Areas Of Laboratory Medicine Research Articles

Brazilian laboratory indicators benchmarking program: three-year experience on pre-analytical quality indicators.

In the laboratory medicine segment, benchmarking is the process in which institutions seek to compare with the macro environment (performance comparison and best practices with different laboratories) and improve their results based on quality indicators. The literature has highlighted the vulnerability of the pre-analytical phase in terms of risks and failures and the use of interlaboratory comparison as an opportunity to define a strategic performance benchmark aligned with the laboratory medicine sector, which has been a promising strategy to ensure continuous improvement, identifying within the pre-analytical process the critical activities to guarantee patient safety. In this context, this paper aims to present the three-year experience (2016-2018) of the Benchmarking Program and Laboratory Indicators- in Portuguese, Programa de Benchmarking e Indicadores Laboratoriais (PBIL)- with emphasis on pre-analytical indicators and their comparison against literature references and other programs of benchmarking in the area of laboratory medicine. PBIL is organized by the Brazilian Society of Clinical Pathology/Laboratory Medicine (SBPC/ML) in conjunction with Controllab and coordinated by a Brazilian group with representatives from different countries. The data presented in this paper involving the performance results of 180 laboratories with active participation. Results are presented in percentage (%, boxplot graphical in quartiles) and Sigma metric, recognized as the metric that best indicates the magnitude of failures in a process. The Pareto Chart was used to facilitate ordering and to identify the main errors in the pre-analytical phase. The Radar Chart was made available in this work for the purpose of comparing the results obtained in Sigma by the PBIL and IFCC Working Group Laboratory Errors and Patient Safety (WG LEPS). In the study period, just over 80% of the pre-analytical failures are related to Blood culture contamination (hospital-based and non-hospital-based laboratories), Recollect and Non-registered exams, with failure rates of 2.70, 1.05 and 0.63%, respectively. The performance of the PBIL program participants was in line with the literature references, and allowed to identify benchmarks in the laboratory medicine market, target ofPBIL, with best practices were observed for some indicators. The results of the program demonstrate theimportance of an ongoing program comparative performance-monitoring program for setting more robust goals and consequently reducing laboratory process failures. Even with these promising premises and results, the contextualized analysis of the program indicators, point to a still significant number of failures in our market, with possibilities for improvement in order aiming to ensure more robust and effective processes.

How well do Croatian laboratories adhere to national recommendations for laboratory diagnostics of chronic kidney disease (CKD)?

Background In 2014, the Joint Croatian Working Group (JCWG) for laboratory diagnostic of chronic kidney disease (CKD) conducted a survey across medical-biochemistry laboratories which demonstrated a large heterogeneity in this area of laboratory medicine. To ensure the tools for the standardization process, in 2017 the JCWG-CKD published the first Croatian recommendations for laboratory diagnostics of CKD. To assess the implementation process, we have repeated a survey to explore how well laboratories adhere to the recommendations. Methods An invitation to the survey was sent to all Croatian medical-biochemistry laboratories (n = 196). The questionnaire was designed in a form of 19 questions and statements, with possible multiple answers. Results The response rate was 98/196 (50.0%). The predominant method for serum creatinine measurement was the standardized compensated Jaffe method (79.2%). There was substantial decrease in the number of laboratories which measure creatinine with the non-standardized uncompensated Jaffe method, compared with the initial 2014 assessment; 7% vs. 40%, respectively. The number of the laboratories that did not report estimated glomerular filtration rate (eGFR) values decreased almost by half compared to the initial data (37.6% vs. 74.4%). However, compared to the 2014 initial assessment, a similar number of laboratories (54/98 vs. 58/80) did not measure urine albumin or protein. Conclusions The collected data showed a substantial improvement in the standardization of the serum creatinine measurement, as well as in the reporting of eGFR. However, albuminuria or proteinuria assessment is still not implemented nationwide, mainly in primary health care laboratories. This demonstrates the importance of promoting and monitoring implementation of guidelines after publication.

