I.

VISION

An exemplar laboratory that will cater the basic diagnostic needs of

the clinicians and patients of the municipal of Claveria and nearby
municipalities.

II. MISSION

The Claveria District Hospital Clinical Laboratory. As the first and

presently the only DOH-licensed Clinical Laboratory in the municipality of
Claveria, Masbate shall make accessible and available to all the residents
of Claveria, as well as to the residents of the nearby municipalities, quality
yet affordable basic laboratory services with up-to-date methodologies and
through the efforts of competent laboratory staff.

1
III. ORGANIZATIONAL STRUCTURE

GLENN M. ANDUEZA, M.D

Chief of Hospital

MADELINE D.L. RAÑOLA, M.D

Laboratory Head

MARISSA A. CARPIO, RMT

Medical Technologist

2
IV. JOB DESCRIPTION

1. LABORATORY HEAD
1. Qualification
1. PRC licensed Doctor of Medicine
2. Fellow or Diplomate of the Philippines Board Pathology
3. Lines of Authority
1. Responsible for the acts and performances of the Chief of Medical
Technologies
2. Accountability
1. Reports to the Chief of Hospital
2. Functions and Responsibilities
1. Organizes and administers the laboratory to provide efficient
laboratory services appropriate to its service capability.
2. Formulates policies and procedures that reflect current
knowledge and principles on laboratory services.
3. Ensures documentation and updating of all the policies,
guidelines, procedures and instructions relevant to the day-to-day safe
operation of the laboratory.
4. Sets the guidelines for the implementation of quality assurance
program including quality control and quality improvement activities.
5. Conduct and preside regular meeting of the laboratory staff.
6. Represents the laboratory in meetings pertaining to laboratory
concerns.
7. Reviews and countersigns laboratory results.
8. Responsible for ensuring that all reports needed by any statutory
or regulatory requirements are complied.
9. MEDICAL TECHNOLOGIES
1. Qualification
1. Graduate of Bachelor of Science in Medical Technology
2. PRC registered or licensed Medical Technologist
3. License Authority
1. Responsibility for the acts and performances of the laboratory Aide or
Assistant.
2. Accountability
1. Reports to the Laboratory Head
2. Functions and Responsibilities
a. Performs phlebotomy and other procedures of specimen collection as
necessary.
3. Performs the laboratory examinations
4. Performs and prepares the result of the laboratory examinations.
5. Records all the laboratory data that need to be recorded.
6. Check daily on the reagents, machines and equipment of the laboratory.

3
 7. Maintains the cleanliness of the laboratory.
8. Prepares the laboratory data needed by the any law or regulations.
9. Prepares and update laboratory technical procedures.
10. Performs quality control procedures.
11. Performs other functions which may be called for or assigned by the Chief of
Hospital and the Head of Laboratory from time to time.

V. PROCEDURE FOR HIRING OF LABORATORY PERSONNEL

1. The procedure for hiring of laboratory personnel shall be in accordance to and follow
the Civil Service Rules and Procedures on hiring of hospital personnel implemented by
the Personnel Unit of the Hospital. A copy of the existing and applicable rules and
procedures must be available in the laboratory. In the absence of which, the following
shall apply.
2. Job vacancies shall be announce through posting of notice in the laboratory premise
for at least two (2) weeks.
3. Applicants are to submit the following documents:
1. Letter of application addressed to the Administrator of the Laboratory.
2. Resume with attached recent (within 6 months) 2x2 picture.
3. Certified true copy of PRC certificate
4. Photocopy of valid PRC ID (back to back)
5. Photocopies of certificates of trainings attended.
6. Record of the latest booster dose of vaccines received.
7. Applications shall be screened by the Head of the Personnel Unit.
8. Qualified applicants shall be informed by phone for the schedule of
examinations for competencies.
9. Applicants who passed the examination shall be scheduled for interview by the
Promotion and Selection Board.
10. The qualified applicant shall undergo Complete Medical Examination and
basic laboratory screening (CBC, UA, CXR, HBsAg).
11. The Chief of Hospital shall appoint the selected applicant and be asked to
sign an appointment document or Contract of Service.

