LAB MANAGEMENT
MLS 405/LABORATORY
CHRISTIAN JOHN VILLAHERMOSA, RMT
[TRANS] LESSON 2: LABORATORY WORKFLOW
TOPIC GUIDE
3 phases of testing process
● Pre-analysis
o Pre-collection variables
o Specimen collection
o Lab policies
▪ Time of collection
o Reasons for specimen rejection
o Specimen transport
o Specimen processing
▪ Centrifugation phase
● Analysis
● Post-analysis
THREE PHASES OF TESTING PROCESS
● PRE-ANALYSIS
o Activities that take place before testing
o Test ordering and sample collection
● ANALYSIS
o Activities that actually produce a result
o Running a sample on an automated analyzer
● POST-ANALYSIS
o Patient reporting and result interpretation
PRE-ANALYSIS PHASE
● 32%-75% of all testing errors occur in this phase
● Errors in this phase create rework or additional
investigations that may cause unnecessary
procedures and costs to the patients and to the
health care system
● Factors:
o Pre-collection variables
o Specimen collection
o Specimen transport
o Specimen processing
▪ Example: You collected a sample for an FBS
from a patient. Unfortunately, you were not
able to use either the red top or the gold top
tube but instead used an EDTA tube which
contains anticoagulant and will interfere with
the orchestrations of the chemical of the
clinical chemistry analyzer methods. So, in that
case, you committed an error during specimen
collection by using the wrong tube so of
course you should collect another sample from
the patient. That is a big red flag because that
is considered an unnecessary procedure
because if you were able to use the correct
tube in your 1st attempt then the 2nd attempt
would have been prevented. The materials,
time, and effort used in 1st attempt will now be
considered waste. Now you will perform again
a 2nd attempt using the correct tube so you
will again use a new tube, syringe, cottons,
plasters.
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▪ Bear in mind that during pre-analysis, knowing
that many errors happen in this phase, you
must be able to be focus and really occupy
your work. No distraction allowed, but again,
sometimes things really go awry, things go
wrong, so it is always important that those
errors should not happen frequently because if
they do happen frequently on your watch, then
it would question your ability as a medical
technologist.
PRE-COLLECTION VARIABLES
● TIME VARIATIONS
Because there are specimens or there are types of
collection that have specific times because of the
nature of their periodicity inside the human body
o Cortisol: higher in the morning (diurnal
variation)
o Microfilaria: best at night
o Malaria: between chills (multiple smears)
▪ Example: The hormone cortisol is higher in
the morning because this hormone exhibits
diurnal variation it is higher in the morning and
as the day progresses the level of cortisol also
decreases. It is important that if your test
requests of your patient are cortisol, you have
to collect the sample in the morning so you
can actually collect higher level compared to
the lower levels later that day
▪ Also, in parasitology, it was discussed that
there are blood parasites that exhibit
periodicity like microfilaria of the Brugia and
Wuchereria. They must be collected best at
night because of their periodicity in their
preferred time of appearance in the
bloodstream so that they can be collected and
viewed under the microscope and. In the case
of malaria, one of the recommended times for
collection is between the chills of the patient.
Sometimes one smear is not enough so it
requires the collection of multiple smears in
order for the medical technologists to be able
to specify the correct species of malaria
present inside the patient and at the same
time to be able to determine the stages of the
malarial parasite in the patient's blood smear.
● EXERCISE
o Strenuous exercise can alter a patient's result.
In the case of creatinine, if a patient had a
strenuous exercise prior to blood collection,
then creatinine is expected to be increased
because of the muscle breakdown.
o Example: Glucose levels tend to lower after a
period of strenuous exercise because of the
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LAB MANAGEMENT
MLS 405/LABORATORY
CHRISTIAN JOHN VILLAHERMOSA, RMT
[TRANS] LESSON 2: LABORATORY WORKFLOW
energy that you have spent doing that exercise
and that is important to bear in mind because in
the case of FBS it is typically, ideally and
routinely collected early in the morning because
of its fasting nature. If a patient has to go to the
laboratory early in the morning for an FBS
extraction, then the patient should have not
performed any exercise prior to collection
because exercise defeats the purpose of
actually measuring the accurate glucose levels.