Analysis of reasons for biological specimens rejection at a university hospital clinical laboratory

Clinical chemistry is the area of laboratory medicine with the largest volume of tests, and it accounts for the majority of clinical decisions impacted by laboratory results. Although the frequency of errors in clinical chemistry has been minimized by automation and high accuracy of analytical instrumentation, contemporary assay technology, and strict quality management programs, occasional results are inconsistent with the clinical situation, indicating possible erroneous test results. In this chapter, the most frequent sources of inaccurate results in commonly ordered small molecule analytes, including creatinine, urea, ammonia, uric acid, glucose, electrolytes, blood gases, lactate, bilirubin, and lipid profiles, are discussed. Pre-analytical causes of variation, including physiologic and pathologic conditions, patient preparation, sample collection, and specimen processing, are also addressed. Common assay methodologies are discussed, highlighting common sources of interferences and analytical errors.

Implications of Monoclonal Antibody Therapeutics Use for Clinical Laboratory Testing.

Monoclonal antibody therapeutics (MATs) represent a rapidly expanding class of biological drugs used to treat a variety of diseases. The widespread use of MATs increasingly affects clinical laboratory medicine. This review provides an overview of MATs currently approved for clinical use in the US, starting from basic biology of antibodies to the engineering, pharmacokinetic and pharmacodynamic properties, nomenclature, and production of MATs. Immunogenicity and the production of antidrug antibodies (ADAs) play a major role in loss of therapeutic response and the development of treatment failure to certain MATs. Laboratory-based monitoring for MATs and detection of ADAs represent emerging needs for optimizing the use of MATs to achieve the best outcomes at affordable cost. In addition, the increased use of MATs affects clinical laboratory testing by interference of MATs with clinical laboratory tests across different areas of laboratory medicine, including histocompatibility, blood bank, and monoclonal protein testing. The number of MATs is rapidly growing each year to address previously unmet clinical needs. Laboratory monitoring of MATs and detecting ADAs represent expanding areas of laboratory testing. Test-based strategies allow for treatment optimization at the level of the individual patient, thus providing a personalized medicine approach. In addition, clinical laboratories must be aware that the increasing use of MATs affects laboratory testing and be ready to implement methods to eliminate or mitigate interference with clinical tests.

Understanding the "philosophy" of laboratory hemostasis.

Unlike many other areas of laboratory medicine, laboratory hemostasis has some peculiarities, which makes it one of the most complex diagnostic domains in clinical medicine. The inherent complexity of the hemostasis process, the components of which have not yet been thoroughly unravelled, is mirrored by a large number of hemostasis disturbances, which can involve single or multiple components. Although laboratory diagnostics represents an unavoidable part of the diagnostic reasoning in patients with bleeding or thrombotic disorders, the basic concept beneath the assumption that in many human pathologies, one single test may be sufficient for the diagnosis, does not hold true in hemostasis. There are in fact many aspects that would lead us to conclude that laboratory hemostasis can be considered a very challenging arena for many clinicians and perhaps also for some laboratory professionals. The most challenging aspects typically include the following concepts; that hemostasis is an intricate and multifaceted process, that more than one test is typically needed to achieve a final diagnosis, that results of screening tests depend on many biological factors and do not allow making a final diagnosis, that harmonization of techniques is still an unmet target, and that the calculations used vary widely among laboratories. This article is hence aimed at discussing many of these aspects, with the hope of presenting a useful contribution to better understand the "philosophy" of laboratory hemostasis.

Lab Tests Online: a Ground-Breaking and Enduring Health Resource

Long before patients were allowed to order lab tests themselves, many patients were confused about even routine tests that their doctor ordered. The American Association for Clinical Chemistry recognized early on the need for concise, peer-reviewed descriptions of individual tests. They set up a system that discussed (i) the reason to get tested, (ii) when to get tested, (iii) the sample required, (iv) any test preparation needed, (v) what was being tested, (vi) when the test should be ordered, and (vii) what the test result meant. Gradually, the included tests were expanded to other areas of laboratory medicine, including microbiology. Lab Tests Online is now a multiple-award-winning website with millions of viewers worldwide. This is the story of the creation and use of the website.

