XI.

STANDARD PROTOCOLS AND QUALITY ASSURANCE PRGROGRAM

A. REQUISITION FOR LABORATORY TESTS (STAT AND ROUTINE REQUEST) Guidelines: 1. The Out-Patient presents the Laboratory request at the laboratory Reception Area following the Number System of Accommodation. 2. The Receptionist gives the Out0Patient an Information Sheet. 3. Patient shall be billed accordingly by the Receptionist. B. SPECIMEN RECEIVING AND RECORDING 1. All Laboratory requests and specimen must be received in the laboratory Reception Area. 2. The Receptionist signs his/her name in the logbook as proof of receipt. 3. The Number System of Accommodation will be applied for OutPatient. OUT-PATIENT: 1. After the payment of bills, the out-patient returns to the Pathology reception Area, presents the official receipts from the cashier’s section and the original doctor’s requisition form. 2. The Pathology receptionist prepares the Pathology charge slip with all the necessary patient’s data and prices of each test. 3. The out-patient is charged according to category if out-patient pay out-patient service. 4. The request are separated by the receptionist for the different Pathology sections 5. The receptionist returns back the following papers: a. All prepared and separated requests. b. The original official receipts (OR). c. The original copy of Pathology charge slip. 6. The out-patient is sent to the extraction area for specimen collection. OUT-PATIENT GUIDELINES: 1. Out-patient presents to the Pathology reception area the laboratory request of the attending physician for pricing. 2. Payment is done at the Cashier’s office. 3. Out-patient returns to the Pathology reception area and presents the official receipts to the Receptionist for issuance of the charge slip. 4. The patient is advised to proceed to the blood extraction area with the request, charge slips and official receipts returns them to the patient before extracting blood. 5. The Medical Technologist labels the proper test tubes with the name of the patient, age, sex, and numbers the test tube with corresponding number of the patient. 6. The Medical Technologist assigned for blood extraction counterchecks the request, charge slips and official receipts returns them to the patient before extracting blood.

These reports can be submitted to the DOH Management and Philhealth if required. urine. Tech staff in-charge of the section. A daily workload sheet shall be used for every section. stool.C. These worksheets are filed daily. For Out-Patients. However. Should there be a problem. REQUISITION FORMS/CHARGE SLIPS should have completed data: a. The Reception Are is in-charge of all incoming laboratory requests and specimen from Out-patients for necessary charging/billing of the requested examination. Receptionist receives the URINE/STOOL and checks them individually. SPECIMEN REJECTION All specimen received should be check and approved by the Med. Tech Staff and immediately inform the Reception Area for Out-patient. 5. Receptionist should put the TIME RECEIVED plus her “INITIALS” on the request received. the hospital should be informed immediately. etc. No OR no extraction or processing of tests. Workload shall be reported daily. 3. If the specimen collected from hospital (in-patient) is inadequate. 3.) for the specific test to be done. E. 2. 2. . Monthly and annual census reports shall be done. as to the sufficiency in amount and compliance with all requirements of the test procedure to be done. PROCEDURE ON REPORTING OF WORKLOAD 1. However for blood specimen extracted from other hospitals/laboratories that are sent as Out-patient. CHARGES/BILLING OF REQUEST/STAT REQUEST 1. 2. they will pay the said amount. the specimen should be rejected by the Med. after a charge slip has been issued to them. D. Name of patients b. 4. The receptionists are oriented as to the volume requirement for each specimen (blood. CRITERIA FOR ADEQUACY/INADEQUACY OF SPECIMEN 1. F. the patient or the relative of the patient is requested to wait at least thirty (30) minutes as to assure that the collected blood sample is sufficient and ideal for testing. Receptionist receives the specimen and will be brought to Clinical Microscopy Section by the Laboratory Technician. the RECEPTIONIST may call the physician. 3. Name of Doctor ** Both request/Charge Slip should indicate ALL tests required **Accompanying SPECIMEN should have the NAME of the patient **If any of these is NOT accomplished. Age/Sex c. the receptionist calls the laboratory for whatever is needed. noncompliance to this. 4.

