HEMATOLOGY LABORATORY FUNDAMENTALS

PN 69968-101
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69968-101 August 2002 New Release

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TABLE OF CONTENTS
INTRODUCTION 2
TIPS FOR EFFECTIVE STUDY 2
GLOSSARY 4

I. GOOD LABORATORY PRACTICES 7–14

Learning Objectives 7
Key Concepts 7
A. What Are Good Laboratory Practices? 8
B. Who Enforces and Sets the Standards? 8
C. Inspections, Standards, and Documentation 10
Summary 13
Review Questions (I) 14

II. QUALITY CONTROL (QC) 15–25

Learning Objectives 15
Key Concepts 15
A. Quality Control and Why It Is Important 16
B. Basic Quality Control (QC) Terminology 16
C. Evaluating QC Results 19
Summary 21
Review Questions (II) 24

III. BASIC HEMATOLOGY 26–39

Learning Objectives 26
Key Concepts 26
A. Overview of Blood 27
B. Terminology and Cell Function 31
C. Red Blood Cell Indices 34
D. Common Disease States 35
E. Hematology Evaluation Process 36
Summary 38
Review Questions (III) 39

INTEGRATIVE SUMMARY 40
ANSWERS TO REVIEW QUESTIONS 41
BIBLIOGRAPHY 42
SELF-ASSESSMENT POST-TEST 43
ANSWERS TO SELF-ASSESSMENT POST-TEST 48
 INTRODUCTION

Introduction
ematology is the study of blood cells and coagulation. This
H study includes measuring the concentration, structure, and
function of cells in the blood. [Nelson, 1984, 578] Most diseases
have expected hematology laboratory test results, and the physician
relies on these results to make decisions in caring for the patient.
Therefore, laboratories are held to standards and governed by guide-
lines in the Federal Register to ensure laboratory tests are performed
correctly. This module will review laboratory practices that align
with these standards and will provide an introduction to hematology.

Section I of this module defines the guidelines for ensuring reliable,

accurate hematology test results and describes who enforces these
guidelines. Section II describes quality control methods for complying
with the laboratory guidelines. Finally, Section III reviews blood cell
types and the test results expected for common diseases.

Tips for Effective Study

This module is arranged for easy study. Note the following features
as you study the module, and then review what you have learned.

1. The text is clearly divided into sections and subsections,

with brief introductions that preview what you will be
learning. Use the introductions to help orient yourself to the
content ahead.

2. Glossary terms appear in bold the first time they are used
in the text.

3. The fast track also summarizes the main points of each

paragraph. Use the fast track to go back later and review what
you have read, as well as quickly find information.

4. Summaries and review questions follow text sections. Use

them to help confirm that you have mastered the section’s
major points.

2 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 TIPS FOR
EFFECTIVE STUDY
5. The post-test is followed by an annotated answer page.
Use the text references to review any material you missed.

6. Reinforcement text appears throughout the module to

highlight tips and relevant information and to summarize
and question key learning points.

The following identifiers are examples of how important information

is highlighted or reinforced for the reader. These include tips,
questions, and connectors to information covered in the module.

Tips provide clinical

information.

Questions remind you

of key learning points.

Connectors remind you

that material was covered
earlier or may be
expanded on later.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 3

 GLOSSARY

A-G
Accuracy: measure of how close a test result is to the “true” value.

Analyte [AN uh light]: the substance that is measured.

Anemia [uh NEE mee uh]: abnormally low number of red blood
cells, amount of hemoglobin, or volume of packed red blood
cells; results in reduced oxygen-carrying capacity of the blood.

Anticoagulated [AN tih koh AG yoo lay ted]: characterized by

prevention of blood clot formation.

Assays: tests to determine the presence of a substance.

Calibrators: materials with known values used to adjust a laboratory

instrument to ensure accurate measurement.

Centers for Medicare and Medicaid Services (CMS): federal

agency that provides health insurance for Americans through
Medicare, Medicaid, and SCHIP (for children); formerly known
as the Health Care Finance Agency (HCFA).

