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Preventing errors in the microbiology lab.

The first words a medical technologist intern learns are relatively simple; yet, they may become the most important of his exhaustive vocabulary list. The two words are often used synonymously, although accuracy and precision carry decidedly different meanings in the clinical laboratory. As defined by Merriam Webster, accuracy denotes "freedom from mistake or error; conforming exactly to truth or a standard." Precision is "the degree of refinement with which an operation is performed or a measurement stated." The novice technologist may not fully grasp the finite distinction between these two words; but, after a year of internship, their significance should be decidedly clear.

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Performing maintenance on a plethora of medical instruments or recording data--whether it constitutes laboratory quality control or patient reports--all require the utmost accuracy. Repeating any specific task, such as performing serial dilutions, taking measurements, or quantitatively analyzing chemical compounds, on the other hand, requires unrelenting precision.

The mere mention of "laboratory error" strikes fear in the heart of every technologist who first experiences an inspection by the College of American Pathologists (CAP). The checks and balances of standardization, automation and quality control, and the daily supervision by experienced laboratory personnel, serve to promote accuracy. An occasional human error, however, can occur in laboratory medicine as in any other field.

Halting pre-analytic errors

Resolution of problems that incur error has been demonstrated in all three laboratory-testing phases: pre-analytic, analytic, and post-analytic. In 2001, medical centers in Michigan, New Jersey, Georgia, and Illinois took advantage of advanced technology to deter specimen mislabeling--a common cause of laboratory error. A hand-held computer system, BD.id Patient Identification (BD Diagnostics) was initiated to scan bar-code identification on both patient ID wristbands and phlebotomist or sample-taker badges. Physicians' test orders could also be scanned. Other deterrents included rejecting blood culture specimens for inadequate sample volume or because incomplete identification forms accompanying clinical specimens were submitted. (1), (2)

In another attempt to halt errors in the pre-analytic phase, a laboratory incident-report classification study was initiated by researchers at the University of Washington and the University of California at San Francisco Schools of Medicine. A database was created for the period from June 2000 to September 2001 to document the laboratory's incident reports (reports generated when a problem that may impact patient care arises). Of 129 reports, 92 or 71% occurred during the pre-analytic phase of testing. This phase includes collection of patient information and physician-ordered lab tests, specimen collection, specimen identification, labeling, transportation, handling and storage, and it ends in the laboratory with specimen processing. (3)

Between 2003 and 2005, "lab-quality research" at the University of California at Los Angeles (UCLA) Medical Center calculated an error rate at 16,000 of 4.29 million blood specimens or approximately 0.4%. Of this number, UCLA reported that 12% were considered "critical errors," defined as those with incorrect labeling--one patient's name on another patient's tube of blood. UCLA instituted a phlebotomy service to operate 24/7 that freed up nurses and doctors who were overwhelmed by other tasks. Parts of the specimen-processing system were automated, and an electronic error-reporting system was installed. Once more, errors were dramatically reduced. (2)

Inadequate specimens, or mislabeling blood or microbiology specimens can lead to incorrect antibiotic treatment or treatment of the wrong patient for the wrong disease. A false-positive or a false-negative result can affect the morbidity and mortality of the patient, when acute illness or malignancy is in question. (2), (4)

Of the studies conducted to address problems of patient safety and efforts to improve accuracy, the subjects of patient misidentification, mislabeled specimens, and the poor quality of specimens are continually highlighted. From the Institute of Medicine's first report in 1999, "To Err is Human," to the recent attempts to classify incident reports, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Centers for Disease Control and Prevention (CDC), the CAP as well as individual medical centers continue to monitor hospital and laboratory procedures to prevent errors. (3)

Objectives in specimen collection

The focus of this article is the microbiology department, often designated the "step-child" of the laboratory because of its more subjective approach to clinical diagnosis. To identify areas where lapses in procedure occur and the potential for human error result, we need to examine the protocol for the pre-analytic phase of testing. Surgical specimens, sampled in the operating suite and transported to the microbiology lab for testing, have been chosen because of their critical nature. The following sections are procedural recommendations taken from the 6th and 8th editions of the Manual of Clinical Microbiology practiced by many certified clinical laboratories. (5), (6)

The first objective of specimen collection is to assure that the utmost quality of the specimen is preserved during collection and handling. Another objective relates to the safety of the healthcare personnel who may be exposed to bacterial or viral pathogens. Above all, establishing a beneficial climate of communication between the surgical staff and the laboratory personnel is essential to carrying out the first two objectives.