VI. POLICY AND PROCEDURE FOR ORIENTATION ON LABORATORY

POLICIES AND PROCEDURES
1. All laboratory personnel shall undergo an orientation on the policies and procedures
of the laboratory before actual assumption of responsibilities in the laboratory.
2. A certification of orientation shall be issued by the Owner of the Laboratory.

VII. POLICY AND PROCEDURE FOR THE PROMOTION OF

EMPLOYEES
1. Promotion of laboratory personnel shall be based on merit and fitness and
qualification standards as indicated in the Civil Service Rules and Procedures.

4
VIII. POLICY AND PROCEDURE FOR DISCIPLINE, SUSPENSION,
DEMOTION AND TERMINATION OF LABORATORY PERSONNEL
1. The Civil Service Rules on Discipline, Suspension Demotion and Termination of
government employees shall be the governing rules in the discipline, suspension,
demotion and termination of employment of a laboratory personnel as being
implemented by the Personnel Unit of the Hospital. A copy of the rules and procedures
shall be available in the laboratory. In the absence of which, the following may be
adhered to:
A. All laboratory personnel are expected to know and follow the policies and rules
of the laboratory on attendance. Tardiness and work ethics.
B. Laboratory personnel who shall violate the policies and rules of the laboratory
shall be dealt with accordingly.
C. Written notice through a memorandum shall always be provided to laboratory
personnel who incur violation of laboratory rules and policies.
D. Laboratory personnel who incur violation shall always be given the chance to
explain his or her side prior to imposition of penalty, if there is any, unless the violation
is so gross and the evidence is available to speak for itself.

IX. SERVICE HOURS

The laboratory is open for services during the following days:
Monday-Friday: 8:00 AM – 5:00 PM

X. SERVICES AVAILABLE
1. Complete Blood Count
2. Hemoglobin and Hematocrit
3. Platelet Count
4. Blood Typing
5. Fecalysis
6. Urinalysis
7. Pregnancy Test
8. FBS
9. Total Cholesterol
10. LDL
11. HDL
12. BUA
13. BUN
14. Creatinine

5
XI. POLICY AND PROCEDURE FOR SUBMISSION OF REQUESTS AND
SPECIMEN FOR EXAMINATION
15. Submission Request
1. Request should be duly accomplished to include patient’s complete name,
age, sex, clinical impressionand the name requesting physician.
2. Necessary preparations of the patients whose blood will be submitted for blood
chemistry analysis is the responsibility of the requesting physician concerned. In case
the patient was not fully instructed, the Medical Technologist who initially received the
request shall instruct the patient of the necessary preparation prior to blood extraction
and examination.
16. Submission/Collection of the specimen
1. Blood collection for hematology shall be from 8:00 AM to 12:00 NN to be
performed by the Medical Technologist.
2. Blood extraction of patients 2 years old and below whose blood needs are
greater than that can be collected in acapillette may be referred to the available
physician.
3. Submission of specimen for clinical microscopy examination (urine and stool)
shall be from 8:00 AM to 12:00 NN.
Both specimen are supposed to be submitted within an hour of collection. If the
patient or doctor insists that the test be performed even beyond an hour of collection, it
will be indicated on the face of the result form that the specimen is unsuitable or not
ideal for examination.
4. Request and specimens may still be accepted and. Ore collected after 4:00
PM. However, the result will be available the following day.
17. Grounds for Specimen Rejection
1. The following are the grounds for specimen rejection:
1. Container of the specimen is not properly labeled.
2. Container has no label
3. Specimen is submitted with no accompanying request form.
4. Hemolyzed specimen in case the blood is previously extracted.
5. Overflowing or underfilled vacutainer tubes, in case the specimen is
previously extracted.
6. Grossly contained specimen.
2. The following are the criteria for adequacy or inadequacy of specimen:
1. Amount or volume of specimen.
2. Use of appropriate tube or container.
3. Use of appropriate preserving solution, chemicals or transport media.
4. Use of appropriate specimen transport container and temperature.

