 Criteria For Sample Rejection (update sample rejection for coagulation test) Amendment 3 Appendix 1: Criteria For Sample Rejection (update sample rejection for G6PD) Amendment 4 Procedure 6.1 c (iii) paperless samples requests to verify with the sample label and LIS request. Appendix 3: Lists of Test can be ordered paperless & Lists of Wards and Clinics using paperless ordering

TITLE: RECORD OF AMENDMENT AND RECORD OF REVIEW

Page Version

3 of 7 3

SIGNATURE OF APPROVAL

2 2 2 2 3 3 3 3

01.08.2010 13.02.2011

20.02.2011

1.11.2011 1.11.2011 12.01.2012

29.07.2012

RECORD OF REVIEW DATE OF REVIEW 05.07.2010 21.03.2011 NAME OF REVIEWER Dr. Marini Ramli Dr. Marini Ramli Pn. Anisza En. Saharim SIGNATURE OF REVIEWER SIGNATURE OF APPROVAL

31.1.2012

Prepared by Checked by Approved by

Dr. Marini Ramli Assoc. Prof. Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Effective Date

01.11.2009

Hakcipta Makmal Hematologi & Unit Perubatan Transfusi 2012

Sebarang cetakan dan penggunaan semula mana-mana bahagian dalam dokumen ini tidak dibenarkan

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM RECEIPT OF SAMPLE (HUSM/HEMA-UPT/QP-01) 1. TITLE: OBJECTIVE, SCOPE, ABBREVIATION, DEFINITION AND REFERENCES Page Version 4 of 7 3

OBJECTIVE Receive ONLY the correct sample and request form from clinics, wards and other hospitals for laboratory tests. SCOPE This procedure is applicable to all types of sample such as blood, bone marrow, body fluids and tissues together with laboratory request form received at the Hematology/Transfusion Medicine Laboratory, HUSM. ABBREVIATION MLT pM PAP STAT HL TML LIS DEFINITION Section Demography : : : : : : : Medical Laboratory Technologist Pembantu Makmal Pembantu Am Pejabat Short Turn around Time Haematology Laboratory Transfusion Medicine Laboratory Laboratory Information System

2.

3.

4.

: :

Various divisions within the HL/TML A process of registering patients data (such as Name, registration number, sex, age etc) into LIS, Computer or registration book. Series of tests that are done during office hours and do not require appointment.

Haematology and : Coagulation routine test 5.

REFERENCES 1) MHT/DD H11 : Buku Panduan Perkhidmatan Makmal Hematologi & Perubatan Transfusi. (http://www.medic.usm.my/hematology/index.php/services/medicallaboratory/buku-panduan)

Prepared by Checked by Approved by

Dr. Marini Ramli Assoc. Prof. Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Effective Date

01.11.2009

Hakcipta Makmal Hematologi & Unit Perubatan Transfusi 2012

Sebarang cetakan dan penggunaan semula mana-mana bahagian dalam dokumen ini tidak dibenarkan

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM RECEIPT OF SAMPLE (HUSM/HEMA-UPT/QP-01) 6. PROCEDURE AND RESPONSIBILITY NO 6.1 ACTIVITY a. Receive ALL samples that have been stamped date and time by Clinic/Ward Staff at the HL/TML counter. b. Stamp the sample dispatch book with receivers name, date and time of receipt. c. Check and verify the sample and request form: i. Accept the sample that fulfills the criteria at least 2 identifiers required (Name and RN patient) Sample and laboratory request form that do not fulfill the criteria should be rejected with explanation. Sample for paperless requests (which are highlighted with blue marker on the top of specimen label), verify the sample label and LIS request. Refer Appendix 3 RESPONSIBILITY *MLT/pM/PAP REFERENCE TITLE: PROCEDURE AND RESPONSIBILITY Page Version 5 of 7 2

*MLT/pM/PAP Refer Appendix 1

ii.

iii.

d. For Bone Marrow & Molecular samples for outside HUSM, stamp the request form with date and time of receipt of sample i. For rejected sample, return the form to the ward/clinic or other hospital and keep the duplicate as record

ii. For rejected form, request for a new complete form. 6.2 a. Request of sample is confirmed through LIS for Haematology routine and Coagulation tests. b. For other tests, the requests are recorded in the computer or registration book at the respective section. 6.3 Distribute the sample to the respective section *MLT/pM/PAP *MLT/pM/PAP Refer Appendix 2

* Note: For TML Lab, only MLTs are responsible for all activities carried out above. Prepared by Checked by Approved by Dr. Marini Ramli Assoc. Prof. Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Effective Date

01.11.2009

Hakcipta Makmal Hematologi & Unit Perubatan Transfusi 2012

Sebarang cetakan dan penggunaan semula mana-mana bahagian dalam dokumen ini tidak dibenarkan

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM RECEIPT OF SAMPLE (HUSM/HEMA-UPT/QP-01) 7. NO 7.1 RECORD TYPE OF RECORD Record of request form LOCATION LIS or computer Registration book at respective Section Store RETENTION PERIOD No limit 7 years TITLE: RECORD Page Version 6 of 7 3

7.2

Request form a. Routine tests b. Tests with interpretative report (FBP, G6PD) Sample Rejection form/book

3 years 7 years 1 year

7.3

Respective section

* Retention period for TML, refer Appendix 1, QP-08

Prepared by Checked by Approved by

Dr. Marini Ramli Assoc. Prof. Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Effective Date

01.11.2009

Hakcipta Makmal Hematologi & Unit Perubatan Transfusi 2012

Sebarang cetakan dan penggunaan semula mana-mana bahagian dalam dokumen ini tidak dibenarkan