REPEAT TESTING It is of great importance that all laboratory test procedures must be done with accuracy and precision. In case of abnormal/panic values. Lab.00 per copy is charged. For an extra copy a P10. 5. the following Standard operating procedure is observed: 1. The requesting physician’s secretary can retrieve the official results for the patient by signing in the logbook of the reception area. prior to the release of the final result. Lab. Med tech shall type the result based on the worksheet. 11. 72 hours and the final result is released after 7 days. He/she is required to present an Official Receipt. Culture and Sensitivity results are released within 3 days except for blood C/S which has an initial result after 48 hours. Reports are given to Associate Pathologists if they are present for signature. Worksheets/logbook/computer printouts must accompany the reports so that the pathologists can check typographical errors and any missing information. Result of Gram Stain. OUT-PATIENT 1. RELEASING OF RESULTS To ensure the release of accurate laboratory test results. the Medical Technology Staff should follow the flow chart in assessing panic values. Non-STAT lab results should be released within 2-3 hours from the time of receipt of specimen. 4. If obtained value is still abnormal. 10. 9. . 2. H. 3. Med tech shall review typed/printed reports and affix their signature/initial. this should be referred to the Pathologist-on-duty who then correlates for clinical compatibility. The official results are release to the out0patient after 2 hours from the time of specimen collection. 8. 7. Results of STAT request should be issued to the patient within 1 hour. G. AFB Stain and other Bacterial/Fungal Smears are within 24 hours.THE FOLLOWING CATEGORIES AND THEIR CORRESPONDING DISCOUNT RATES Senior Citizen 20% STAT FEE – a surcharge of 20% of the regular rate of the stat lab examination should be implemented for all patients. The patient or his authorized representative may claim the official result at the Reception Area. 6.

2. The out-patient/authorized representatives with official receipts/charge slip claims the official results from the receptionist. 3. Any request marked as “stat” will get immediate attention. For in-patients: The laboratory aide will be the one to deliver the results in every nurse station. Laboratory reports must be checked for accuracy of typing//transcription errors/complete information before you can affix your signature and release the reports. 3. We must ensure that our laboratory reports are accurate and complete. This means all other work must be stopped immediately with “stat” test being run. P10. 2. A. 4. For ER stat request. 5. All results delivered will be signed in print name and signature and time of receiving nurse on duty to the releasing of results logbook. For lost results. The doctor’s secretary can retrieve official results for the patient by signing in the laboratory results issuance logbooks. when the doctor insists on asking for it.2. No verbal order is accepted. 3. Routine Tests: 1.00 is strictly observed. B. . The doctor’s secretary can retrieve official results for the patient by signing in the laboratory releasing logbook. No stat results are given to the relatives of the patient. COUNTER CHECKING OF LABORATORY REPORTS 1.00 fine shall be strictly observed. Relaying of Results by Phone-note the name of the nurse who receives the call and the time results for the second time only. For lost results and another copy is needed. get the written request and collect specimen immediately then send to the laboratory. The stat results are relayed directly to the requesting physician. For OPD patients: All results being released are signed by the requesting OPD patient in the releasing logbook with time of release and upon presenting official receipt of payment. Test orders as routine will be performed and reported the same day. 2. STAT results are released 1 hour after blood collection. Each Laboratory reports must be compared with the laboratory worksheet or logbook or original computer printouts from the respective sections. The “stat” request must be immediately hand-carried to the laboratory and handed to the medical technologist. Stat request should be reserved to patients needing prompt service. a fine of P10. 5. STAT Requests: 1. Stat results are released one hour after blood collection 4.

2. For OPD patients: All results being released are signed by the requesting OPD patient in the releasing logbook with time of release and upon presenting official receipt of payment. STAT Requests: Any request marked as “stat” will get immediate attention. 1. B. The “stat” request must be immediately hand-carried to the laboratory and handed to the medical technologist. when the doctor insists on asking for it. The stat results are can be relayed to nurse on duty and in cases of critical value the results are relayed directly to the requesting physician.I. the rule No Relaying of Results is strictly implemented. A. For in patients: The laboratory aid will be the one to deliver the results in every nurse station. The doctor’s secretary can retrieve official results for the patient by signing in the laboratory releasing logbook. Stat results are released on hour after blood collection. get the written request and collet specimen immediately then send to the laboratory. RELAYING OF RESULTS For Out-patient. No stat results are given to the relatives of the patient. It is better. a fine of P10. Stat request should be reserved to patients needing prompt service. if the faxed copy be forwarded to him/her. Relaying of Results by Phone – note the name of the nurse who receive the call and the time results were relayed. Routine Tests: Test orders as routine will be performed and reported the same day. This means all other work must be stopped immediately with “stat” test being run. once the written results have been released to their respective wards. . Relaying of results over the phone WILL NOT BE DONE. Relay the results for the second time only. For ER stat request.00 is strictly observed. except if the Doctor is the one getting the result. Nurses are expected to write the results being relayed in the chart. No verbal order is acceptable. For lost results and another copy is needed. All results delivered will be signed in print name and signature and time of the receiving nurse on duty to the releasing of results logbook.