XII. PLICY OF PHLEBOTOMY

18. The Medical Technologist will first confirm if the patient is the same as the one on
the request. He will introduce himself as such and then explain the phlebotomy
procedure. He will ask the patient if he may already extract such specimen.
19. He will the extract the specimen utilizing standard phlebotomy procedures and fill up
the tubes in proper order. He will label each of the specimens with the patient’s name.
20. He will inform the patient or the patient’s relatives how the results will be released.

6
XIII. CHARGES OR BILLS FOR SERVICES RENDERED
21. All laboratory request shall be charge according to the schedule of fees fixed.
22. All the charges must be paid first prior to acceptance of and collection of specimen.

XIV. RELEASE OF RESULTS

23. Target turnaround time for routine requests is 1-2 hours, as workloads permits.
Twelve o’clock noon (12:00nn) at the latest on the same day if the specimen was taken
prior to 9:00 AM.
24. Presentation of the official receipt will be required before the release of the result is
effected.

XV. POLICY ON STAT REQUEST

25. All requests clearly stamped or written with STAT on its face shall be prioritized.
26. The examination shall be done on its shortest turn-around time.
27. The laboratory result shall be released the soonest the possible time to the
appropriate room, ward or unit and the name of the recipient of the result, the date and
time released shall be properly recorded in the realizing book.

XVI. POLICY ON SEND-OUT

28. The laboratory shall not accept laboratory requests wherein the tests are not
available in the laboratory. Hence, there shall be no send-out specimens. The patients
shall instead be advised to bring the laboratory requests to a laboratory where the test
is available.

29. The following shall be turn-around-time for STAT requests:

TEST TIME
CBC Within 1 hour
CBC with PC Within 1 hour
Urinalysis Within 1 hour
Fecalysis Within 1 hour
Pregnancy Test Within 30 minutes
Blood Typing Within 30 minutes
Blood Chemistry Within 40 minutes

XVII. ECPECTED WORK ETHICS

30. The Medical Technologist and other laboratory personnel are required to know the
Laboratory SOPs. It will be made available to all laboratory personnel upon entry into
the laboratory and each will be asked to sign indicating that he has read and understood
the SOPs.
31. The Laboratory Head is expected to report at least once a month and as the need
arises. She will be on-call for any problem that may arise upon the report of the Medical
Technologist.
The Medical Technologist is expected to report from Monday to Friday, 8:00 AM to 12
NN and 1:00 PM-5:00 PM.

7
All laboratory personnel are expected to sign in and out in the logbook of attendance
whenever the report to the laboratory.
32. All personnel are required to attend the regular staff meeting which is to be held
semi-annually, 3rd Friday of the February and November, 3 PM.

XVIII. REPORTING ANALYSIS OF INCIDENTS AND ADVERSE EVENTS

33. All unusual, unexpected, extraordinary, abnormal and untoward incidents or events
shall be recorded in a logbook specifically designated for such incidents and events.
34. The laboratory staff who is directly involved and who personally observed or
witnessed the event or incident shall be the one responsible for recording the incident in
the logbook.
35. The information to be recorded in the logbook shall include the date and time of the
incident, the place of the event, the persons involve in the incident if there are any, the
circumstances surrounding the incident, the action taken by the laboratory staff on duty
if there is any, the date and time that the recording was made and the name and
signature of the laboratory who logged in the incident.
36. The Medical Technologist is responsible for reporting the incident to the
Manager/Administrator.
37. The event or incident shall be include in the discussion in the next regular laboratory
staff meeting.

XIX. HANDLING OF COMPLAINTS

39. All complaints must be noted and entertained by the laboratory personnel who
initially received or heard of the complaint.
40. All complaints must be directed to the Medical Technologist who will initially
investigate on the matter.
41. The Medical Technologist may provide verbal explanation to the client base from his
investigation. In case the client is not satisfied with explanation of the Medical
Technologist, the case is referred to the Laboratory Head.
42. In case the Head of he Laboratory cannot be reached, the matter may be brought to
the Hospital Administrator in case immediate actions and decisions are imperative or
vital.
43. All complaints and the handling of complaints must be tackled during the regular
meeting, to be used as guide in formulating or improving the policies of the laboratory.

