SEM100 - MTAP100 - MLSCI 100 | MEDICAL LABORATORY SCIENCE INTERNSHIP

PRE-ANALYTICAL, ANALYTICAL AND POST ANALYTICAL PROCEDURES

Shiela Mae Peligrino, RMT and Zhainal Mark Julaine, RMT. July 31, 2021

OUTLINE 3. Disinfect again using povidone-iodine

I. Main Heading II. Content Formatting 4. Wipe and disinfect the site using alcohol
A. Subheading A. Subheading 5. Then proceed to phlebotomy and collect about (5-10mL
B. Subheading Font and INDEX: APPENDIX children) of blood from the patient (20-30mL adult)
Sub-subheading 6. Transfer the extracted blood onto the culture bottles
7. Gently mix the bottle by inversion
I. PRE-ANALYTICAL PROCEDURES 8. Label the specimen and make sure to include which
● Occurs prior to specimen testing and may include site
variables involving the process of obtaining a specimen ▪ Label which bottle is the first bottle and label the site
collected from
▪ Sample collection should have an interval of 1 hour
and should be from different sites
Cerebrospinal Fluid
● To diagnose a disease or condition affecting the central
nervous system
● Collected through lower back by a procedure called
lumbar puncture/spinal tap
● Preparation prior to sampling
● Bottle collected:
→ If any special instructions are needed, instruct the
→ 1st: chemistry/serology
patient accordingly (e.g. fasting)
→ 2nd: microbiology
→ Verifying patient identity
→ 3rd: hematology
● Sampling/handling
→ excess bottle: microbiology
→ How to store the sample
→ e.g. bilirubin should not be exposed to light, samples
for blood gasses should be iced.
● Transport/Storage
→ Cary-Blair for stool
→ Broth for specimens for microbiology
● Preparation prior to analysis
B. SPECIMEN COLLECTION
Blood Culture
● Ordered when the doctor suspects for blood infection
● Bacterial or fungal
Throat and Nasopharyngeal Swab
● 1-2 blood culture bottle per patient is usually requested by
the physician ● To check for any signs of infection from the respiratory
→ Negative for two bottles secretions
▪ Doctor will request for another bottle ● Technically any lab processes of each of the swabs
▪ Possibility that the bacteremia/fungemia may not (nasal, NP, and throat) are exactly the same
have been detected on the first two bottles ● Put in thioglycollate medium to preserve the throat swab
● Types: → If not, swab will dry up and will yield false negative
→ Aerobic results
→ Anaerobic → Sputum is expectorated, not swabbed
→ Pediatric ● Swab size:
→ ARD (Antimicrobial removal device) → bigger swab: oropharynx
▪ used when a patient is on antibiotic treatment → smaller swab: nasopharynx
● Volume Required for BactAlert:
→ Adult: 20-30 mL
→ Children: 5-10 mL

● Collection procedure:
1. Locate extraction site
2. Disinfect the site with alcohol
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 → For sputum AFB, check 100 LPF
Bartlett’s Classification
● Not applied in reality
● Reject if more than 25 squamous epithelial cells are
present regardless of neutrophil count
→ indicates sample is salivary
→ Reject if epithelial cell count is equal to neutrophil count
● Accept if more than 25 neutrophils are present
→ Accept when neutrophil count is greater than epithelial
cells
→ Presence of neutrophils indicate good quality sample
● Bartlett Score ( viewed in LPF)
→ >0 - Reject the sputum sample
→ Green: Viruses → <0 - Accept the sputum sample
→ White: Viruses and bacteria
→ Red: Viruses, chlamydia B, and mycoplasma
Swab Procedures
● NASOPHARYNGEAL SWAB
→ Tilt patient’s head back 70 degrees
→ Gently and slowly insert a mini tip swab with a flexible
shaft (wire or plastic) through the nostril parallel to the
palate (not upwards) until resistance is encountered
→ gently rub and roll the swab
→ leave swab in place for several seconds to absorb
secretions
→ slowly remove swab while rotating it
→ place swab, tip first, into the transport tube provided.
→ Nota bene!
▪ Swab should be painful; questionable if the
procedure was not painful.
● THROAT (OROPHARYNGEAL) SWAB
→ Insert swab into the posterior pharynx and tonsillar
areas
→ Rub swab over both tonsillar pillars and posterior
oropharynx and avoid touching the tongue, teeth,
gums
→ Place swab, tip first into the transport tube provided
Sputum
● Container must be:
→ 30-50 mL capacity
→ Translucent or clear material
→ Serile, single use
→ Leak-proof, screw cap
→ Wide mouth