11. Uric Acid. Introduction of new procedure for the maintenance of Diabetes Therapy: i. Electrolytes are none fasting but as much as possible fasting required. As per order by Infection Control Committee. during the first 1-2 hours following sample collection. 5 ml Lavender top 6. whenever BLOOD C/S is requested. 5.TEST EXAMINATION AND PREPARATION 1. Triglycerides. Cholesterol and Triglycerides should always b included in HDLLDL package. HBA1c. 9. 2-HR OGTT a. Food should be consumed within 15 minutes 2. 7. 3. Glycosylated Hemoglobin ii. Liver Enzymes. A high Triglyceride level may lead to an over-estimation of the Creatinine Level. Creatinine. Glucose should be consumed within 5 minutes. For BUN. For PT and patient is taking medication the receptionist or Medical Technologist if patient is taking medications like Warfarin and Coumadin. Start timing as soon as the patients start eating. UNLESS the Doctor insists on shorter fasting hours. b. Start of procedure – PROSTATE SPECIFIC ANTIGEN (PSA) for all patients (MALE) 50 years old and above. 2 hours after a heavy meal. 12-14 HOURS FASTING is required. HDL. 4. Start of the MODIFIED IVY METHOD for Bleeding Time using Blood Pressure Apparatus. 2 HR PPBS a. The following test requires FASTING: Fasting Blood Sugar: 6-8 hours Lipid Profile (Cholesterol. c. Patients should be well instructed about the importance of fasting. 8. ALL BLOOD C/S (AEROBIC & ANAEROBIC) should be done at all times with all patients PRIVATE/SERVICE. . and LDL): 12-14 hours OGTT and OGCT: 6-8 hours 10.

Aide who will transport and pick-up the result as well or to the lab aide of a particular referral laboratory. b. LABORATORY ACCIDENTS Any laboratory personnel who met accident (minor or major) in the performance of duty shall be immediately referred to a doctor. REFERRALS TO THE LABORATORY HEAD / ASSOCIATE PATHOLOGISTS For doubtful results or critical values obtained. The laboratory is responsible for send-out specimen to the laboratories. A MOA from a referral laboratory is made for send-outs. New Syringes should be used at all times. hand this over to the Lab. burns and splash from reagents. If smear if POSITIVE – Report as POSITIVE c. for first aid or other medical treatment and assistance free of charge. *Do QBC and prepare 3-5 smears – report as NEG. The Medical Technologist collects the blood and prepares the same for transport. analytical and post-analytical discrepancies. prepares the send-out request form and together with the specimen. etc. Examples are needle pricks.) before referring to the Chief Medical Technologist verifies the results and checks for any pre-analytical. for record purposes. clerical errors. cuts from microtone knife. use of controls. 13. Out-patients – Clinical Pathology will be responsible in extracting the blood and doing the test. HANDLING OF SEND-OUT LABORATORY REQUEST 1. report SPECIE & QUANTTY (+.if POS. 4. the medical technologist-in-charge should check everything (calibration. Malarial Smear a. L. K. 3. The Med.12. cuts from broken tubes and slides. 3 slides .+++) J. . He then refers to the Associate Pathologist on duty/head of the laboratory who then investigates the case and correlates the result with the status of the patient. 14. needles and cotton balls should be placed in special containers for incineration. No more autoclaving used/washed syringes for all “sharps” like syringes. This shall be properly documented. Internal SOP for blood extraction.++. Tech. 2. If the smear is NEGATIVE – Do QBC – Report as Positive or Negative. Activated Partial Thromboplastin Time (APTT) will used as a measure of clotting activity instead of Clotting Time.