Present status and future prospect of accreditation of proficiency testing provider in the area of laboratory medicine in China

The accreditation of Proficiency Testing Provider(PTP)has gone through more than a decade in China. Over the past ten years, from nonexistence to existence, the domestic PTPs in the area of laboratory medicine have gradually standardized and developed. By reviewing the international and domestic practice, this paper gives an outline of the present status of the accreditation of PTP in the area of laboratory medicine, explores the difference with other countries, the main problems and some suggestions for improvement, and makes a prospect of the development of the accreditation of PTP in the area of laboratory medicine in China.(Chin J Lab Med, 2016, 39: 326-328) Key words: Laboratory proficiency testing; Health personnel; Accreditation; Clinical trial

Effective Use of Mass Spectrometry in the Clinical Laboratory.

Historically the success of mass spectrometry in the clinical laboratory has focused on drugs of abuse confirmations, newborn screening, and steroid analysis. Clinical applications of mass spectrometry continue to expand, and mass spectrometry is now being used in almost all areas of laboratory medicine. A brief background of the evolution of mass spectrometry in the clinical laboratory is provided with a discussion of future applications. Prominent examples of mass spectrometry are covered to illustrate how it has improved the practice of medicine and enabled physicians to provide better patient care. With increasing economic pressures and decreasing laboratory test reimbursement, mass spectrometry testing has been shown to provide cost-effective solutions. In addition to pointing out the numerous benefits, the challenges of implementing mass spectrometry in the clinical laboratory are also covered. Mass spectrometry continues to play a prominent role in the field of laboratory medicine. The advancement of this technology along with the development of new applications will only accelerate the incorporation of mass spectrometry into more areas of medicine.

New areas of laboratory medicine in the 21st century:terahertz laboratory medicine

The terahertz laboratory medicine (THz-LabMed) is an intergrated cross-frontier field which involves multi-disciplinary including medicine, biology, biomedical engineering, physics, optics, computer science, information and materials. Using THz technologies for label-free detection and analysis of biomedical macromolecules, cell and tissues, the THz-LabMed is also the core components of terahertz biomedine (THz-BioMed) which focuses on the biomedical application of THz technologies. THz label-free detection is being paid more and more attention because of its unique advantages worldwide and becomes a hot spot for the application of THz wave technology and methods in life science. Application of THz technology in biomedicine involves many fields globally, including disease diagnosis, recognition of protein status, label-free DNA sequencing, mechanism for absorption differences of biological tissue to THz wave, and radiation influence on biological samples and biological process. THz-LabMed is the global synchronized research in THz-BioMed field in China. It is important to seize the opportunities to develop new disciplines of laboratory medicine. (Chin J Lab Med, 2015, 38: 1-3) Key words: Terahertz; Laboratory medicine

Laboratory diagnostics of chronic kidney disease in Croatia: state of the art.

IntroductionEarly identification and management of chronic kidney disease (CKD) is highly cost-effective and can reduce the risk of kidney failure progression and cardiovascular disease. In 2014, the Joint Croatian Working Group (JCWG) for laboratory diagnostic of CKD on the behalf of Croatian society of medical biochemistry and laboratory medicine (CSMBLM) and Croatian chamber of medical biochemists (CCMB) conducted a survey across Croatian medical-biochemistry laboratories to assess the current practice in this area of laboratory medicine. The aim of this study was to present the data collected through the survey and to give insight about laboratory diagnostics of chronic kidney disease in Croatia.Materials and methodsAn invitation to participate in the survey was sent to all Croatian medical-biochemistry laboratories (N = 196). The questionnaire was designed in a form of questions and statements, with possible multiple answers, comprising 24 questions.ResultsThe response rate was 80/196 (40.8%). 39 answers were from primary medical-biochemistry laboratories. 31/78 (0.40) laboratories measure creatinine with non-standardized method (uncompensated Jaffe method). 58/78 (0.74) of laboratories that measure creatinine do not report eGFR values. Similar number of laboratories (58/80, 0.73) do not measure urine albumin or protein.ConclusionsThere is a large heterogeneity among Croatian laboratories regarding measuring methods, reporting units and reference intervals (cut-off values), both for creatinine and urine albumin or protein. The two key prerequisites for CKD screening, automatic reporting of eGFR and albuminuria or proteinuria assessment, are not implemented nationwide. There is a need for harmonization in laboratory diagnostics of CKD in Croatia.