XX. MAINTENANCE OF EQUIPMENTS AND MACHINES

44. An inventory of all machines and equipment shall be done annually on the last
quarter of the year.
45. A schedule for the equipment maintenance shall be prepared annually by the Head
of the Laboratory at least once a month prior to the year of implementation.
46. The Medical Technologist is expected to record all the preventive and corrective
maintenance procedures performed.

XXI. CONTINUING PROGRAM FOR STAFF DEVELOPMENT AND

TRAINING

8
A. There shall be an annual plan of program of activities for the continuing education of
the laboratory personnel.
B. The plan shall be prepared by the Head of the Laboratory on the last quarter of the
preceding year and shall be based on the assessed need for the improvement of the
services offered.

XXII. CONTIGENCY PLAN

1. Personnel
1. The Medical Technologist must always be around to perform the laboratory
examinations and his other functions.
2. In case the Medical Technologist will be absent due to unavoidable cause, he
shall inform the Laboratory Head as soon as possible.
3. The Medical Technologist shall inform the Head of the Laboratory upon return,
of the matter of incident, preferably through notes or written report.
4. Equipment
1. All machines and equipment, preferably, must have a back-up
equipment as a contingency measure in case of breakdown of the equipment.
2. Out-of-order or non-functional equipment must be reported at once by
the laboratory staff assigned for the maintenance of such equipment to the
engineer or technician-in-charge, as soon as it is discovered.
3. A logbook for the reporting of maintenance of equipment shall be
available in the laboratory.
4. The laboratory staff in-charge shall record in the maintenance logbook the
equipment, the date of the discovery of the breakdown of the equipment and the date of
the report to the engineer or technician in charge and the measures taken.
5. All laboratory examinations that are that temporarily unavailable due to the
breakdown of an equipment or a machine shall be referred to a DOH-licensed Clinical
Laboratory.
6. Reagents and Supplies
1. In case of sudden and unexpected utilization and consumption of
supplies and reagents, the laboratory staff who first noted of the lack of supply
shall report it to the Chief of Medical Technologist at once, who is then
responsible for reporting to the Head of the Laboratory.
2. The Head of the Laboratory shall take measures to answer the
immediate need.
3. Electricity
1. In case of brown-outs, all machines and equipment that are nor
supplied by the generator must be unplugged by the laboratory staff on
duty.
2. The one who unplugged the machine or equipment shall be
responsible for plugging back the machine or equipment if needed to be
plugged.
3. In case the electricity supply is not back or is not expected to be
back during their shift, the equipment that need to be plugged must be
endorsed by the laboratory staff in charge of the equipment to the
laboratory staff going on duty on the next shift.

XXIII. POLICY ON LABORATORY BIOSAFETY AND BIOSECURITY

9
BIOHAZARD
Is an inherit danger or risk posed by biological materials, mainly infectious
agents, to humans and the environment.
THE POTENTIAL HAZARDS OF CLINICAL LABORATORY WORK AT
CDH CLINICAL LABORATORY
1. Spillage of blood during extraction or collection.
2. Spillage of fluid specimens during preparation for examination.
3. Needle prick during blood extraction.
4. Exposure to infectious agents through the infectious specimen such as sputum, feces
and urine during specimen preparation and specimen examination.
5. Exposure to fumes of reagents such as eosin, hematoxylin, ethanol, xylene and
acetone.
6. Exposure to fumes of fixatives such as ethyl alcohol and formalin.
BIOSAFETY
Are the measures set forth to eliminate prevent or minimize exposure to a
biological hazard. The basic principle of biosafety is the need to protect the worker, the
environment and the work.
SAFETY PRECAUTIONS IN THE CLINICAL LABORATORY
1. All specimens are to be treated as potentially infectious.
2. Blood extraction should be done in a specified area with suitable chair with arm vest
were both the patient and the phlebotomist are comfortable and at ease during the
procedure.
3. All the materials needed should be reachable during the procedure of specimen
collection.
4. All specimens must be place in well-sealed properly labelled containers.
5. Gloves and mask must always be worn whenever in the laboratory premises,
particularly when performing laboratory procedures.
6. All reagents and fixatives must be place in well-sealed bottles and must be stored in
closed cabinets when not in use.
7. Quantities of flammable reagents on the bench in the bottles should be keep to the
smallest volumes compatible with working needs.
8. Bulk quantities of flammable reagents should be keep in safe, cool, well-ventilated
storage place.
9. The airflow in the working area should be established in such a ways that will keep
infectious particles away from the performer and other people.
10. The working area in which the specimens are handled must be disinfected with 5%
phenol/Lysol/sodium hypochlorite (chlorox) after use.
11. Never leaved any processed material with disinfection for it could be a source of
infection to the people by accident spill, or contact with rodents or insects.
12.Be sure to wash with disinfectant soap after handling specimens. If possible, also
apply 70% alcohol for further disinfection.
13. Eating, drinking and smoking is strictly prohibited.