HAEMATOLOGY AND TRANSFUSION MEDICINE LABORATORY, HUSM RECEIPT OF SAMPLE (HUSM/HEMA-UPT/QP-01) 8. FLOW CHART TITLE: FLOWCHART Page Version 7 of 7 3

Receive sample at counter

Check and Verify

No Request fulfill criteria

Yes Accept if fulfill the criteria in checklist Reject with explanation Record

Distribute to the section

Prepared by Checked by Approved by

Dr. Marini Ramli Assoc. Prof. Dr. Suhair Abbas Assoc. Prof. Dr Rosline Hassan

Effective Date

01.11.2009

Hakcipta Makmal Hematologi & Unit Perubatan Transfusi 2012

Sebarang cetakan dan penggunaan semula mana-mana bahagian dalam dokumen ini tidak dibenarkan

Appendix 1 CRITERIA FOR SAMPLE REJECTION 1. Clotted sample except when serum is required. 2. Duplicate request 3. Insufficient sample. Refer to Buku Panduan Perkhidmatan Makmal Hematologi & Unit Perubatan Transfusi. (http://www.medic.usm.my/hematology/index.php/services/medical-laboratory/bukupanduan) 4. Excess sample. Refer to Buku Panduan Perkhidmatan Makmal Hematologi & Unit Perubatan Transfusi, bahagian panduan penolakan spesimen dan ujian. (http://www.medic.usm.my/hematology/index.php/services/medical-laboratory/buku-panduan) 5. Lysed sample. 6. No prior appointment for special tests 7. No accompanying request form. 8. No accompanying sample. 9. Wrong container. Refer to Buku Panduan Perkhidmatan Makmal Hematologi & Unit Perubatan Transfusi. (http://www.medic.usm.my/hematology/index.php/services/medical-laboratory/bukupanduan) 10. Unlabeled container. 11. Discrepancy of Name & RN between the request form and sample. 12. More than 4 hours of sample collection (For Morphology Test) 13. More than 2 hours of sample collection if send without ice (For Coagulation Test) 14. More than 4 hours of sample collection if send with ice (For Coagulation Test) 15. Sample is not transported in ice that is put in separate plastic (For Coagulation Test) 16. Sample is embedded or placed directly in the ice (For Coagulation test) 17. No stated time of the sample collection (for Coagulation test) 18. Incomplete request form except Haematology tests: at least 2 identifiers are required. 19. Carbon copy is not filled up. 20. Sample which is not registered in the LIS system 21. Leaked sample 22. Wrong test request 23. No test request in LIS 24. Request in LIS, but no sample and form received 25. Form and sample not clearly labeled 26. Expired container 27. For patient requiring blood transfusion under emergency or critical condition, the request will be processed even if the following conditions are not conformed: Carbon copy request form is not filled up Volume of specimen less than required volume. Data regarding history of previous transfusion and patients blood group are not filled up in the request form. Blood request form slip is not accompanied when taking the blood however, need two patients identifications presented ie name and RN Plain tube used or clotted patients sample

28. G6PD sample not sealed in biohazard plastic & clipped to the request form directly.

HUSM/HEMA-UPT/QP-01/A1

Hakcipta Makmal Hematologi & Unit Perubatan Transfusi 2012

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Appendix 2

LIST OF ROUTINE AND COAGULATION TESTS REQUESTED THROUGH LIS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Full Blood Count (FBC) Full Blood Picture (FBP) Reticulocyte Count (Retic) Erythrocyte Sedimentation Rate (ESR) Bleeding Time Prothrombin Time (PT) Activated Partial Thromboplastin Time (APTT) D-Dimer Fibrinogen Level DIC Screening Thrombin Time Reptilase Time Mixing Test Factor assays Thrombophilia Workup a. Protein C activity b. Protein S activity c. Free Protein S d. Anti thrombin III e. APCR f. Lupus anticoagulant 16. Von Willebrands Workup a. Factor VIII b. Von Willebrand factor antigen c. Von Willebrang factor activity d. RiCof e. Collagen Binding Antigen (CBA) 17. Platelet aggregation test 18. Hemolisis Test: a. G6PD b. Osmotic Fragility Test (OFT) c. Schumms Test d. Methemoglobin Test e. Hams Test (Acidified Serum Test) f. Sucrose Lysis Test g. Kleihauer Test

HUSM/HEMA-UPT/QP-01/A2

Hakcipta Makmal Hematologi & Unit Perubatan Transfusi 2012

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Appendix 3 LIST OF ROUTINE AND COAGULATION TESTS ORDERED PAPERLESS 1. Routine Hematology Tests: a. Full Blood Count (FBC) b. Differential Count (DC) c. Reticulocyte Count (Retic) d. Erythrocyte Sedimentation Rate (ESR) 2. Routine Coagulation Tests: a. Prothrombine Time (PT) b. Activated Partial Thrombine Time (APTT) c. D-Dimer d. Fibrinogen Level e. Fibrin Monomer 3. Hemolisis Test: a. G6PD (Labour Room only) LIST OF CLINICS AND WARDS USING PAPERLESS REQUEST 1. Clinics: a. b. c. d. e. f. g. h. Klinik Rawatan Keluarga (KRK) Klinik Pakar Perubatan (KPP) Klinik Pediatrik Klinik O&G Klinik Psikiatri Onkologi Klinik Staf Perubatan Nuklear

2. Ward a. Labour Room (LR) (G6PD only)

HUSM/HEMA-UPT/QP-01/A3

Hakcipta Makmal Hematologi & Unit Perubatan Transfusi 2012

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