Coefficient of variation: the standard deviation expressed as a

percentage of the mean; measure of population dispersion.

Control materials: fixed and stabilized preparations with a range of

concentrations for the measured test parameters. Controls are
used to determine whether an instrument is operating with
accuracy and precision.

Data points: outcomes of testing procedures, results.

Erythrocyte [uh RITH roh sight]: mature red blood cell.

Federal Register: official daily publications for Rules, Proposed

Rules, and Notices of Federal agencies and organizations, plus
Executive Orders and other Presidential Documents; CLIA is
recorded in the Federal Register.

4 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 GLOSSARY

Granulocytes [GRAN yoo loh sights]: type of white blood cells

important in direct destruction of foreign organisms; subtypes
are neutrophils, eosinophils, and basophils.

H-P
Hematocrit [hee MAT oh krit]: the percentage of whole blood that
consists of red blood cells.

Hemoglobin [HEE muh gloh bin]: the protein in red blood cells
that carries oxygen. Hemoglobin gives red blood cells their
characteristic color.

Histograms [HIS toh gramz]: graphs that compare the cell size to
the relative cell number, such as white or red blood cells and
platelets.

Levey-Jennings™ graph: a plot showing the distribution of data

points relative to the mean. Trends and shifts are much easier to
detect from such a graph compared to looking at raw data.

Maintenance: procedure necessary to keep instruments in state of

readiness to run assays.

Mean: the sum of all results or values divided by the number of

results or values; the average of a set of numbers.

Panic values: test limits at which a medical alert should be given to

a caregiver.

Plasma [PLAZ muh]: the liquid portion of the blood still containing
clotting proteins, after the cells have been removed.

Precision: measure of how repeatable a result is.

Proficiency testing: a form of external quality control in which the

laboratory analyzes unknown samples sent by a testing organi-
zation. The results are compared to those obtained by other
participating laboratories and referees.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 5

 GLOSSARY

Q-Z
Quality control (QC): laboratory procedures that ensure the test
methods are working properly.

Random error: error introduced by chance that affects the precision

or reproducibility of a test.

Reagents: substances that take part in a chemical reaction.

Reliability: the ability to have both accuracy and precision in

test results.

Result: data point; outcome of testing procedure.

Serum: liquid portion of plasma that remains after clot is removed.

Shift: abrupt change in several data points as compared to

previous data.

Specimen: material obtained from a patient for testing.

Standard deviation: statistical measure of the scatter of control

values around a mean.

Systematic error: error that affects all results equally and is

usually identifiable and correctable, e.g., instrument problems,
calibration.

Trend: data points that gradually deviate from previous data in

one direction.

Westgard® Rules: a set of guidelines or limits used to determine if

QC results are out of control.

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 GOOD LABORATORY
PRACTICES
I. GOOD LABORATORY PRACTICES
he goal of laboratory testing is to achieve accurate results that
T can be used optimally by the physician. Good laboratory
practices are steps taken to achieve these results. This section will
define good laboratory practices and describe the agencies that
establish standards for testing.

Learning Objectives
1. State the purpose of good laboratory practices.

2. Briefly describe the Clinical Laboratory Improvement

Amendments of 1988 (CLIA ’88) and its relationship to good
laboratory practices.

3. List key agencies involved in enforcing CLIA ’88 regulations.

4. Identify two general features needed for a successful labora-

tory inspection.

Key Concepts
1. Good laboratory practices ensure that laboratory tests are
done correctly in a timely manner to provide the physician
with critical information for patient care.

2. CLIA ’88 are laboratory standards established as law by

Congress. These standards are minimum guidelines for
laboratory activities and personnel to ensure quality testing.

3. The federal Centers for Medicare and Medicaid Services

(CMS) oversees adherence to the CLIA ’88 regulations.
CMS inspectors inspect and certify testing laboratories.

4. Following good laboratory practices and maintaining docu-

mentation of all activities in the laboratory are necessary for a
successful inspection.