Urine
● 30-50mL capacity, same with sputum container
● Translucent or clear material
● Sterile, single use
● Leak-proof, screw cap
● Wide mouth
● if the request is coupled with urinalysis, process first in
microbiology
● Specimen of choice:
→ Midstream catch
→ Catheterized for those unable to produce urine
→ Suprapubic if anaerobic culture
● Must be preserved or refrigerated if not processed
● Ideal time of collection is morning + gargle with water immediately
before collection → Boric acid is a suitable preservative
● Nota bene! Stool
→ May often be contaminated with normal flora so it is ● Stool specimens/Rectal swabs must be placed in sterile
important to evaluate the quality of the specimen container of appropriate size with a tight-fitting leak proof
→ Note the number of squamous epithelial/LPF and lid
PMNs to evaluate acceptability of specimens ● Should be processed within 2 hours of collection
→ Reject in the presence of blood → If not, place in transport media (CARY-BLAIR)
▪ leads to false positive results. Genital Tract Specimen
→ Perform Gram Stain
▪ Check for presence of neutrophils and other WBC
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● All specimens should be collected during a pelvic ● Wrong identification of patient
examination using a speculum. ● Missing physician’s order
→ The speculum may be moistened with warm water → Sputum KOH, Sputum AFB,
before use, but antiseptics or gynaecological → Physicians may order different tests
exploration cream should not be used, since this may ● Use of inappropriate container
be lethal to gonococci → Sterile
● Gonococcal/Chlamydial culture - endocervix ● Patient not appropriately prepared for the test
● After inserting the speculum, cervical mucus should be → AFB: patient should not eat anything prior to collection
wiped off with a cotton wool ball ▪ Must reject if food particles are found in sputum
→ Sampling swab should then be introduced into the sample; increased artifacts
cervical canal and rotated for at least 10 seconds ● Wrong procedure of sample collection
before withdrawal ● Errors in specimen transport to the laboratory
● Blood collection vials not properly labeled
● Requisition form not properly filled (wrong patient name,
wrong tests entered)
● Inadequate sample volume
→ Proper volume: adult: 20-30 mL; children: 5-10 mL
● Referral of specimen
Concerning the preanalytical phase, CLIA requires that
laboratories:
● Have written procedures for the preanalytical phase
● Provide documentation of personnel qualifications and
training
● Monitor sample quality indicators
IV. ANALYTICAL PHASE
● For the collection of urethral specimens: ● Includes what is usually considered the “actual” laboratory
→ A swab with a narrow diameter or a sterile testing or the diagnostic procedures, processes, and
bacteriological loop should be inserted 3-4cm into the products that ultimately provide results
urethra and gently rotated before withdrawal
→ Purulent discharge can be collected directly on a swab A. GUIDELINES IN PROCESSING OF REQUEST AND
or on the inoculating loop SPECIMEN
→ The composition of both the tip and the shaft of the Processing Area (Bench A)
swab is important
● Receiving of request
→ For the culture of Neisseria gonorrhoeae,
● Classification of request/specimen
charcoal-treated cotton tips or calcium alginate or
→ Request are classified according to the type of
Dacron tips are preferred
Microbiology examination
▪ Culture and Sensitivity
▪ Direct smears
▪ Gram’s stain
▪ Acid-fast stain
▪ KOH preparation
→ If immediate plating and incubation are not possible, a ▪ India ink
transport medium Amies or Stuart transport medium ▪ Wet mount
should be used. → Specimen are classified according to type:
▪ Urine
▪ Exudates
▪ Body fluids
▪ Blood
▪ Stool
▪ Other respiratory specimen
▪ Cervico-vaginal/Urethral discharge
● Entry of data into corresponding receiving and processing
worksheet
→ Name of patient is listed in receiving worksheet
II. GUIDELINES IN RECEIVING OF REQUEST AND → Individual worksheet prepared to each
SPECIMEN FOR MICROBIOLOGY EXAMINATION request/specimen and filed to corresponding specimen
folder
● Check laboratory request for completeness of data
● Processing of specimen
● Check receipt for correct billing of laboratory tests
→ Preparation of smears
● Evaluate suitability of specimen for requested laboratory
→ Inoculation of specimen to appropriate culture plate and
test
broths
● Evaluate specimen if fit for processing
● Check if there’s any missing data in LIS Isolation Area: After 24 hours of Incubation (Bench
● Inform ward personnel/watcher for any discrepancy B)
regarding specimen ● Arrangement of incubated culture plates/broths
● Claim stub with requested test will be issued to watcher ● Reading of culture plates/broth
and informed of the date to be claimed ● Performance of work-up procedures on culture plates
→ Culture can be as long as 5 days ● Incubation of work-up tubes and plates at appropriate
● Endorse request and specimen to the processing area temperature for 18-24 hours
A. PRE-ANALYTICAL ERRORS ● Reading of growth in culture plates/broths
● Inappropriate quality of specimen