It is always important that before a FBS
collection, or any blood collection for that
matter, no strenuous exercise is advised.
● DIET
o Glucose and triglycerides increase after eating
▪ We have specimens that requires fasting like
FBS that requires 8-10 hours of fasting and
for lipid profile is 10-12 hours of fasting, so
it’s very important that these tests are strictly
confined into fasting states so as not to
erroneously measure these analytes.
● STRESS
o Increases ACTH, cortisol, and catecholamines
▪ If you are stressed, your stress hormones
are released therefore they will increase in
your circulation. Under stressful conditions, it
is expected that there are increased levels of
ACTH or adrenocorticotropic hormone,
cortisol, and our fight or flight hormones
which is the catecholamines, epinephrine
and norepinephrine.
▪ Again, aside from not allowing our patients
to have strenuous exercise before a blood
collection, it is also advised that a patient
should not be in a stressful state prior to
blood collection in order to prevent any
possible false increase of any of the stress
hormones.
● POSTURE
o For outpatients, they are supposed to be sitting.
o For admitted patients, either they are seated or
they may remain lying down in their hospital
beds
o Upright: increases hydrostatic pressure which
increases protein concentration
▪ Do not extract blood when the patient is
standing since it can also eventually cause a
false increase in the measurement of
growth, so that is inaccurate result.
o From supine to sitting position: increases
hemoglobin, hematocrit, and RBC count
▪ If the patient changes their position from
supine to sitting position, this scenario also
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increases although the increase in
hemoglobin, hematocrit, and RBC count is
transiently (for a while, not permanent).
▪ So, let the patient be if they are already in a
supine position.
o Prolonged tourniquet application may increase
serum enzymes, proteins, and protein-bound
substances
▪ It is not really recommended to tie the
tourniquet around the arm of our patient in a
long period of time.
o Patients should be advised to avoid changes in
the diet, consumption of alcohol, and strenuous
exercise 24 hours prior to blood collection
▪ This is not in our hands anymore because
most of our patients, especially for the
outpatients (OPD), they enter the lab only
when it is already extraction time. So, we do
not have any opportunity to talk to them a
day before the day of blood collection
because that is under the domain or
jurisdiction of their physician.
▪ So, we just trust that their physicians
mention these things to them so accurate
reporting of blood collection is done.
▪ In the case of patients who are admitted in
the hospital, obviously their diet is controlled
depending on their condition and alcohol is
not consumed inside the hospital and they
could not perform any strenuous exercise
inside the hospital.
● AGE
o Analytes higher in children and they are higher in
infants, that's why it's very important to know the
age of the patient. It's one of the important
information that is asked to inpatients and
outpatients. So, the machine can use its pre-
programmed reference intervals or reference
range of the results.
● GENDER
o For example, males have higher creatinine
because of more muscle mass compared to the
average muscle mass in women.
SPECIMEN COLLECTION
TEST ORDER
• One of the most frequent errors: selecting the wrong
lab test
o We only do whatever is written on the test
request or whatever is checked on the test
request
• May be electronic or in writing
o If written manually, it is important that it is
readable
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LAB MANAGEMENT
MLS 405/LABORATORY
CHRISTIAN JOHN VILLAHERMOSA, RMT
[TRANS] LESSON 2: LABORATORY WORKFLOW
• Verbal requests may be made during emergency
situations and should be documented
o Official lab request must be placed after the
blood is drawn
● ‘add ons’
o Additional tests requested on a specimen
previously collected
o Pahabol tests on a specimen previously
collected
▪ Example: Blood (serum) is collected now for
FBS after 30 minutes the doctor requested for
creatinine, urea, ammonia, and etc. That can
be accommodated if the specimen that will be
used is the same from previous collection. In
the case of creatinine, urea and ammonia, it
requires a serum specimen so it can be done.
o Problems (Disadvantages): specimen is not
the proper type, residual volume is insufficient,
storage conditions result in analyte deterioration
▪ Not the proper type - example the specimen
collected is serum for FBS, then the doctor
asks for pahabol blood typing which requires
whole blood. Blood typing tube is EDTA
which is not the tube for FBS collection. This
needs to have another collection from the
patient.