XXIV. WASTE HANDLING, COLLECTION AND STORAGE

10
WASTE SEGREGATION AND STORAGE
Segregation is the process of separating different types of waste at the point of
generation and keeping the isolated from each other. Appropriate resource recovery
and recycling technique can be applied to each separate waste stream. Moreover, the
amount of hazardous waste that needs to be treated will be minimized or reduce
subsequently.
Hazardous waste should be placed in clearly marked containers that are
appropriately labelled for the type of waste. Except for sharps and fluids, hazardous
waste are generally put into plastic bag, plastic lined-cardboard boxes, or leaked proof
containers.
Color-Coding Scheme for Health Care Waste
The most appropriate way in identifying the categories of health care waste is by
sorting the waste into color-coded plastic bag or containers.
1. Black - non-infectious dry waste
2. Green - non-infectious wet waste
3. Yellow - infectious and pathological waste
4. Yellow with black band - chemical waste
5. Red - sharps
Apart from color-coding system for health care waste, the following practice
should also be observe:
1. Sharps should be all collected together regardless of whether or not they are
contaminated.
2. Highly infectious and other hazardous waste should be treated immediately

XXV. WASTE TREATMENT AND DISPOSAL

1. General Waste.- shall be treated as an ordinary waste and shall be dealt with by the
municipal disposal system. Recyclables are to be separated from the non-recyclables.
2. Infectious Waste
1. Used gloves, test strips and specimen bottles – shall be treated first before
final disposal by soaking into 1:10 dilution of 5-10% sodium hypochlorite for at least 6
hours.
2. Glass test tubes and glass slides – after soaking into 1:10 dilution of 5-10%
sodium hypochlorite for 24 hours in properly cleaned and sterilized into an oven for at
least 30 minutes an can be re-used for another purpose.
3. Blood and other body fluids – shall be put into container that is half-filled with
5-10% sodium hypochlorite before final disposal into septic tank.
4. Sharps
1. Needles and lancets – shall be separated first from the syringes and soaked
into rigid plastic container half-filled with 1:10 dilution of 5-10% sodium hypochlorite
before it is temporarily stored into the temporary.
2. Syringes – plunger is first separated from the whole syringe and separately
soaked into a container half-filled with 1:10 dilution of 5-10% sodium hypochlorite, the
remaining of the syringes separately soaked also into a container half-filled with 1:10
dilution of 5-10% sodium hypochlorite prior to disposal.
XXVI. POLICY ON RETENTION AND PRESERVATION OF DOCUMENTS
AND RECORDS