a quality control chart is prepared monthly for each test procedure done on the different machines. in the performance of each test procedure. PROFICIENCY AND ACCREDITATION PROGRAMS The Bureau of Health Facilities and Services of the Department of Health awards the Arnaiz Hospital Department of Laboratory a certificate of license to operate a clinical laboratory. O. There will also be policies on developing preventive measures.M. A review of the organization chart of the Cooperative and of the Diagnostic Laboratory is necessary to indicate which individuals should communicate with whom. solutions are made and corrective measures are formulated. PUBLIC RELATIONS The Arnaiz Hospital Laboratory personnel must communicate with each other at various levels and with various groups within the Laboratory. Regardless of the organization of the laboratory established lines of authority and communication are of paramount importance. If there are reports these are recorded and investigated. N. Q. INTERNAL QUALITY CONTROL PROGRAMS AND MAINTENANCE OF QUALITY CONTROL GRAPHS AND QUALITY CONTROL CHARTS As a part of quality assurance program. QUALITY IMPROVEMENT There shall be a system in detecting problems/deviations from the quality management system standards. We will receive unknown samples from NEQAS for Hematology and Clinical Chemistry. . PARTICIPATION IN EXTERNAL QUALITY ASSURANCE PROGRAMS LIKE NRL The Arnaiz Hospital Laboratory is an active institutional member and participant in the different Quality Assurance Program of the Philippine Council for Quality Assurance in Clinical Laboratory (PCQACL) and NRLs locally. There will be a form on reporting deviations and incident reports. This QC chart serves as a tool for evaluation of accuracy and precision of all the test results released by the laboratory. inclusive of all the precautionary measures and other technical concerns to be observed. MANUAL OF LABORATORY PROCEDURES A compiled Manual Procedures in each of the different sections of the laboratory is provided for guidance and step by step direction. P. Thereafter. Each section is required to plot daily all control results on the chart displayed on the bulletin board. R.

Communications Bulletin Boards /White Boards are used to disseminate general information such as policy changes. 5. 2. and other medical and non-medical staff.Disciplinary measures. It contains all documents of policies and procedures in current use. in a language best understood by the patient. The chief medical technologist shall make sure that the bulletin boards/white boards are current ad up-to-date. Patients Communication with patients and its relatives should be direct and clear with no intention of deceit and malice. Methods 1. Nurses and other Medical Personnel Good lines of communication are established in an effort to promote discussions that will aid in resolving issues and conflicts involving patient care and improvement in laboratory service. reports of accidents and so on should be described in details. The Laboratory should have good public relations with various groups such as physicians. patient. Company Representatives The company’s sale representative or distributor. Mutual understanding and harmonious relation between end-users and the company’s concern are always fostered. Manual of Laboratory Tests and Procedures The Quality Manual should be kept in use within the Diagnostic Laboratory. . All active members of the medical staff are oriented with the laboratory’s policies and protocols. goods or services from other departments. queries and needs of their patients. 4. Physicians The laboratory should establish contacts with physician and other members of the medical staff regarding improvements new tests. Only certain designated individuals should have authority to make requisitions for repairs. 3. 1. The company sale representative clearly understands that they come to visit on specified. the responsibility of keeping certain groups informed. nurses. This should be aided with information sheets or easy-tounderstand instructions. S. communicate/present/offer the laboratory management all the items/equipment they would like to promote. procedures for complaints.

Reduce the cost of reagents by either proper purchase or manufacture. 2. Make specimen collection easier. . 7. Increase efficiency b. c. Reduce the number and quantity of reagents. Change of Methods To change a method. Introduce the production line methods if the procedure is not automated. and types of ample and containers to be used for each laboratory procedure. Reduce the amount of space for the performance of the procedure. 6. emergency series available. An incident report will be submitted within 48 hours by all concerned Laboratory Staff/Personnel to the department head coursed through the Associate Pathologist and the Chief Medical Technologist for the necessary recommendations. inclusive of all precautionary measures and other technical concerns. XII. T. Decrease the amount of the specimen required. A compiled Laboratory Manual of Procedure in each of the different Laboratory Section is provided for guidance and reference in the performance of each test procedure. f. The requested papers/forms are compiled as one in a monthly basis. It shall describe the range and scope of all services available.The Manual of Laboratory Tests should be freely available. The requested papers forms are filed and kept for two years. 4. e. 5. any restrictions in terms of the opening times of the laboratory. ADMINISTRATIVE SANCTION FOR VIOLATION OF POLICIES A. COMPLAINTS AND INCIDENTS All received complaints from the doctor/patients (both from the hospital and Out Patients) will be handled and dealt with accordingly by the Staff on Duty of that particular shift. All logbook and duplicate files are kept for five years The files should be stored in a closed cabinet and arranged chronologically by date. 3. d. g. RETENTION OF RECORDS 1. any personnel. It should be well explained and clearly emphasized to the complainant that the incident will be investigated and they will soon be informed about it with the appropriate action that shall be taken. a pilot work is done but it does not end with the adaptation and use of a method but continues with efforts in connection with each procedure to: a. h. Increase turn-around time. Proper/visible labels are attached in very logbook and files for easy retrieval of results. All results (duplicate) are filed everyday and segregated by sections. All results are logged to corresponding laboratory section logbooks. 2.