Safety: Adherence to "universal precautions" (based on the CDC recommendations published in the 1980s) is a universally instituted protocol in all U.S. hospitals and medical centers. These precautions apply to all steps of the collection, transport, and processing of specimens in the microbiology laboratory. Healthcare personnel must be protected from exposure to pathogens while specimen integrity is maintained in an appropriate environment prior to processing as follows:

1. Specimens must be submitted in leakproof containers.

2. Syringes must be capped with needles removed.

3. Paperwork must include patient identification/bar-code information.

4. Labels or requisitions that accompany specimens must be contained in separate plastic bags.

Identification and labeling:

1. Specimen containers must include patient information with bar code, if used, to include:

* source or site;

* date of collection;

* time of collection; and

* initials of collector.

2. Explicit details of the specimen are required (e.g., exact location, numbered order of sampling).

3. Unless the physician can be contacted, unlabeled specimens will not be processed.

Suitability of specimen: A list of common surgical/clinical specimens suitable for culture of bacteria, anaerobes, fungus, and mycobacteria or acid-fast bacillus (AFB) are presented in Table 1. Microorganisms that are likely pathogens and those that are likely contaminants are also included. A more detailed listing of common specimen types with instructions for collection, transportation, and storage can also be found in the 6th and 8th editions of the Manual of Clinical Microbiology. (5), (6):

* environmental and storage guidelines of time and temperature;

* collection techniques and suggestions for transportation;

* instructions for avoiding contamination;

* inappropriate or unacceptable specimens;

* handling of specimens likely to harbor unusual or fastidious microorganisms;

* handling pediatric specimens; and

* screening and media considerations.
Table 1. Collection and handling of surgical specimens for
culture *

Specimen (site) Likely pathogen(s) Likely
 contaminant(s)

Abscess and Aspirates MRSA, Group A Coagulase negative
[greater than or equal strep, staphylococcus and
to]1 mL (pus, necrotic Enterobacteriaceae, corynebacteria,
material, tissue) Enterococcus spp., propionibacteria,
 P aeruginosa, saprophytic
 Candida spp., other Neisseria spp.
 fungi, AFB,
 anaerobes

Blood (venous and Presence of any Coagulase-negative
arterial), tissue microorganism until staphylococcus and
 proven otherwise corynebacteria
 (including AFB and propionibacteria,
 fungus) saprophytic
 Neisseria spp.

Bone, bone marrow Presence of any Coagulase-negative
 microorganism staphylococcus and
 corynebacteria

Cerebrospinal fluid or Presence of any Coagulase-negative
tissue microorganism S staphylococcus and
 pneumoniae, N corynebacteria
 meningitides,
 Leptospira sp.,
 Listeria spp.,
 Cryptococcus spp.,
 Haemophilus
 influenzae, S
 aureus

Ear (inner fluid) S aureus, S Coagulase-negative
 pyogenes, P staphylococcus and
 aeruginosa, Vibrio corynebacteria
 spp., S aureus, S
 pneumoniae, H
 influenza,
(external) M catarrhalis,
 rarely GNRS, and
 anaerobes

Eye S pneumoniae, S Coagulase-negative
 aureus, H staphylococcus and
 influenzae, fungi, corynebacteria
 N meningitides, C
 trachomatis, AFB,
 and fungus

Fluids (not CSF or blood) MRSA, Streptococcus Coagulase-negative
pleural, pericardial, spp., N staphylococcus and
synovial peritoneal meningitides, N corynebacteria
 gonnorhoeae, fungi,
 anaerobes,
 Mycobacteria spp.