▪ Residual volume is insufficient - the
specimen you’ve collected previously can no
longer accommodate the doctor’s follow up
request. So, it’s not possible to add on. Wag
tipirin. It’s always better to collect another
sample than to risk.
▪ Storage conditions- there analyst that can
easily deteriorate for example, electrolytes.
Example: if blood is collected for FBS and
then after 5 hours the doctor requested for
sodium potassium. This is not allowed
because 5 hours is already a long period of
time for the electrolytes. Electrolyte has
deteriorated. If the length of time that has
elapsed is long then collect another sample to
be safe.
o Advantage: Save laboratory time to collect again
and use new sets of tubes and syringes if the
specimen is same
• Laboratory Policies
o If a patient refuses to have blood drawn
▪ Varies from one laboratory to another – this
has to be put down in writing in order for the
application to be uniform to all the staff. Then
it should be relayed to our personnel in order
to know what to do.
o If the patient was unable to be drawn
▪ Typical attempts to draw blood in the same
medtech is two times, if third attempt is still
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fail, it should be done by the other medtech
na.
▪ Ask for help sa co-workers
o If the patient is unavailable
▪ Pag pasok sa room, wala ang patient.
Hanapin or mag wait sa lab.
o If the patient is combative
▪ Nanununtok, nagwawala, some patients spit.
▪ Wait for the patient to calm down or restrain
the patient
o If the patient becomes ill or faint
▪ Should we pause, ask for first aid, let the
patient rest for a while, fast the next day, etc.
• Time of Collection
o ASAP collection
▪ As soon as you are vacant/free
▪ Urgent but can wait
o Stat collection: collected and analyzed
immediately
▪ Drop what you’re holding, stop what you’re
doing
▪ Collect the sample immediately
▪ Urgent but can’t wait
o Timed specimens: OD, TID, BID, Qn (e.g.
Q12, Q8, Q6, Q4, Q1)
▪ OD (once a day_Time: ask the nurse / doctor
station)
▪ TID (Thrice a day_every 8 hours; when to
start? Ask the doctor)
▪ BID (Twice a day_every 12 hours; when to
start? Ask the doctor)
▪ Qn (Q- every; n – Hour) Ex: Q4_every 4hrs
o Trough specimens: reflect the lowest level in
the blood; drawn 30 minutes before the drug is
administered
▪ To determine the dosing interval
▪ Measures kung gano kabilis maeliminate sa
system ang drug na binigay
▪ Used to detect the level of medications sa
system ng patient
▪ Refers to the lowest level of the drug in the
blood
▪ Common drugs: Anti-seizure drug, some
antibiotics, and immunosuppressants
o Peak specimens: drawn shortly (30mins) after
medication is given
▪ To determine the dosing interval
▪ Measures kung gano kabilis ma absorb and
maeliminate sa system ang drug na binigay
▪ Used to detect the level of medications sa
system ng patient
▪ Refers to the highest level of the drug in the
blood
▪ Common drugs: Anti-seizure drug, some
antibiotics, and immunosuppressants
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LAB MANAGEMENT
MLS 405/LABORATORY
CHRISTIAN JOHN VILLAHERMOSA, RMT
[TRANS] LESSON 2: LABORATORY WORKFLOW
o 2-hour postprandial
▪ 2-hour after meal to collect the sample
o Glucose tolerance test
▪ Multiple extraction
▪ Fasting sample then iinom ng glucose
solution provided by the laboratory then after,
blood extraction after 1hr then 2hrs then 3hrs
after maubos ang drink depending on the
doctor’s request
REASONS FOR SPECIMEN REJECTION
• Hemolysis/lipemia (high lipid content)
o Hemolysis: Increase in potassium level of the
patient; cellular electrolyte
• Clots present in an anticoagulated specimen
o Hindi proper ang mixing yung blood sa
anticoagulant
• Non-fasting specimen when test requires fasting
• Improper blood collection tube
• Short draws, wrong volume
• Improper transport conditions (e.g. no ice for blood
gases)
o Ex. Arterial blood gas – no ice; it needs ice to
preserve the analytes that we have to measure
• Discrepancies between requisition and specimen
label
o Do not conclude agad agad
• Unlabeled or mislabeled specimen
• Contaminated specimen/leaking container
SPECIMEN TRANSPORT
• Transport of blood, urine, body fluids, and tissue
specimens from collection site to the lab
• Excessive agitation must be avoided to minimize
hemolysis
o If hemolyzed, reject
o If sige uyog uyog ang test tube, it can lead to