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GOOD LABORATORY
PRACTICES
A. What Are Good Laboratory
Practices?
Good laboratory practices Good laboratory practices are based on standards established by
are based on standards
regulating how laboratory
agencies that regulate laboratory tests performed on specimens from
tests are performed. human patients. Standards are established to guarantee that the best
information is provided to the physician or other health care provider
for assessing a patient’s health, deciding on a diagnosis, or treating an
illness. To accomplish this goal, standards ensure that all laboratory
tests are performed by qualified personnel and done correctly in a
timely manner. [Clinical Laboratory Improvement Amendments
(CLIA), 2002] All laboratories are expected to employ good labora-
tory practices, follow manufacturers’ instructions for performing tests,
and allow for unannounced, random inspections.

B. Who Enforces and Sets the

Standards?
Laboratory standards are developed by panels of experts in laboratory
testing, and many agencies have developed such standards. To ensure
quality standards for all laboratory testing, Congress passed into
CLIA ’88 are laboratory law a set of standards called the Clinical Laboratory Improvement
standards that must
Amendments of 1988 or CLIA ’88. The CLIA regulations were
be followed by law.
finalized in 1992, incorporating three levels of complexity with
increasingly stringent regulations based on the complexity of the
tests performed by the laboratory. The three levels are waived,
moderate, and high complexity. [Centers for Medicare & Medicaid
Services (CMS), 2002]

You should obtain the most recent copy of the guidelines and be
thoroughly familiar with the areas that pertain to your laboratory.
Information about CLIA regulations can be found at the CMS
website: http://www.cms.hhs.gov/clia/. You can also contact your
CMS regional office. To find the regional office for your area,

8 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 GOOD LABORATORY
PRACTICES
look at the following website: http://www.cms.hhs.gov/providers/
regions/default.asp. Another source of information on laboratory
standards is your state’s Health and Human Services Department.

The agency that oversees adherence to

CLIA regulations apply
CLIA standards is called the Centers
to laboratories that
for Medicare and Medicaid Services diagnose, prevent, or
(CMS; formerly called Health Care treat disease or assess health
Finance Agency or HCFA). CMS has by testing human specimens.
a staff of trained inspectors who period- CMS inspects laboratories
to ensure adherence to
ically visit laboratories to ensure that laboratory standards are being CLIA regulations.
followed. These visits are called inspections or surveys. After a
laboratory successfully demonstrates to the inspectors that laboratory
standards are being met, the laboratory becomes licensed or certified.
The lab must then adhere to recertification requirements to remain
in compliance.

Other national and state agencies develop laboratory guidelines and Other agencies that perform
inspections and work
perform inspections. These agencies work closely with CMS and
closely with CMS are:
include the following organizations: • CAP
• COLA
• JCAHO
• College of American Pathologists (CAP). CAP inspects
laboratories in both physicians’ offices and hospitals.

• Commission on Office Laboratory Accreditation (COLA).

COLA is a non-profit, physician-directed organization for
voluntary participants, established as a private alternative for
physician office laboratories that comply with CLIA ’88.

• The Joint Commission on Accreditation of Healthcare

Organizations (JCAHO). The JCAHO inspects hospitals
in the United States. A hospital’s satellite physician office
laboratories may also be inspected by JCAHO.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 9