Gastric tissue/ulcer H pylori Coagulase-negative
 staphylococcus and
 corynebacteria

Genital tract (male and N gonnorhoeae, C Coagulase-negative
female) trachomatis, H staphylococcus and
 ducreyi, T corynebacteria
 pallidum, U
 urealyticum

Pelvic abscess; perirectal Mixed aerobes and GNRs, anaerobes
abscess anaerobes (unless from
 sterile site or
 perirectal
 abscess)
 Coagulase-negative
 staphylococcus and
 corynebacteria

Tissue Presence of any Coagulase-negative
 microorganism until staphylococcus,
 proven otherwise corynebacteria,
 propionibacteria,
 and saprophytic
 Neisseria spp

Wounds (see abscess and MRSA, Group A Coagulase-negative
aspirates) Strep, staphylococcus and
 Enterobacteriaceae, corynebacteria
 Enterococcus and
 Candida spp.
 Clostridium,
 Bacterioides spp.,
 P aeruginosa, AFB,
 and fungus

Necrotizing fasciitis/gas Toxin-producing Coagulase-negative
gangrene Group A beta staphylococcus and
 streptococcus, corynebacteria
 MRSA, Clostridium
 spp., mixed aerobic
 and anaerobic
 bacteria

Bite (animal) Pasteruella spp.

Storage timeline Acceptable Usually rejected

Best: [less than or Syringe; sterile tube Dry swabs; swabs
equal to]2 hours in or container; few drops from surface or
syringe, sterile tube of saline for [less sinus wounds
2nd best: [less than or than or equal to]1
equal to]24 hours at RT mL/mg or two swabs in
(25[degrees]C) in Stuart's, Aimes or
holding media anaerobe transport
Note: Do not system
refrigerate

[less than or equal Sterile screw-cap tube, Dry swabs; tubes
to]24 hours at RT blood-culture bottles; without
 SPS and EDTA anticoagulant
 preservatives

[less than or equal As above Dry swabs; tubes
to]24 hours at RT without
 anticoagulant

[less than or equal Sterile tube or Dry swabs or
to]2 hours at RT anaerobic transport swabs in holding
Note: Do not system media
refrigerate

[less than or equal Sterile tube, anaerobe, Additives or
to]24 hours at RT or swab transport preservatives
(inner) system
[less than or equal
to]24 hours at
4[degrees]C (external)

Plates: [less than or CA-SBA; sterile tube; Dry swabs;
equal to]15 min. RT; saline drops OK; slide additives or
swabs [less than or for C trachomatis preservatives
equal to]2 min.
Note: Do not
refrigerate

[less than or equal Anaerobic transport; Dry swabs,
to]24 hours at RT in sterile tube, BC additives/
holding media; bottle, >1 mL to preservatives,
4[degrees]C (sterile centrifuge saline
tube and fungal)

[less than or equal Sterile tube, container Dry swabs
to]24 hours at or HP transport-slide
4[degrees]C

[less than or equal Saline drops OK; swab Additives,
to]24 hours at RT transport, slide for preservatives
Note: Do not antibody screen
refrigerate

[less than or equal Anaerobic transport; Additives/
to]24 hours at RT or at sterile container; preservatives
4[degrees]C (container) slide for antibody
 screen

[less than or equal Large: sterile Swabs; additives
to]24 hours at container; Small: add or
4[degrees]C saline to container or preservatives
 use anaerobic transport
[less than
or equal to]24 hours at
RT in anaerobe
transport

[less than or equal Same as abscess Same as
to]24 hours at RT abscess
Note: Do not
refrigerate

[less than or equal Surgical debridement of Swabs
to]15 mins. at RT necrotic material; STAT
Sterile tube(s), Gram stain and culture
container

[less than or equal [less than or equal Dry swabs
to]2 hours at RT for to]12 hours, do not
sterile tube culture
[less than or equal Sterile tube
to]24 hours at RT for holding media