hemolysis
• Samples for bilirubin testing must be protected from
light
o Ma lower ang concentration nang bilirubin pag
ma expose sa lights
o If naay bilirubin, prepare a paper to cover test
tubes
• For local, onsite transport, pneumatic tube systems
may be used
o Rapid efficient, and cost-effective
o Blood specimens are placed in a carrier with
liners to prevent leakage and padding to ensure
it remains intact
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PNEUMATIC TUBE SYSTEM
• Black circle: For sending
• Yellow circle: Destination (to receive) then suction
back to laboratory
• It maintains the integrity of specimen transport
SPECIMEN PROCESSING
● Ideally, all measurements should be performed within
45 minutes to 1 hour after collection
o Rule: If received by the laboratory, immediately
test it
● Plasma or serum is preferred for most biochemical
determination
o Serum is the specimen of choice due to its
simplicity in collection and handling and no
interference from anticoagulants
▪ Plasma is the liquid form anticoagulated blood,
therefore, an addition of anticoagulant which
interferes testing
▪ Some anticoagulants may have granules that
may be suctioned by the built-in pipette
analyzer that causes blockage, hence, serum
is commonly used
● Serum or plasma must be stored at 4 to 6 degrees C
if analysis is to be delayed for longer than 4 hours
o Ex: collection of blood first before the request,
malfunction (machine)
CENTRIFUGATION PHASE
● A centrifuge uses centrifugal force to separate
phases of suspension by different densities
● One should look for a centrifuge with the highest
possible centrifugal force and not the rotational
speed
● Relative Centrifugal Force (RCF) = (1.118 × 108 -5 ) ×
r × (rpm)2
o r: radius in cm between the axis of rotation and
the center of the centrifuge tube
o Rpm: speed in revolutions per minute
o Why is RCF more important that rpm?
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[TRANS] LESSON 2: LABORATORY WORKFLOW
▪ Rpm may be a good indicator of a centrifuge, ▪ Qualitative abnormalities of blood cells:
but RCF is better when it comes to measure should prepare blood smear for further
the force applied on an object in a rotating evaluation
environment - Common for patients with leukemia (large
▪ RCF—stable, consistent, constant WBCs; immature WBCs are released by
the bone marrow) and blood cancers
o Flags for problematic results
▪ If values fall outside the linear range:
automatic or manual dilution and then
reanalyzed
- Common in creatinine, patients with kidney
failure have a high creatinine levels
● Critical values
o Also known as panic or alert value
o Requires rapid communication with a healthcare
provider who can provide necessary medical
interventions
▪ Ex: myocardial infarction—if it increased/high,
report to the nurse station or doctor’s
• Horizontal centrifugation is better the RCF is larger
emergency room
compared to fixed-angle centrifugation.
▪ Ex: low platelet count—critical value for
• In fixed-angle centrifugation, there is a possibility of
interaction between RBCs and buffy coat and plasma dengue patients or for any patients with blood
because it is slanted. In horizontal, it is evenly disorders. If it will fall perilously low, elicit
distributed and only a little leakage of RBCs bleeding to the patients
• Laboratories may have horizontal centrifugation like
microhematocrit centrifuge, although it only uses
capillary tubes instead of test tubes

ANALYSIS
● Sample Introduction and transport to cuvette or
dilution cup
o There are machine where you can place the
whole test tube but there are also other machine
where it uses sample cup; it varies
● Addition of reagent
● Mixing of sample and reagent
● Incubation
● Detection and calculations
● Readout and result reporting

POST-ANALYSIS
● Alarms and flags
o Refers to a prompt given by the machine which
gives a signal that there is something wrong with
the sample
o Role of flag—allows medtech to perform the
necessary corrections to produce accurate results
o Flags for problem specimens
▪ Inadequate samples
▪ Presence of high concentrations of interfering
substances (lipids, hemoglobin)
- Automatically reject before putting it in the
machine to save time
o Flags for specimens that require additional
analysis with another method
▪ Commonly seen in the hematology

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