11
1. The following laboratory documents and records shall be keep and preserved:
1. Laboratory request – 1 month
2. Duplicate copy of laboratory results – 5 years
3. Logbook of records of laboratory results – 5 years
4. Letters and communications – 1 year
5. Written policies and procedures – as long as valid and applicable
6. A shelf designated for storage of all documents and records shall be
maintained in the laboratory and properly marked and labelled.
7. All laboratory documents and records, particularly the laboratory results are to
be regarded as confidential. Hence, only laboratory personnel are allowed to have
access to all the records and documents of the laboratory.
8. Discretion to grant requests for access to laboratory documents and records
shall be with the laboratory head and administrator.
XVII. PROCEDURE FOR REPORTING OF WORKLOAD
1. A census of work for the day shall be prepared by the Medical Technologist daily.
2. A summary census for the month shall be prepared by the Medical Technologist on
or before the second Monday of the following month to be submitted to the Head of the
Laboratory.
3. A summary census for the year shall be prepared by the Head of the Laboratory on
or before the first Monday of February to be submitted to the Administrator of the
Laboratory.
4. All records of work shall be compiled in the folder designated and properly labeled for
such and shall be kept in the designated shelf.
XXVIII. PROCEDURE FOR THE INVENTORY OF MACHINES,
EQUIPMENTS, MATERIALS AND SUPPLIES
1. A logbook for recording of the inventory of machines, equipment, glass wares and
materials shall be maintained.
2. Machines and equipment are to be inventoried annually and recorded in the logbook
by the Senior Medical Technologist and checked by the Head of the Laboratory.
3. Glass wares and other materials use shall be inventoried and recorded semi-annually
by the Senior Medical Technologist and checked by the Head of the Laboratory.
4. Preventive and curative maintenance of machines and equipment shall be performed
following the guidelines on item IX of this manual.
5. A written report on the status of defective and faulty machines and equipment shall
be furnished to the Administrator of laboratory.
6. Defective, broken and malfunctioning materials and glass wares shall be reported to
the Administrator of laboratory for possible replacement.
7. Stock cards for supplies particularly the consumables shall be maintained.
8. The Medical Technologist is expected to record supplies (reagents, kits, strips) they
obtain from the stock of supplies.
9. The Medical Technologist must check on the inventory of supplies at least once a
week for its timely replenishment.
10. The Medical Technologist is expected to report loss of laboratory supplies,
materials, machines and equipment as soon as possible.
XXIX. POLICIES ON QUALITY ASSURANCE AND CONTROL
MEASURES

12
1. GENERAL QUALITY CONTROLS MEASURES
1. All procedures for testing shall strictly according to the procedures as stated in
the manual of procedures for the use of machines, equipment, materials and reagents.
2. All machines, equipment, materials and reagents to be use must comply with
the standards set by the authorized agencies, particularly the standards set by the
Department of Health, Bureau of Health Services and by the National Reference
Laboratories.
3. All reagents kits to be use must be approved by the concerned agency or by
the National Reference Laboratories.
4. All copies of procedures or inserts accompanying a machine, equipment, glass
wares. Materials and reagents shall be keep in a clear book for easy reference to
include the updated Material Safety Data Sheets (MSDS).
5. Photocopy of procedures from inserts shall be posted.
6. Particular quality control measures for each section of the laboratory shall be
written as part of the technical standard and shall be strictly followed.

2. INTERNAL QUALITY ASSURANCE SCHEME

1. The Head of the Laboratory shall conduct an unannounced monitoring of the
personnel, reagents, supplies, equipment and machines to assess its performance.
2. A checklist is to be utilize for internal monitoring of the quality of all procedures
as indicated:
PROCEDURE YES NO REMARKS
1. Specimens accepted for examination pass the
criteria set for acceptance.
2. Laboratory personnel is wearing laboratory
gown during the performance of procedure.
3. Reagent refrigerator’s temperature monitored
and kept at optimal temperature.
4. Preventive maintenance of equipment is done.
5. Proper phlebotomy procedures performed.
1. Patient properly identified.
2. Tubes were legibly labeled with patient’s name
and ward.
3. Standard blood extraction procedure performed.
4. Stool and urine are examined within an hour
after receipt of the specimen.
5. Normal and abnormal control for the week is run
for chemistry procedures.
6. Written procedures for laboratory examination
strictly followed.
7. Incident reports, near miss report, adverse
events, and complaints are documented.

Checked by:

_________________________
Date: ____________________

13
8. The internal monitoring shall be done semi-annually or as seemed necessary by the
Head of the Laboratory.
9. EXTERNAL QUALITY ASSURANCE
1. The laboratory shall participate in the annual National External Quality
Assurance System as conducted by the respective National Reference Laboratories.
2. All procedures must be according to the procedures stated by the reference
laboratory conducting the EQAS.
3. In the event that the performance of the laboratory in the EQA is
unsatisfactory, measures shall be done to improve its performance, such reviewing of
the work instructions, checking the quality of reagents and equipment and re-training of
the staff.