Key: MRSA = methicillin resistant S aureus; AFB = acid-fast bacillus

* Note: This table represents examples of specimen types and
microorganisms but is not a complete listing. Viruses, protozoa, unusual
bacteria, and so forth are not included. (5), (6)


Specimen carriers: Note: Unless tubes or bottles are commercially prepared with specific preservatives (e.g., for urine or blood), addition of any preservative--other than saline--can destroy specimen integrity. The following are recommended:

1. Swab transport system, Aimes or Stuart's (<1 mL of material; for superficial wounds).

2. Anaerobic transport system (<1 mL of material).

3. Sterile cup/container (for tissue, bone, necrotic material or fluid).

Note: Large specimens must be cut to appropriate size for grinding and emulsifying.

4. Syringes preferred for [greater than or equal to]1 mL of aspirated fluid.

Note: A large volume is preferred. The lab will centrifuge and process an aliquot.

5. Examples of blood-culturing systems:

* Bactec System, Becton-Dickinson Diagnostic Instrument Systems, Sparks, MD.

* Microscan System, Dade-Behring, Deerfield, IL.

* Lysis Centrifugation System, Wampole Laboratories, Cranberry, NJ.

6. Viral transport media.

7. Vacutainer tubes (Red-top: clotted blood; Green-top: heparinized blood). (5), (6)

Transportation, handling, and storage

The effects of time, temperature, and storage conditions can be detrimental even to common bacteria. Therefore, laboratory instructions must be strictly followed by all healthcare personnel who participate in the transit of specimens, particularly those from irreplaceable surgical sites. General guidelines given for culturing commonly isolated microorganisms from specific sites are given in Table 1.

Explicit guidelines for recovering fastidious bacteria and obligate anaerobic bacteria are also outlined in the Manual of Clinical Microbiology. Specimens that may harbor temperature-sensitive microorganisms can be held at room temperature (RT)(25[degrees]C) for up to 24 hours in appropriate holding medium, but never refrigerated. These include Shigella spp., Neisseria gonnorhoeae, Neisseria meningitides, Haemophilus influenzae, Streptococcus pneumoniae, Cryptococcus sp., Francisella sp., or Bordetella sp., and anaerobic bacteria. (5), (6)

When transportation is necessary between laboratories, materials and packaging must adhere to the safety regulations for "biohazardous materials" described by the CDC (www.cdc.gov/od/ohs/biosfty/shipdir.htm). U.S. Department of Transportation regulations also apply. (5)

Recovery of fungi and mycobacteria (acid-fast bacteria): Handling specimens that may harbor mycobacteria or fungi is considered biohazardous because of the following potential pathogens: Mycobacterium tuberculosis; other Mycobacterium spp.; fungi such as Coccidioides immitis, Histoplasma capsulatum, Cryptococcus neoformans, or Blastomyces dermatitidis. Swabs submitted for recovery of these and similar microorganisms are not acceptable. Only sterile, leakproof containers, test tubes in leakproof bags are appropriate methods of transport. The Lysis Centrifugation System is suggested for blood and bloody fluids that may harbor these pathogens, and submission of detailed paperwork defining the patient's case history is paramount to ensure correct specimen processing. Storage [less than or equal to]1 hour at 30[degrees]C or RT is appropriate for fungi such as Histoplasma capsulatum, Blastomyces dermatiditis, or Cyptocolcus neoformans. For all other fungi, one to two hours at 4[degrees]C in specified containers is appropriate when delay is anticipated. (5), (6)

Specimen processing

Because of the wide variation in protocol used to process microbiology specimens among medical centers, private hospitals, and reference laboratories throughout the United States, this section will cover, only briefly, general considerations that apply to the subsequent detection of microorganisms. Detailed safety requirements can be found in Chapters 3 and 9 of the 8th edition of the Manual of Clinical Microbiology. (5), (6), (7)

Special considerations and procedures: Microorganisms that are fastidious or labile require that culture processing, Gram stain, or antigen and nucleic-acid testing proceed in a timely manner. If specimen processing is delayed, adherence to strict regulations of temperature and environmental conditions must be followed.