Why hold a congress of Laboratory Medicine in Brazil?

Sociedade Brasileira de Patologia Clinica/Medicina Laboratorial (SBPC/ML) annually holds a Brazilian congress on its specialty. But why? The reasons are innumerable. At a scientific congress one can keep up-to-date and meet colleagues from other regions of the country and of the world. Technical scientific updating in the medical area is fundamental, considering that significant modifications rapidly occur in diagnostic procedures, with the development of more robust methods, and the exploitation of novel resources of automation and computing. It is in congresses that novelties are presented, either by well-qualified speakers, in lectures, conferences and round-table discussions, or by input and equipment companies. During such events, the possibilities are huge for exchange and acquisition of knowledge, directly from the generating sources, by the presence of eminent researchers.Meeting colleagues is always a reason for satisfaction and rejoicing; it strengthens friendship ties, and allows the sharing of everyday experiences. Interaction, though for just three or four days, with professionals from different areas of laboratory diagnosis, and from other medical specialties that make frequent use of the clinical laboratory, creates a highly productive setting where benefits and limitations can be clearly and informally discussed.Companies, manufacturers or distributers of input and equipment actively participate in the success of the congress by organizing a trade fair, where they display state-of-the-art devices, systems and methodologies. It is the opportunity not only to learn what is being presented, but to negotiate trade agreements.Soon, from September 29 to October 2, in Fortaleza, Ceara, the 49th Brazilian Congress of Clinical Pathology/Laboratory Medicine and the 1st Brazilian Congress of Laboratory Informatics will be held. The choice of Fortaleza as their seat was a dream come true for clinical pathologists and laboratory workers from the whole Northeast region of Brazil.The main theme of the Laboratory Medicine Congress will be “Integration for diagnosis”. It is the view that currently guides Laboratory Medicine, prizing integration among professionals from different areas and reflecting the reality of our days, with growing integration among the several diagnostic tools.The 1st Brazilian Congress of Laboratory Informatics will convene activities related to information technology in its own and simultaneous meeting, lasting one day, when participants will improve their knowledge without missing the scientific program of the event as a whole. For both congresses, 170 Brazilian and 10 foreign speakers are invited. A total of 24 conferences will be held, besides 45 round-table discussions, covering all areas of Laboratory Medicine. Approximately 122 companies, including manufacturers and distributors of clinical laboratory products, governmental entities of education and health, and private laboratories will be present, actively participating in all the activities.The chosen place, Centro de Eventos do Ceara (CEC), opened in 2012, is considered the most modern and well-equipped venue for events of this nature. The center has the ideal infrastructure for the congress, with a wide area for technical-scientific exhibitions, rooms, auditoriums, lounges and circulation areas that ensure participants’ comfort.In addition, the capital of Ceara, with many tourist attractions, has excellent hotel and restaurant facilities to host big events. The increased frequency of direct flights between Fortaleza (Aeroporto Internacional Pinto Martins) and European countries encouraged the participation of many foreign guests.Welcome and enjoy Fortaleza.