GOOD LABORATORY
PRACTICES
To be knowledgeable about
the inspection process, you
should obtain guidelines
from your local agency.
Inspections may consist of
observing testing and the
physical surroundings and
examining documentation.
An inspector will ask
to see evidence that
certain practices are
routinely performed.
Reagents, controls, and
calibrators must be
correctly labeled…
10 • HEMATOLOGY LABORATORY FUNDAMENTALS
C. Inspections, Standards, and
Documentation
Inspecting agencies determine if laboratory standards are being met
and whether laboratory practices are properly documented.
1. Inspections. A good laboratory will be ready for an inspection
at any time. It is important that the person responsible for testing
in the laboratory know the guidelines used in the inspection process.
You should obtain a copy of the guidelines
Preparation is
from your local agency. The guidelines
essential for a
represent good laboratory practices
good inspection.
which incorporate traditional principles
of quality control and record keeping.
Laboratory inspectors verify that standards are being met. Verification
may consist of watching testing in the laboratory, observing the
physical and safety conditions under which testing is performed, plus
examination of testing documentation and personnel records.
2. Standards. Each standard addresses general procedures that
demonstrate good laboratory practices. These involve equipment,
reagents, calibrators, controls, components, and maintenance.
These practices should be a part of the laboratory’s daily activity.
Ensure that these practices are used routinely, prior to inspection,
since inspectors will ask to see evidence (commonly documentation)
that these practices are followed.
• All reagents, controls, and calibrators must be labeled correctly
to include identity, recommended storage requirements,
preparation, expiration dates, and any additional information
required for proper use. This information is generally
provided on the manufacturer’s label.
PN 69968-101
 GOOD LABORATORY
PRACTICES
• Reagents, controls, and calibrators must not be used beyond
their expiration date. Sufficient supplies should be available …and must not be used
to cover the types and volumes of tests performed and to beyond the expiration date.

maintain quality during all phases of testing.

• Lot numbers of reagents, calibrators, and controls must be Lot numbers must be
current and recorded
current and recorded in logs, as appropriate. Reagents, in a log.
controls, and calibrators must be labeled with date opened
(placed in use).

• Reagents of different lot numbers must not be intermixed.

Reagent usage, storage, and handling must follow the product Follow manufacturer’s instruc-
tions for reagent storage,
information supplied by the manufacturer. usage, and handling.

• Calibration logs provide evidence of the date a calibration Calibration logs show when
and why calibration
procedure was performed and the reason for performing
was done.
the calibration.

• Problem logs and service records provide evidence of correc- Problem logs must show
corrective action.
tive action taken when results recorded on quality control logs,
equipment maintenance logs, and/or calibration logs do not
meet the acceptability criteria of the laboratory.

• Equipment and instruments must show evidence of scheduled Equipment must show main-
tenance evidence.
maintenance and function checks. Maintenance must be
performed according to manufacturer specifications and
should be documented in a maintenance log.

• Specimen/patient logs or records track and document the date, Specimen/patient logs
record date, time, and
time, and results of the testing performed.
results of testing.

• Quality control logs or records provide evidence of the perfor- Quality control logs show
evidence of testing QC
mance of quality control samples and information regarding
samples and information
the quality of analysis. about testing quality.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 11

GOOD LABORATORY
PRACTICES
Laboratory policies and
procedures must be docu-
mented, with maintained
daily logs.
How does documenta-
tion help the labora-
tory inspectors?
3. Documentation. Documentation may consist of policies and
procedures that specify how laboratory testing is performed and logs
or journals that are maintained daily. Examples of laboratory infor-
mation that must be recorded are instrument calibration, quality
control, maintenance, corrective action, patient testing, personnel
training, and competency testing. Much of this information should be
kept in log books. Log books should contain all necessary cali-
bration and other information pertinent to your instrument. All of
this documentation must be available to inspectors during their visit.

The laboratory fails the
inspection if standards
are not met.
The laboratory fails the inspection if it does not demonstrate that
laboratory testing meets the standards. The laboratory will be given
a period of time to become compliant depending upon the severity of the
noncompliance. If the noncompliance is severe and places the patient in
jeopardy, testing will be prohibited until compliance is achieved.