B. They shall analyze the incident/accident report objectively not blaming the person involved because oftentimes the problem is in the system. • Failure to provide the medical records or reports appropriately requested in the course of patient care • Fee splitting. Third Offense – Suspension/Force Registration/Dismissal C. Medicine’s ethical creed places the patient’s interests above one’s own. 4. However. Examples of unprofessional conducts include: • Conviction of a crime arising from the practice of medicine • Patient abandonment • Working while under the influence of alcohol or illicit drug • Volitional falsification or misrepresentation of medical reports and records. the cause is really negligence on the part of the staff. First Offense – Verbal warning B. wilful overcharging for professional services. the body relies upon the Philippines . 3. PROCEDURE ON REPORTING AND ANALYSIS OF INCIDENTS AND ADVERSE ACCIDENTS 1. The head of the laboratory shall call a meeting with the associate pathologist in charge of the section involved and the staff. The penalties are: A. deceptive billing practices or collection of fees for services not rendered • Malpractice or incompetent. negligent or wilful misconduct in the practice of medical technology. the person/persons involved shall submit an individual report addressed to the head of the laboratory thru the chief technologist within 48 hours. his/her Performance Evaluation System (PES) is rated accordingly. 2. 6. If however. In addition to technical and intellectual proficiency. corrective measures shall be made. Second Offense – Written Reprimand C. All incidents and adverse accidents shall be reported. UNPROFESSIONAL CONDUCT The reports shall be analyzed objectively and the staff shall be given due process. Note: No single list or source can offer a complete guidance in every conceivable circumstance. It shall be emphasized that the objective of reporting is not to punish the staff or whoever committed errors but to analyse the system if it’s at fault and make corrective actions. If any incident or adverse accident occurs. the public expects laboratory staff to maintain a high standard of professionalism. After analysis of the report. 5.

Such penalties may be modified depending on the presence/absence of either or both mitigating and/or aggravating circumstances. D. and assessment of fees to cover the administrative costs of proceedings. . a suspension probation subject to conditions and requirements. mandatory participation in a remedial continuing medical education program. compelled submission to care. as defined by law and established during the investigation conducted by the proper authorities.Association of Medical Technologist (PAMET) and Philippine Society of Pathologist (PSP) code of ethics as the legal standard. A variety of sanctions may be administered including: a reprimand. counselling or treatment. The body shall deliberate the graveness of the alleged offense. GENERAL DISCIPLINARY An administrative body will conduct a thorough investigation for written complaints of unprofessional conduct. A majority of members of the body must concur in order for an individual to be found guilty of unprofessional conduct.

and eyes from splattering of blood and other body fluids or impacting objects. 4. after removing gloves. Specimens for transport between institutions should label clearly. 3. double-bagged or paced in second leak-proof puncture resistant container. Laboratory gowns or coats should be worn as protection from splashes of any biological material and removed before leaving the laboratory. racks. 5. etc. such as Hepatitis B virus (HBV). Contaminated clothing must be decontaminated by appropriate methods. enamel trays. 2. even during disinfection and cleaning. Generation of aerosol splashes and spills should be avoided. They are intended for single use only. nose. bens or break a needle. blood and blood products and other body fluids should be treated as potentially infectious regardless of the lack of knowledge of their HIV serostatus. Gloves should be worn whenever handling or obtaining specimens of any kind. protective eyewear or face shields should be worn to protect mucous membranes in the mouth. before being laundered. They also apply to work with agents of other blood borne diseases. Mask. The following precaution outlines practices and procedures to keep accidental exposure to a minimum: 1. Specimens should be transported in rigid containers. they can be reprocessed following the methods attached.g. such as autoclaving or soaking in chemical disinfectants. . Wash hands in between patients. Never MANUALLY recap. Dispose needles and other sharp objects in puncture resistant containers. 6. and before leaving laboratory or as needed. In some situations when reuse is unavoidable. e.LABORATORY SAFETY AND PRECAUTIONS UNIVERSAL PRECAUTIONS – Emphasize that all patients. After performance of tests.