Trends in Teaching Laboratory Medicine in Microbiology to Undergraduate Medical Students: A Survey Study

The teaching laboratory has long been a component of medical microbiology courses. Limited data suggest that many medical schools have eliminated their teaching laboratory for diagnostic microbiology despite support for active learning over didactic lectures and a concern that undergraduate medical student’s education in the area of laboratory medicine is inadequate. A survey study of North American medical schools was conducted to determine if there is a trend towards decreasing or eliminating this teaching laboratory. The study also documented reasons for changes to this teaching laboratory, curricular content of existing microbiology teaching laboratories, and use of computer-assisted instruction. There was a 53 % response rate to the survey. Forty-three percent of medical schools decreased the hours or eliminated the teaching laboratory in diagnostic microbiology entirely between 2002 and 2012, and an additional 7 % of schools have plans to decrease hours or eliminate this teaching laboratory. Changes to the teaching laboratory were most often due to limited resources, reduced teaching hours, and overarching curricular changes. Because the way in which medical students are taught laboratory medicine in microbiology is undergoing a significant change, educators need to ensure that the learning experience is sufficient, and the quality is not compromised as a result.

Organization of laboratory analytics into centers – meaningful or not? 1

Abstract Specialists working in the field of in-vitro diagnostics increasingly make use of similar methods. This applies to laboratory medicine, microbiology and virology, pathology, hygiene, environmental medicine, and, in part, transfusion medicine and human genetics. Although the diagnostic issues and/or the specimens differ in most cases, the molecular, cellular, immunologic, mass-spectrometric and other separation and detection procedures are based on identical principles and technologies. With some of these procedures costly multiple investments are unavoidable, since several specialties make use of them. Furthermore, an increasing degree of mechanization and the need for modern IT-based process controls in all specialty fields tie up additional resources. On the other hand, it is exactly these specialty fields in German hospitals that find themselves under considerable cost pressure, intensified by the competition with private large-scale laboratories and laboratory chains. Hospitals that still run their own laboratories and institutes in these specialties are considering either partnerships with such laboratories or outsourcing. Such changes, however, go hand in hand with the curtailment of each hospital's decision and development autonomy. For this reason many hospitals are seeking autonomous solutions. As yet no university medical center in Germany has decided on permanent outsourcing. To increase their economic efficiency on their own, hospitals have attempted to develop rationalization programs and to achieve qualitative added value by establishing laboratory centers. Large municipal hospitals had earlier already pursued this approach, some university clinics adopted it some years ago. They created competence and organizational centers like “diagnostic centers”, “centers for clinical pathology”, etc. with the objective of utilizing the technical and organizational synergies of the specialty fields mentioned above. In particular, the focus here is on joint methodological competencies, identical or similar instrumentation, similar requirements for IT-based process controls as well as overlapping qualifications of medical and technical personnel. These primarily specialized aspects unfold their potential for cost savings only when they are organized appropriately. Hence the key to success for the creation of a center is to change a specialty-centered organization into an organization that spans multiple specialties and is aligned along synergies. In view of the importance of technical decisions this challenge can be met only with expert leadership. Therefore successful concepts always envision such centers to be under the direction of a physician, regardless of their varying designs. In competition with large-scale laboratories and laboratory chains, large centers at this time can still frequently capitalize on their technical breadth as a unique selling proposition in their respective areas. So far private large-scale laboratories are active primarily in the areas of laboratory medicine, microbiology and virology and less frequently also in the area of human genetics, but only rarely in the areas of transfusion medicine and pathology. In comparison, the centers of large hospitals with greater technical breadth cannot only make even wider use of synergies, but can also bring to bear their comprehensive technical competence. Hence, the formation of centers can be a path to economic efficiency and to a strengthening of the competitive position above all for large hospitals.

Discrepant DNA analysis in three patients with inherited arrhythmia: Molecular genetic test results deserve a second glance

Molecular results provide a basis for diagnosis, risk assessment, medical management and genetic counseling. Unlike other areas of laboratory medicine, molecular genetic tests are rarely repeated. We describe three patients with suspected inherited arrhythmia in whom genetic testing was arranged via clinical and/or research laboratories. In all three instances, initial test results appeared falsely negative, with no deleterious mutations detected by various methodologies in selected long-QT or catecholaminergic polymorphic ventricular tachycardia-related genes. Discordant results emerged upon repeat analysis in separate laboratories. The cases highlight the importance of clinical judgment and assessment of genetic test results and methodology, in addition to the role of re-testing in molecular genetic medicine, particularly in the case of uninformative negative results.