XXX. POLICY ON THE MAINTENANCE OF PHYSICAL PLANT

The following standards shall be followed to ensure that the safety of the clienteles,
blood bank staff, equipment, blood units and materials:
1. The laboratory receiving area shall be located in an area that accessible to the
patients or clienteles.
2. The laboratory working area shall be restricted and only authorized laboratory and
hospital personnel shall be allowed to enter.
3. The roof, ceiling and walls must have no leaks anytime. Any leaks noted must be
recorded in the corrective action/preventive action (CAPA) logbook and reported to the
maintenance department of the hospital in writing by the medical technologist on duty
on the day that the leak was noted.
4. Cleanliness of the laboratory shall be maintained at all times.
5. The laboratory working area shall be at room temperature (18-24°C) at all times. The
room temperature shall be recorded by the medical technologist on duty every shift.
6. Unnecessary, defective, damaged, broken, expired or out-of-order equipment,
materials and supplies shall be taken out as soon as possible from the blood bank.
7. There shall be an area for storage of reagents and supplies.
8. Records, manual and references shall be properly labelled and orderly arranged.
9. All storage and filling equipment must be properly labelled.
10. The laboratory must be well-lighted and ventilated at all times. Defect in lighting and
ventilation must be recorded in the CAPA logbook and reported by the medical
technologist in charge to the maintenance department of the hospital as soon as
possible.
11. Eating, drinking and smoking is strictly prohibited in the laboratory premises.
12. There shall always be a clean source of water. Water interruption and leaks shall be
recorded in the CAPA logbook and reported by the medical technologist to the
maintenance department rural health unit.

XXXI. POLICY ON ENVIRONMENTAL MANAGEMENT AND BIOSAFETY

14
The following standards shall be to ensure the safety of the laboratory staff, patients
and laboratory premise:
1. The laboratory staff shall follow all safe work practices.
2. Only authorized personnel shall be allowed in the laboratory premises.
3. Laboratory gowns shall be worn at all times in the working area.
4. Laboratory staff assigned to do laboratory procedures shall were close shoes
whenever he or she performs laboratory procedures.
5. Personal protective equipment shall be worn as necessary.
6. Blood extraction should be done in a specified area with suitable chair with arm rest
where both the patient and the phlebotomist are comfortable and at ease during the
procedure.
7. All the materials needed should be reachable during the procedure od specimen
collection.
8. All specimens shall be treated as potentially infectious.
9. Cleanliness of the laboratory shall be maintained at all times.
10. The working area on which the specimens are handled must be infected with 5%
phenol/Lysol/sodium hypochlorite (chlorox) after use.
11. Laboratory staff must wash hands with disinfectant soap after handling specimens
whenever he/she goes out of the laboratory. If possible, apply 70% alcohol for further
disinfection.
12. Unnecessary, damage, broken, expired or out-of-order equipment, materials and
supplies shall be taken out as soon as possible from the laboratory.
13. There shall be a space for storage of blood reagents, supplies and materials and a
space for storage records, manual and references.
14. Records, manuals and references shall be properly labelled and orderly arrange.
15. All storage areas and filling equipment must be properly labelled.
16. The laboratory must be well-lighted and ventilated at all times.
17. Eating, drinking and smoking is strictly prohibited in the laboratory premise.
18. There shall always be a clean source of water.
19. Proper waste management shall be strictly followed.

XXXII. POLICY ON PREVENTION OF NEEDLE STICK INJURIES OF

LABORATORY PERSONNEL
1. General Statement
1. All laboratory personnel/staff are required to practice universal precaution at all
times during the tour of duty.
2. All laboratory personnel should have complete immunization for hepatitis B, and a
serum quantification of Anti-HBsAg IgG every 5 years.
3. In case the serum Anti-HBsAg IgG of the laboratory personnel is low, a booster dose
of immunization shall be required.
4. Policy on Recapping of Needles
1. Recapping of used needles, particularly needles used for blood extraction of
patient is highly discouraged among laboratory personnel.
2. In case recapping of needle is unavoidable, the laboratory personnel is
expected to practice the one-hand technique in recapping to avoid needle stick injury.