Pathogenic organisms may be lost due to overgrowth with colonizing or indigent bacteria found in wounds or abscesses. On the other hand, presumed sterile fluids, such as cerebrospinal fluid, joint, and other body fluids are considered "infected," regardless of species or quantity of microorganism present until proven otherwise. Anaerobic cultures may be ordered for appropriate specimens only; this decision is determined by the individual hospital or medical center's infectious-disease service. Instructions found in the anaerobic transport system materials address details of transportation and storage.

The Lysis Centrifugation System can be used to isolate fastidious microorganisms (e.g., Legionella spp., Francisella spp., or Bartonella spp.) and for AFB and fungus. The blood specimen is concentrated by centrifugation to form a pellet, which is then inoculated to recommended culture media for enhanced recovery or used in rapid-testing procedures.

Specimen acceptability is based on various factors that apply to a particular source/site of sampling. The quality and/or volume of the specimen as well as its condition upon arrival at the microbiology laboratory are all important considerations. Immediate smear examination (e.g., Gram stain or acid-fast stain) can determine the need for further specimen-sampling. The presence of polymorphonuclear neutrophils, or PMNs, and the type and number of epithelial cells and microorganisms seen are among the criteria used to determine sample acceptability. (5), (6) Table 1 lists surgical specimens suitable for culture with transportation and storage guidelines, and Table 2 lists specimens for processing with suggestions for stain and culture media.
Table 2. Specimen processing, stains, and culture media *

Specimen Stain Aerobic media Anaerobic
 media

Abscess Gram SBA, CA, Mac Not for
 swab
Aspirates Gram, AFB Add AFB and BBA, LKV,
 fungus media BBE, CNA

Blood, bone marrow Gram, AFB BC bottles, BBA
 SBA, BBA, CA,
 AFB and
 fungus media

CSF Gram, AFB SBA, CA, BBA
 Thioglycolate
 broth, AFB
 and fungus
 media

Ear (external) Gram SBA, CA BBA
 (internal) Add Mac

Eye Gram SBA, CA Not
 done

Fluids (not CSF) Gram, AFB SBA, CA, Mac, BBA
 BC bottles,
 Thioglycolate
 broth, AFB,
 and fungus
 media

Genital Gram SBA, TM, BBA, LKV,
 Pelvic or broth for BBE, CNA
 perirectal Group B strep
 screen SBA,
 CA, Mac, TM

Tissue Gram, AFB SBA, CA, Mac, BBA, LKV,
 BC bottles, BBE, CNA
 Thioglycolate
 broth, AFB,
 and fungus
 media

Wound/abscess Gram, AFB SBA, CA, Mac Not for
aspirate(see above) Add AFB, and swab BBA,
 fungus LKV, BBE,
 CNA

Media Key: SBA = sheep agar, CA = chocolate agar, Mac = MacConkey agar,
BC = blood culture, TM = Thayer-Martin, BBA = brucella-blood agar, LVA
= laked vancomycin agar, BBE = bile esculin agar, CAN =
colistin-nalidixic agar

* Note: This table represents examples of specimen types, stains and
culture media, but is not a complete listing. (5), (6)


Quality assurance

Guidelines to ensure patient safety and prevent hospital or laboratory error have been developed by various professional institutions. Additional protocol is available to aid physicians in clinical practice and antibiotic therapy. Aside from the CDC, others include the Infectious Disease Society of America (IDSA); the American Thoracic Society, or ATS; the American Society, for Clinical Pathology, or ASCP; and the Clinical Laboratory Standards Institute, or CLSI, that provide an annual update of standards specific to the clinical microbiology laboratory. Laboratory accreditation by JCAHO and the CAP is also recommended. (7)

Among the published guidelines for microbiology laboratories recommended in 2004 are the following examples:

1. Screening tests that are both specific and sensitive for a group of sexually-transmitted pathogens (STDs). A nucleic-acid amplification technique is available for the rapid detection of Chlamydia trachomatis and Neisseria gonorrhoeae, the two most common STDs in the United States. Other STDs to screen include Group B beta hemolytic streptococcus, or GBS--a deadly infection of the newborn--and human papillomavirus, or HPV, an agent of squamous cell carcinoma of the cervix. Guidelines for antibiotic therapy and vaccine recommendations are also provided. (7)

2. Implementing culture, susceptibility, and molecular detection testing has resulted in a marked reduction in nosocomial infection with methicillin resistant S aureus, or MRSA, and vancomycin-resistant Enterococcus spp., or VRE. The 2003 surveillance data from the Society for Healthcare Epidemiology of America indicate that screening cultures, contact, and other prevention measures are worth the added cost to decrease both morbidity and mortality from infection with these pathogens. (7)

3. Screening platelet units by culturing for bacterial contamination, usually done by the blood center collecting the platelets, is now required by the AABB (American Association of Blood Banks) and is considered a "Phase II laboratory deficiency" by the CAP (TRM 44955) when not performed. (7)

State and local regulations, and in-house quality-control monitoring apply to all U.S. clinical laboratories. Professional organizations provide accreditation following onsite laboratory inspection. That inspection applies to the three phases: pre-analytic, analytic, and post-analytic. The first step, or pre-analysis, has been demonstrated here. The second step, analysis, requires quality assurance of all steps in the automated, semi-automated, and manual methods of culture, susceptibility, and molecular-detection testing. The third phase, or post-analysis, is the important area of reporting, where accuracy of performance and communication of results to the provider are reviewed. Electronic reporting may reduce errors, but there is no substitute for monitoring computer entry and system accuracy that is provided by the critical eyes of medical technologists, their supervisors, and managers. (3), (7)

Present and future challenges

The familiar "bugs"--S aureus and Enterococcus spp., which are known causes of nosocomial infection--have evolved to include the hyper-resistant strains, MRSA, vancomycin-intermediate S aureus (VISA), vancomycin-resistant S aureus (VRSA), and VRE. MRSA has further evolved to become the community health hazard, community-acquired methicillin resistant S aureus (CA-MRSA).

Other microorganisms in the newly emerging group include the food contaminating E coli serotype 0157:H7, known for its devastation to children from fast-food hamburgers and, more recently, fresh produce. Combined with the emerging antibiotic resistance in both Gram-negative and Gram-positive pathogens, the challenge to medical technologists in microbiology has become an increasing burden. (8)

Unfortunately, non-compliance among laboratories with the recommended guidelines for error prevention is common. The reasons are varied but include lack of resources, lack of agreement to a timeline for updates (e.g., IDSA says two years; in reality, it may be three to six years before changes are enacted), fear of legal liability, and disagreement among professional groups. The ever-increasing number of guidelines recommended (e.g., more than 1,000 in the National Guidelines Clearinghouse 2001 database) requires more time to implement. (7)

Clinical microbiology came under unprecedented public scrutiny when anthrax spores threatened the U.S. postal system in 2001. A view of less than state-of-art laboratories desperately needing funding was only too apparent. Fortunately, the biotechnology field was able to answer the demand for rapid testing with nucleic-acid amplification and the latest molecular technology for identifying emerging viruses such as SARS and avian influenza. (8)

Suggestions have been made that the American Society of Microbiology (ASM) play a greater role in developing and updating quality-assurance guidelines for microbiology practice as they did in response to the anthrax attacks. Collaboration with the Association of Public Health Laboratories, or APHL, and the CDC helped establish regulations and guidelines for the control of possible etiologic agents of bioterrorism. Updating the ASM publication series, Cumitech, initiated as clinical-practice guidelines to address on-going problems of error prevention, is a pressing need. Its suggestions for creating a more systematic approach in the microbiology lab are invaluable. (7), (8)

