Instrument Flags Should Never be Ignored

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Recently we have encountered several laboratories in which the employees were not paying adequate attention and in some cases ignoring flags generated by hematology analyzers during testing.  The technological developments over the past thirty plus years have enabled guidelines to be programmed into the analyzers that will flag results notifying testing personnel of the need for additional action.


Some flags may indicate when the analytic reportable range as determined by the instrument verification procedure has been exceeded.  Values exceeding reference range generally are flagged.  Values which are sufficiently abnormal to be considered “alert” results which should lead to practitioner notification also will have flags.  Many of these flags are useful in the laboratory but also are helpful to the treating clinician reviewing patient results.

Specimen pre-analytic issues can be highlighted by flagging specimens which are lipemic or specimens containing clots which could lead to erroneous results.  In addition, the presence of abnormal red or white cells (such as nucleated red blood cells or immature white cells), or clumped platelets can be indicated by instrument flags alerting the technologist to the potential for action before reporting patient results.  

It is an imperative that the technologists operating the hematology analyzer understand the instrument flags, their use and their meaning with particular attention being paid to those where action on the part of the technologist is indicated.  It is important to review all flags described in the operator manual which comes with your hematology instrument.  When results are flagged, if there is unfamiliarity with the flag meaning, the manual should be consulted.  

Likewise, in a CLIA moderate complex laboratory, if a flag which indicates the possible need for review by peripheral smear examination of a specimen, the technologist needs to be certain the specimen is referred for examination to an appropriate facility, as indicated in the laboratory procedure manual.   In addition, your laboratory should have a procedure for “alert” or “critical” values with the procedure indicating what these values are, who should be immediately informed and how the transmission of the results is documented.


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About the author

Dr. John Daly

John T. Daly, M.D. is Chief Medical Officer of COLA. Dr. Daly received his MD degree at Weill Cornell University Medical College, performed his internship and residency in Anatomic and Clinical pathology at Duke University Medical Center and a residency in Forensic Pathology at the Office of the Chief Medical Examiner in Chapel Hill, N.C. He is board certified in anatomic, clinical and forensic pathology. Through the course of his career, Dr. Daly has had extensive experience directing and advising laboratories of all sizes including physician office practices, Federal Health Clinics, surgical centers, Community Hospitals and the integrated academic health system clinical laboratories of Duke Medicine. He retired as Director of Laboratories of Duke Medicine, and continues his affiliation as a member of the emeritus staff. He then joined the accreditation organization, COLA, as the Chief Medical Officer. In this role he continues to provide guidance that helps labs improve safety in labs, standardize and streamline operations while achieving CLIA compliance.


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