TABLE 1 Contents Function

Documentation for Test procedure manual
compliance with CLIA:
inspection guidelines require
that certain procedure manuals
and log books be used Quality control records
in the laboratory.
Calibration procedures/logs
Maintenance manual
Proficiency testing (PT) manual
Specimen/patient logs
Quality assurance (QA) guide
To ensure consistent test results, instructions for
each procedure the laboratory performs are
recorded; includes calibration techniques, normal
values, and panic values.
Written quality control procedures must be
followed to monitor and evaluate the quality of
the analytical process of each test method. Logs
are kept of the control data and corrective actions
taken when quality control results do not meet the
acceptability criteria of the laboratory.
Written instructions tell how and when to calibrate
laboratory instruments. Logs are kept of the
reagents used in the calibration.
Procedures for regular maintenance of each labora-
tory instrument are recorded, and a log is kept
showing when and which maintenance activities
were performed.
The PT manual describes the PT programs in which
the laboratory is enrolled and for which substances
analyzed. It also describes other relevant findings
from the program, including test results and any
corrective action.
Records are kept on each patient, including the
ordering physician, the person who logged in the
specimen, and the test results.
The QA plan is described, including what will be
monitored, when and how, and what will be done
with the information obtained.

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 GOOD LABORATORY
PRACTICES
Summary
Good laboratory practices are essential for producing accurate testing
results for the physician. The federally mandated Clinical Laboratory
Improvement Amendments of 1988 (CLIA ’88) establish minimal
standards of good laboratory practices to ensure quality testing.
The Centers for Medicare and Medicaid Services (CMS) is charged
by Congress with enforcing the CLIA ’88 regulations. Testing
laboratories are inspected before certification and periodically
thereafter. During these inspections, the laboratories must supply
proper documentation of their methods and record keeping to the
CMS staff. Agencies that work closely with CMS, developing labora-
tory guidelines and performing inspections, include the College of
American Pathologists (CAP), the Commission on Office Laboratory
Accreditation (COLA), and the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO).

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 13

GOOD LABORATORY
PRACTICES
Review Questions (I)
DIRECTIONS. Circle the letter corresponding to the correct
response in each of the following items.

1. CMS is charged with ensuring that laboratories that test

human specimens adhere to ________ standards.

a. CAP
b. CLIA
c. COLA
d. JCAHO

2. Which of the following is the goal of good laboratory

practices?

a. to encourage the development of centralized laboratories

b. to ensure that Congress is aware of laboratory practices
c. to provide accurate, timely test results to the physician
d. to reduce cancer rates

3. Examples of laboratory information that must be recorded are

all of the following, except

a. instrument calibration.
b. instrument maintenance.
c. instrument operator’s age.
d. personnel training.

4. A laboratory inspection may consist of observing the

performance of tests and examining documentation.

a. true

b. false, only written documentation of quality control and

instrument calibration are reviewed

c. false, the laboratory conditions, not test performance,

Check responses on page 41. are observed

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 QUALITY
CONTROL
II. QUALITY CONTROL (QC)
he primary purpose of a laboratory is to provide accurate test
T results to a physician for use in the diagnosis, assessment, or
treatment of disease. A quality control program is a vital component
in meeting that purpose. Quality control involves statistical analysis
to evaluate the instrument and the person performing the test. This
documents that the procedures are working properly, helping assure
quality results. Displaying documentation of quality is a major
requirement of all certification programs.

Learning Objectives
1. Define quality control.

2. List basic QC terms.

3. Describe the benefits of evaluating quality control results.

4. Describe the relationship between good laboratory practices

and QC programs.

Key Concepts
1. Quality control is a statistical process to ensure each test result
reported by the lab is valid and reliable. This statistical
process detects potential analysis errors.

2. Terms that describe the outcomes of QC test procedures

include mean, accuracy and precision, standard deviation,
coefficient of variation, systematic errors, random errors,
shifts, and trends.

3. QC results are used to identify potential sources of error, so

that corrections can be made prior to patient testing.

