July 23, 2004

Flow Cytometry

In order to calculate results for flow cytometric analysis of lymphocyte populations, it is necessary to have the results of a CBC Profile (CBCPR). Reporting of flow cytometry results will be facilitated by the ordering of a CBC Profile at the same time that a request for Flow analysis is made.

Tissue specimens submitted for culture

The preferred container for submission of tissue for culture is a sterile urine cup. Please do not submit tissue samples for culture in any kind of tube. Submitting samples this way compromises the sterility of the tissues when they have to be extracted from a small tube especially if the tissue is large. Tissues submitted in sterile urine cups are acceptable for all microbiology tests including anaerobes.

New Leukens Traps

The 70 ml specimen mucus traps (Leukens Traps) available from the hospital store room (bin # 92401) are now supplied with a solid separate cap. After collecting the specimen, remove the cap with the tubing and replace securely with the solid cap included in the same packaging. The specimen may then be safely transported to the laboratory through the pneumatic tube system.

Laboratory Relocation

The Medical Laboratories main Core Laboratory is scheduled to relocate from its current location on the second floor of University Hospital to a new building located directly behind the SunTrust Bank and Papa John’s on West Main Street in early 2005. This move is necessary to support hospital expansion (a.k.a. the Bustle Project). Planning groups have begun to meet in order to ensure a smooth transition and resolve concerns.

In addition to the Core Lab, Microbiology and Molecular Diagnostics will also move into the new building. The facility will be linked into the main hospital pneumatic tube system to ensure timely specimen transport and maintain acceptable turn-around-times.

For updates or questions regarding the upcoming relocation please contact Cavell Kopetzky in Medical Laboratories Administration at 434-243-2649 (email: cak3w@virginia.edu).

Updated Specimen Acceptance Policy

The Medical Laboratories continue to receive a large number (150-200) of samples each month with incorrect or missing identification labels. A multidisciplinary team examined this issue and has recommended several changes to strengthen the Specimen Acceptance policy. The revised policy is available at: http://knowledgelink.healthsystem.virginia.edu/OPR/manuals/mc/083.pdf

This revised policy confirms the institution’s commitment to patient safety and complies with the JCAHO’s 2003 Patient Safety Goals.

Of particular importance are the following components of the revised policy:

The laboratory will no longer allow completion of waivers for mislabeled or unlabeled specimens unless the specimen is irreplaceable. The list of what is considered irreplaceable is:
- Normally Sterile Body Fluids (i.e.: pericardial, peritoneal, CSF)
- Bone Marrow
- Fine Needle Aspirates (FNA)
- Tissue Biopsies/Surgical Specimens
- Bronchoscopy/Endoscopy Specimens (i.e., BAL’s)
- Drug levels timed for treatment (peak and trough)
- Blood Cultures
- PAP smears/Thin Preps

If the attending Physician concludes that the specimen was difficult to collect (arterial, central vein, femoral, subclavian) or the patient is no longer accessible, the physician must contact the laboratory supervisor who will consult with the Clinical Pathology Resident on call, as needed.

In order to provide traceability to the collector, the sample should be identified with the collector’s initials.

There are no changes to the Typenex ID system for identification of Blood Bank specimens collected for transfusion purposes.

Thank you for assisting in reaching the Patient Safety Goals by your attention to the revisions to this policy.