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BENCH C1 A. POST-ANALYTICAL ERRORS
● Reading of Biochemical, Preliminary and Confirmatory test ● Transcription error
● Evaluation of isolate ● Delayed report of result
● Identification of isolate ● Failure to report the results
● Evaluation of identified organism according to antibiogram ● Loss of test results
requirement ● Incorrect interpretation of results
● Performance of susceptibility test
Concerning the post analytical phase, CLIA requires
BENCH C2: After 24 hours of incubation that laboratories:
● Arrange of incubated susceptibility plate according to their ● Report STAT results and critical values promptly have a
respective specimen groupings written quality assurance program
● Evaluation of Zone of inhibition → Broad spectrum antibiotics, can administer without
● Measurement of Zone of inhibition susceptibility tests.
● Interpretation of Zone of inhibition → Narrow spectrum antibiotics should not be
● Documentation of results on corresponding worksheet administered without susceptibility testing.
folders → STAT in the context of microbiology, refers to STAT
BENCH D collection of samples, not processing.
● Generate Levy-Jennings or trend plots of QC results to
● Disinfection identify changes in test performance
● Decontamination ● Reduce human error through root-cause analysis,
● Media preparation process control, and education/communication
B. ANALYTICAL ERRORS
● Sample lost
● Sample mix up
→ Label not on proper location
● Equipment failure
→ Malfunction of automated equipment
● Undetected failure in quality control
● Procedure not followed correctly
Concerning the analytical phase, CLIA requires that
laboratories: VI. LABORATORY INFORMATION SYSTEM
● Establish and maintain written policy process and ● Database system for patients
procedure manuals → Can see physician requests, medical history, laboratory
● Provide training and perform competency evaluation of test results, etc.
personnel ● Safest, most accurate, most precise
● Participate in a proficiency testing program appropriate ● Computer software that processes, stores, and manages
for their test menu and specialties data from all stages of medical processes and tests
→ NEQAS: National External Quality Assessment → Not limited to medical technology laboratory processes,
Service includes radiography tests and all other laboratory
▪ external quality assessment, usually 3 unknown processes in a hospital
samples ● Involved in storing, recording, recovering and
→ The processing will be upon the discretion of the consolidating laboratory information from the clinical and
laboratory. anatomic sections of the laboratory
● Verify instrument performance and track instrument ● Standardize workflows, tests and procedures, while
calibration and maintenance providing accurate control of the process
● Maintain records of the laboratory environment (e.g.,
temperature, humidity, refrigeration) Classification by Function: Clinical Pathology
● CC
V. POSTANALYTICAL PHASE → Hba1c, serum electrolytes
● Refers to recording, releasing, and interpretation of test → Utilizes red-top tube for serum
results by physicians to formulate diagnosis to guide ● Hema
patient management → CBC, WBC differential, hematocrit level, blood smears
● IS
→ HIV testing, VDRL (Treponema pallidum), Hepa B/C/A
→ Utilizes red-top tube for serum
● BB
→ Blood typing, bloodletting, antibody panels
● CM
→ Semenalysis, urinalysis, fecalysis
● Microbiology
Post-Analytical Processes → Gram staining, AFB staining, KOH staining, plate
● Documentation of results on corresponding worksheet reading, biochemical testing, culture, aseptic
folders techniques, antibiotic susceptibility testing
● Recording of results on corresponding logbook ● Molecular biology
● Preparation of result ● Toxicology
● Preparation of second copy of the official result ● Cytogenetics
● Presentation of claim stub at Receiving/Releasing area ● Therapeutic drug monitoring
(OPD Only)
● Endorsement of claim stub at Microbiology Receiving Area Classification by Function: Anatomic Pathology
(OPD Only) ● Surgical pathology
● Release of official result signed by Microbiology staff ● Immunohistopathology
→ Preservation of tissue, preparation of tissue smears,
use of microtomes
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● Cytology ● Failure to report or reporting to the wrong health care
● Autopsy provider
● Forensic pathology ● Transcription errors
● Molecular pathology ● Incorrect results
● Misunderstanding of the result by the clinicians
A. GOALS OF LIS
● Failure of clinicians to see the reports
● Conform to standard classification and validity of data set
by DOH
→ HFSRB: Health Facilities and Services Regulatory
Bureau
▪ Under office of DOH
▪ Set laws and requirements for accreditation of
laboratories
→ Designs and creates platforms for laboratories
▪ Approx. costs 1 million pesos to create a laboratory
● Ensure the integrity and internal consistency
● Maintain patient confidentiality and security of the
information
● Allow easy access by the laboratory managers up to the
health professionals
● And allows various data to be integrated to the laboratory
data
B. PURPOSE OF LIS
● Improve the quality of data because it plays a central role
on laboratory making
● Optimize efficiency in the laboratory operations for
healthcare delivery
● Connects with patient registration, billing systems, and
EHR
● Provide accurate and timely results
● Assist in the decision-making of health professionals for
the promotion, diagnosis, treatment and management of
health

C. COMMON ERRORS IN THE LABORATORY

WORKFLOW
Pre-Analysis
● Obtaining inadequate or insufficient samples
● Samples taken from the wrong patients
● Specimen replaced in the wrong chemical/container or
tube
● Ordering wrong tests
● Identification problems related to the patient and the
source of the specimen
● Lack of clinical information when required
Analysis
● Bad reagent lot
● Instrument failures
● Wrong data entry
● Erroneous transcript
Post-Analysis
● Delay of the delivery of the result
→ GSCS takes approximately 48 hours (if no growth)

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 INDEX: APPENDIX

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