) Save the excess unknown samples in the freezer.PROCEDURE IN THE ACTUAL PERFORMANCE OF THE EQAP ACTIVITIES: For unknown samples received from EQAP.) Record/document the nature of breakdown of the instrument in the logbook C. Tech at once B. E. the following instructions should be followed: A. C. D.) Read carefully the instruction given by the sending agency B.) Back-up procedure must be done as soon as possible. and Lung Center) thru mail.) Both samples (2 vials) should be run together with the specimens of the day. CONTIGENCY PLAN IN CASE OF EQUIPMENT BREAKDOWN The following steps should be done during an equipment breakdown: A.) Record the results on the sheet provided. E.) Verify the results and send it back to the sending laboratories (NKTI. D. .) Report all breakdown of instruments to the Chief Med.) Inform the supplier and ask for assistance.) Specimens maybe sent to a Reference Laboratory.

POINT OF CARE TESTING Policy: When there is a need to know the patient’s capillary blood glucose. 5. Remove a fresh UNI-CHECK Blood glucose test strip from the bottle and replace the cap tightly. apply the drop of blood to the circle of the test strip. Report result in mg/dl Fasting Value 60-130 mg/dl After 1 hr meal < 180 mg/dl After 2 hr meal < 150 mg/dl . 8. An “insert strip” message will appear on the meter. Press on/off button of the glucometer. The meter then counts down from 45-0 seconds. HGT (HAEMO-GLUCO TEST) is requested. Procedure: 1. Prick side of the finger and massage a hanging drop of blood 6. Insert the uni-check strip into the meter. At the end of the countdown. When the message “apply sample” appears on the meter display. 9. 7. Make sure hands (patient’s) are dry 2. Done on One-Touch Lifescan Glucometer. 3. Press the on/off button to turn meter off and discard the used strip. a series of beeps will sound and the result is displayed. whether on stat or timed collection. 4.

Upon receipt. 2. All equipment/ machines to be used in the testing shall be properly prepared and calibrated. 5. Internal quality control measures shall be done prior to the testing. The medical technologist shall perform the tests separately from the patient samples of the day. 8. 7. and/or problems in testing to the chief medical technologist and Head Pathology. 4. He/shall coordinate with the sending NRL in cases of incomplete set of materials sent or non-viability of the samples received. The final report of the results shall then be prepared and signed by proper laboratory personnel and eventually will be submitted to the sending NRLS. . The Laboratory shall regularly participate in the EQAP testing done by the different National Reference Laboratories (NRLs) of the Dept. He/she shall then inform the chief medical technologist and head Pathologist of such receipt. The Laboratory shall receive all EQAP testing materials sent by the NRLs.PROCEDURE IN THE PERFORMANCE OF EXTERNAL QUALITY ASSURANCE PROGRAM (EQAP) 1. He shall record all results. of Health and other organizations. the medical technologist on duty shall ascertain for the viability of the samples based on the guidelines from the NRLs. The medical technologist who received the testing material shall secure and store the materials in the proper conditions stipulated in the guidelines set by the sending NRLs. schedule for the testing of the materials received and shall inform the medical technologist who will perform or assist in performing the testing. The chief medical technologist shall collate the results and report to the Head pathologist. and shall be evaluated for its proper operation. The latter shall review and possibly recommends retesting with different medical technologist if needed. With its present secondary category. The chief medical technologist shall. for possible acceptance and rejection of the materials sent. the Laboratory is presently mandated to participate yearly in Hematology and Clinical Chemistry EQAP testing. 6. 3. upon consultation with the Head Pathologist.

Sign up to vote on this title
UsefulNot useful