4. QC programs provide a necessary adjunct to good laboratory

practices by ensuring that reagents and patients’ samples are
handled optimally and safely.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 15

 QUALITY
CONTROL
QC activities ensure that
physicians receive reliable
information about the patient.
QC is a statistical process
for assessing the reliability
of laboratory testing.
The mean is the arithmetic
average of a set of data points.
Accuracy is how closely the
measured value is to the
analyte’s true value.
16 • HEMATOLOGY LABORATORY FUNDAMENTALS
A. Quality Control and Why It
Is Important
The purpose of QC activities is to help detect instrument or operator
error, and thereby ensure that the reported results for patient sample
testing are correct and reproducible. In addition to detecting error,
QC activities can help determine the type and source of error and aid
in correcting the problem. An incorrect test result could mislead the
physician or other health care provider, creating a potentially dangerous
situation. To assure that results are precise and accurate, a quality
control program must be maintained at all times.
Hematology tests (or assays) are often performed early
in the diagnostic process as screening tests for serious
disorders. An abnormal result may subject the patient
to expensive, uncomfortable tests. QC is intended to
ensure precise and accurate results.
B. Basic Quality Control (QC)
Terminology
Quality control is a statistical process for assessing the reliability of
laboratory testing. To determine if the laboratory results are accurate,
clinical laboratories use control materials prepared by manufacturers.
Important QC concepts in assessing controls are mean, standard
deviation, accuracy, precision, coefficient of variation, systematic
error, random error, shifts and trends.
1. Mean. The mean is the arithmetic average of a set of data
points. It is calculated by taking the sum of all values in the set, then
dividing by the number of values. The mean is calculated for each
parameter at each level of control that is tested.
2. Accuracy and Precision. Accuracy is defined as how closely the
measured value of an analyte agrees with its “true” value. Accuracy
is determined by a known standard or a reference method.
PN 69968-101
 QUALITY
CONTROL
Precision is the reproducibility of a test. That is, precision is the
ability to repeatedly achieve the same test results on a sample. A test Precision is the reproduci-
bility of a test.
may be precise, but not accurate. Figure 1 shows the relationships
between precision and accuracy.

A. B. FIGURE 1
Accuracy vs. precision:
measurements for the same
analyte should ideally be both
accurate and precise.

Precise Neither precise nor accurate

C.

Precise and accurate

3. Standard Deviation. The standard deviation (SD) is a statistical The SD is a statistical

measure of the scatter of control values around a mean. The smaller measure of precision.

the scatter, the more precise the measurement. Over the years, the
laboratory community has adopted limits for QC results as the mean QC results should fall within
±2SD of the mean.
± 2SD (see Figure 2). Test results falling within that range are
considered valid.
A laboratory’s X FIGURE 2
mean and standard -1SD +1SD
Bell-shaped (or Gaussian) curve:
Frequency

deviation should 95% of the normal results

(expected variation) are within
vary only slightly -2SD +2SD two standard deviations on
from the manufac- either side of the mean.
turer’s values for
the controls. -3SD +3SD

Range

95.44%

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 17

 QUALITY
CONTROL
Like the SD, the CV
measures the variability
(precision) of test results.
Random error occurs
by chance, whereas system-
atic error is explainable
and correctable.
Changes in values from the
mean can occur gradually—
a trend—or abruptly—
a shift.
FIGURE 3
Trend vs. shift: a trend
A) shows a gradual change,
compared to the abrupt
“jump” seen in a shift B).
18 • HEMATOLOGY LABORATORY FUNDAMENTALS
4. Coefficient of Variation. The coefficient of variation (CV) is the
expression of the standard deviation as the percentage of the mean:
CV = (SD/mean) x 100
Like the SD, it is a measure of the variability (precision) of results.
The smaller the CV, the more precise the instrument.
5. Systematic and Random Errors. Errors or deviations from the
expected mark are either random or systematic. Random error is
introduced by chance and is a natural occurrence that can never be
eliminated. Systematic error is caused by some explainable and
usually correctable cause that affects all results equally.
6. Trends and Shifts. Systematic errors cause trends and shifts.
A trend is a progressive drift of control values from the mean
(see Figure 3A). A shift is an abrupt alteration in values from the
mean (see Figure 3B).
A: Trend
Concentration
Time (days)
B: Shift
Concentration
Time (days)
PN 69968-101
 QUALITY
CONTROL
C. Evaluating QC Results
Each laboratory must have a quality control policy that describes
how and when quality control is performed and describes a system
for frequency of review. This policy must meet the minimum Each laboratory’s QC policy
must meet the minimum
requirements defined by CLIA. In addition, the QC policy defines CLIA requirements.
unacceptable control results and provides actions to be taken to
resolve and document testing problems when control results are
outside acceptable limits. Quality control results must be reviewed
each time control materials are analyzed, in order to identify control
problems and isolate the source of the error, so corrections can be
made prior to analyzing patient samples. Hematology laboratory The two primary compo-
nents of hematology labora-
quality control programs consist of two primary components—
tory QC are calibrating the
calibrating the analyzer and running daily quality control materials. analyzer and running daily
QC controls.
1. Calibration. Hematology analyzers are calibrated using
commercially prepared materials with assigned values (calibrators).
Laboratory standards require that calibration be verified every Calibration must occur at
6 months or upon replacement of major instrument parts or least every 6 months
according to CLIA regulations.
major preventive maintenance. [CDC, 2001, Subpart K 493.
1217-Hematology] The instrument must be in optimal condition
for calibration, and calibration must be performed according to
manufacturer’s protocols.