Leadership may be on the horizon with a newly formed organization entitled the Institute for Quality in Laboratory Medicine (IQLM). Under the auspices of CDC, the IQLM is not another regulatory agency but a group of experts dedicated to the single purpose of ongoing quality improvement in laboratory testing and services. The organization's first conference was held in Atlanta in 2005. (9)

The evolution of microorganism behavior to include such phenomena as species jumping, increasing virulence, and emerging antibiotic resistance has reinforced our dependence on microbiology lab expertise. Education and training in the field of medical technology--and, particularly, microbiology--has been tragically neglected. Motivation among young people to enter the field of microbiology requires education of both general and patient populations, who can then inspire their children and grandchildren to fill this important need. In the final analysis, confidence among hospital and laboratory directors, providers, and their patients rests squarely on the higher education, stringent training, and personal integrity of their laboratory personnel, who remain the cornerstones of error prevention.

CONTINUING EDUCATION

To earn CEUs, see test on page 22.

LEARNING OBJECTIVES

Upon completion of this article, the reader will be able to:

1. Differentiate accuracy and precision.

2. State the three phases of laboratory testing.

3. Identify resources and guidelines for error prevention in the microbiology lab.

4. Describe collection, transport, and storage requirements for particular types of specimens.

5. Assess specimen suitability for culture.

6. Discuss specific actions that could reduce errors in the clinical microbiology lab.

References

(1.) Woeste S. Technology to reduce specimen collection errors. Lab Med. 2004; 35(8):471-475.

(2.) Landro L. Hospitals move to cut dangerous lab errors. The Wall Street Journal. June 14, 2006.

(3.) Astion ML, Shojania KG, Hamill TR, et al. Classifying laboratory incident reports to identify problems that jeopardize patient safety. Am J Clin Pathol. 2003;120(1):18-26.

(4.) Howanitz PJ. Errors in laboratory medicine: practical lessons to insure patient safety. Arch Path Lab Med. 2005;129(10):1252-1261.

(5.) Thomson RB, Miller JM. Specimen collection, transport and processing: bacteriology. In: Murray PR, Baron EJ, Pfaller MA, et al. eds. Manual of Clinical Microbiology. Vol 1. 8th ed. Washington, DC: American Society for Microbiology Press; 2003:286-322.

(6.) Miller JM, Holmes HT. Specimen collection, transport and storage. IN: Balows A, Hausler WJ, Herrman KL, et al. Manual of Clinical Microbiology. 6th ed. Washington DC: American Society for Microbiology Press; 1999:19-32.

(7.) Gilligan PH. Impact of clinical practice guidelines on the clinical microbiology laboratory. J Clin Microbiol. 2004;42(4):1391-1395.

(8.) Cockerill FR III, Smith T. Response of the clinical microbiology laboratory to emerging (new) and reemerging infectious diseases. J Clin Microbiol. 2004;42(6):2359-2365.

(9.) Stombler RE, Pollock A, Taylor JR, et al. Highlights from first landmark summit--an opportunity to enhance medical care. Presented at: Institute for quality in laboratory medicine: recognizing excellence in practice. April 28-30, 2005; Atlanta, GA. Available at: http://www.iqlm.org.

By Cynthia B. Schofield, MPH MT(CAMT)

Cynthia B. Schofield, MPH, MT(CAMT), retired in 2001 after more than 20 years at the VA San Diego Healthcare System, working first as a medical microbiology technologist and later as a technical supervisor. She earned a BS degree at the University of Michigan and an MT(CAMT) certificate after training at Scripps Memorial Hospital in La Jolla, CA. After attending San Diego State's Graduate School of Public Health, majoring in Epidemiology and Bio-statistics, she received her MPH degree. Her article "The Platinum Loop Group, Memoirs of a Medical Technologist" was published in 2004 in ASCP's Laboratory Medicine.
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Author:Schofield, Cynthia B.
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Geographic Code:1USA
Date:Dec 1, 2006
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