The Microbiology Bench Companion

Diagnostic testing for infectious diseases is an increasingly complex area of laboratory medicine. The microbial community continues to evolve and adapt to changing environmental influences, and the distribution of human pathogens has become more global. Our recognition of the spectrum of microorganisms that cause invasive human disease has exploded with the use of culture-independent methods to detect and characterize pathogens. Clinicians, epidemiologists, and public health officials can benefit from consultative interactions with laboratory professionals to assist with optimizing diagnostic test options and interpretation of test results. For technologists without access to board-certified laboratory professionals who can guide the work-up of infectious agents in a microbiology laboratory, a concise guide can be extremely beneficial. In this handbook, J. Michael Miller, a highly experienced clinical microbiologist, distills a great deal of information into 120 pages, largely formatted as tables and flowcharts. Molecular methods for detecting or identifying microorganisms are notably absent, which may reflect the author’s intent to address readers who perform conventional diagnostic tests only. The handbook is divided into 3 sections. Section 1 focuses on routine laboratory bench algorithms for identifying bacteria, fungi, and parasites. Although most of this information can be found in clinical microbiology textbooks, the flowcharts are an easy reference, especially for medical technologists. Section 2 is entirely formatted with tables listing clinical syndromes (e.g., cellulitis, pneumonia, gastroenteritis) and their possible infectious causes. The lists of etiologic agents are extensive, yet practical, and would be of most benefit to infection control practitioners, nurses, and laboratory technologists. Section 3 is devoted to therapeutic choices for various microorganisms and is intended to inform laboratorians of treatment options; it is not a guide for therapeutic decision-making by clinicians. Although certain taxonomic classifications and susceptibility guidelines do not reflect the current standard, most information, such as annotated remarks for pathogens classified as select agents, is timely. The author valiantly furnishes us with pearls and nuances of clinical microbiology in this clear and concisely written handbook. The task was Herculean. As the author aptly notes in the introduction, no handbook can capture every parameter or indication for identification of all clinically relevant microorganisms and describe these microorganisms in public health or patient-centered contexts. Overall, the author delivers a wealth of information that can benefit technologists and healthcare practitioners in regions with limited access to professionals who specialize in clinical microbiology or infectious diseases.

Learning needs in clinical biochemistry for doctors in foundation years

Most medical school curricula have reduced the amount of time available for teaching in pathology despite the fact that junior staff in the early stages of their training were responsible for requesting the majority of pathology tests on acutely ill hospital patients. So, the lack of specific training in this area means that test requesting may be poorly performed and the results ill understood by these staff. This paper describes a questionnaire, which was designed to assist laboratory staff providing targeted teaching in this area. Doctors in Foundation year 1 (F1) and Foundation year 2 (F2) in Sheffield teaching hospitals were given a questionnaire to ascertain how confident they were in requesting and interpreting the results of clinical biochemistry tests. The doctors were also asked about which areas of laboratory medicine they would like to be taught. Responses were received from 82 doctors, about half those in F1 and F2. The survey revealed areas where juniors are less confident in requesting tests and interpreting results. Despite lack of confidence in interpreting the result, 18% were confident about requesting tests. Doctors were also unsure of the effects of common problems like haemolysis on the interpretation of results. More than 70% of the doctors requested specific teaching in these areas. Foundation doctors have learning needs in clinical biochemistry, addressing which would assist them in patient care. While better training in medical school may help in future, there are specific needs for those on the wards now that require targeted teaching.