15
 3. The one hand recapping technique is as follow:
1. Before blood extraction, make sure that the cap is placed on the part of
the laboratory rack/tray with easy access for recapping.
2. Use the dominant hand during extraction.
3. After blood extraction, still using the dominant hand, place the blood in
the proper container such as red tap, lavender tap, slide and the like.
4. Continue holding the syringe with your dominant hand, and the insert
the needle to the cap using only the dominant hand.
5. When the entire length of the needle is inside the cap, push it against
the hard surface of the laboratory rack/tray until there is a click. This is to lock the cap.
6. Never used both hands to avoid injury to your hands.
4. Reporting of Needle Stick Injury
1. All the needle stick injury must be immediately reported by the
personnel concerned to the Chief Medical Technologist and/or to any available
Medical Technologist who can assist him or her to seek consult to an available
Medical Resident on-duty for management or treatment.
2. The Chief Medical Technologies shall also report to the Head or
Assistant Head of the Laboratory who shall then be responsible to report to the
Infection Control Committee Head.

3. Monitoring and Evaluation

1. The Chief Medical Technologist shall implement and monitor this
policy in the laboratory.
2. Reporting of Violations
1. Violations shall be reported by the Chief Medical Technologist to
the Laboratory Head or Assistant Head.
2. Penalty for violation of one-hand recapping technique shall be as
follows as adopted in the policy issued by the hospital:
1. First Offense
1. Warning
Due to the gravity of consequences of needle stick injuries, a memorandum
stating a stern warning shall be issue by the Head of Service and noted by the Medical
Director at that same day or instant the violator was caught on hand (prima facie).
2. Reorientation on the policy and blood-borne infections from needle stick
injuries
The Service Head shall schedule the reorientation within 7 days from the day of
the incident. After the reorientation, the violator shall perform a return demonstration in
the presence of the Laboratory Head/Assistant Head. Non-appearance of the violator
shall automatically elevate the case to the Human Resource Development Unit Head
who will review the case and recommend corrective measures.
3. Submission of Medical or Nursing Journal
Needle Stick Injury studies shall be submitted by the violator within 10 days
(including Saturdays and Sundays). The journal for submission shall be appraised first
by the Service Head and the Medical Director. The appraisal shall be included in the 10-
day period. Non-submission of journal shall automatically elevate this case to the
Human Resource Development Unit Head who will review the case and recommend
corrective measures.
4. Second Offense

16
 1. Reprimand
The Service Head shall issue a reprimand to the violator. A reprimand is
considered a penalty and shall be a permanent part of the personnel employment data.
2. Reorientation on the policy and blood borne infections from the needle stick
injuries with return demonstration, same as indicated in the first offense.
3. Journal presentation within 10 days.
The journal shall be reviewed by the Service Head and the Medical Director. The
Service Head shall schedule the presentation within 10 days from the day of the
violation. All personnel in the service shall attend the journal presentation.

XXXIII. POLICY ON POINT OF CARE TESTING

At the present, the Claveria District Hospital does not perform any point of care
test. However, in the event that a point of care test (strips and/or glucometer for blood
sugar determination, kits for serologic determination and pulse oximeter for oxygen
saturation determination and the like), the following shall be the guidelines:
1. The examination/test must be performed by a nursing or laboratory staff of the
hospital.
2. The nursing or laboratory staff performing the test shall be the one responsible for
ensuring that the strips, kits and apparatus are of good quality, in good condition or
calibrated, if calibration is needed.
3. For the test perform by the nursing staff, test result shall be written on the chart of the
patient with the date and time performed and the name and signature of the nursing
staff who performed the test. No official laboratory result shall be issued for any point of
care test that are performed by non-laboratory personnel.
4. For the test performed by the laboratory staff, the result shall be issued in a
Miscellaneous Test Result Form indicating the methodology, apparatus or kit used.
5. The result shall be solely for the use of the hospital doctors.

Prepared by:

MADELINE D.L RAÑOLA, MD, DPSP

Laboratory Head

Approved by:

GLENN M. ANDUEZA, MD
Chief of Hospital

17