Phage display‐based molecular methods in immunohematology

The goal of the current Food and Drug Administration-sponsored workshop was to explore the feasibility of utilizing newly developed molecular approaches in the area of immunohematology. As stated by the workshop’s organizers, conventional methods for blood grouping and associated compatibility testing have served us well for many decades, yet blood incompatibility remains a significant problem in transfusion medicine. This is due, in part, to the variability in the performance characteristics of preparations of polyclonal or monoclonal antibody reagents as well as to certain inherent limitations in a detection scheme that is agglutination-based. Furthermore, in comparison with diagnostic testing performed in other areas of laboratory medicine, current pretransfusion-testing methods are extraordinarily labor-intensive, an order of magnitude more expensive, subjective with respect to the interpretation of assay results, and tend to defy the development of high-throughput automation. Another drawback, as expressed by the Food and Drug Administration, is that current blood bank testing is a “single ‘analyte’ per test kind of test,” in other words, one antibody/agglutination result per tube. The ability to get more than one result per test, that is, “multiplexing” blood

Improving Training in Laboratory Medicine

In this issue of Clinical Chemistry , we publish a proposal for curriculum content of residency training in laboratory medicine and for evaluation of resident competency (1). The proposal was developed by the Academy of Clinical Laboratory Physicians and Scientists (ACLPS) and covers residency training in all areas of laboratory medicine. Why have we chosen to publish this curriculum? Why did we publish the entire document, rather than just the portion related to clinical chemistry? Why is the curriculum important to the readers of Clinical Chemistry —particularly PhD and MD laboratory directors? In a broad sense, the first reason for publishing the document is that it represents a comprehensive, well-written template for curriculum content for training of residents in laboratory medicine. Because Clinical Chemistry is a leading journal in laboratory medicine, we know that many of those individuals who are responsible for training pathology residents are among our readers and are members of AACC, which publishes the journal. Now is an important time to address the curriculum of residency programs. As the authors of the curriculum document clearly state in their introduction, the field of laboratory medicine and training in pathology have changed dramatically since the last consensus recommendations were published in 1995 (2). At that time, routine molecular diagnostics was just beginning, the clinical use of pharmacogenomics was only being hinted at, “proteomics” consisted of 2-dimensional gels and serum protein electrophoresis, point-of-care testing was primarily portable glucose meters, and electronic medical records existed only in the VA system. Simultaneous to this explosion of knowledge and technology, the length of residency training in pathology was decreased by 1 year for both combined anatomic pathology/clinical …

Technology to improve quality and accountability

A body of evidence has been accumulated to demonstrate that current practice is not sufficiently safe for several stages of central laboratory testing. In particular, while analytical and perianalytical steps that take place within the laboratory are subjected to quality control procedures, this is not the case for several pre- and post-analytical steps. The ubiquitous application of auto-identification technology seems to represent a valuable tool for reducing error rates. A series of projects in Oxford has attempted to improve processes which support several areas of laboratory medicine, including point-of-care testing, blood transfusion, delivery and interpretation of reports, and support of decision-making by clinicians. The key tools are auto-identification, Internet communication technology, process re-engineering, and knowledge management.

Poor knowledge and faulty thinking regarding hemolysis and potassium elevation

A questionnaire to assess knowledge of the expected elevation in serum K measurement with different grades of hemolysis was administered to medical technologists working in biochemistry laboratories, hospital physicians and nurses. The questions involved different grades of hemolysis (mild, 1.0, moderate, 2.5 and severe, 5.0 g/L) and different final K measurements (2.9, 4.0, 5.2 and 8.2 mmol/L). Subjects estimated the K concentration in a non-hemolyzed sample for each scenario. Adjustment values (difference between final hemolyzed K concentration and subject's response) were calculated. For the 132 respondees, the mean correct score was 1.7/12. Mean adjustment values were: mild, 0.43 mmol/L (K 2.9), 0.55 (4.0), 0.88 (5.2) and 1.53 (8.2); moderate, 0.85 (2.9), 0.92 (4.0), 1.33 (5.2) and 2.50 (8.2); and severe, 0.93 (2.9), 1.48 (4.0), 1.96 (5.2), 2.96 (8.2). Correct adjustments were: mild, 0.28; moderate, 0.70; and severe, 1.40 mmol/L. Healthcare staff overestimated the effect of hemolysis on potassium measurement and used an incorrect proportional adjustment approach to the problem. Such poor knowledge and faulty thinking could lead to diagnostic delays or misdiagnoses. There is potential for such faulty thinking in all areas of laboratory medicine, and laboratories should review their educational responsibilities and reporting practices in light of this.