2. Control Materials. A control is a material that is as physically

and chemically similar to patient samples as possible. Commercial Commercial controls are
usually fixed, stabilized blood
controls normally consist of fixed and stabilized blood cells with cells with known values.
manufacturer-defined ranges for each measured parameter. The
manufacturer provides an expiration date for each lot number of
control material, which applies only to unopened vials. Opened
containers have their own stability limits. Stability is decreased if
the manufacturer’s recommendations for handling and storage are
not followed.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 19

 QUALITY
CONTROL
Commercial controls include
normal, abnormally high, or
abnormally low values.
A common problem in
hematology QC is the failure
to properly prepare the
controls for sampling.
Review of Levey-Jennings™
graphs permits early detec-
tion of QC problems.
FIGURE 4
An example of a blank
Levey-Jennings™ graph:
when test results are plotted,
the graph provides a picture
of shifts, trends, and other
errors in QC results over time.
20 • HEMATOLOGY LABORATORY FUNDAMENTALS
Commercial control preparations consist of either two or three “levels”
of control material. Levels are generally defined by the values they
produce for the measured parameters. One level typically produces
values consistent with a “normal” specimen, whereas the other levels
produce abnormally high or low values. Most laboratories use three
levels of control: low, normal, and high.
Hematology laboratory standards require that at least two levels of
controls be analyzed for each cellular measurement (parameter)
being tested on each work shift or every 8 hours. [CDC, 2001, Sub-
part K493.1253-Hematology] A common problem in hematology
QC is the failure to adequately prepare the controls for sampling.
Manufacturer directions should be strictly followed. The two
most critical steps are warming the controls to room temperature
and adequate mixing. Failure to warm and mix causes inaccurate
results, because the cells typically settle at the bottom of the tube.
3. Evaluation. Quality control results are plotted on graphs called
Levey-Jennings™ graphs (see Figure 4). Careful review of these
graphs will permit early detection and prevention of QC problems.
Laboratories use guidelines called Westgard® rules to determine
when testing is out of control. Rules that detect both random and
systematic errors should be selected. A common rule for hematology
testing is that a procedure has failed when a control level falls outside
two standard deviations twice or falls outside three standard devia-
tions once. [Westgard, 2000, 5]
+2SD
+1SD
Concentration
Mean
-1SD
-2SD
Time (days)
PN 69968-101
 QUALITY
CONTROL
4. Isolating the Source of Error. In analyzing a problem, the first
critical decision is to determine if all levels of control indicate the To isolate a testing problem,
first determine if all control
same problem. For example, if WBC counts are too low, do all three
levels show the same problem.
controls show similar problems? If problems are not occurring with
all levels of controls, then try rerunning the control level in question.
Otherwise, the problem may be a bad bottle of control material and
a new bottle should be prepared for testing.

It is important to review troubleshooting, reagent, and maintenance

records when all levels of controls indicate similar problems. A
gradual trend in QC results indicates a problem that is developing
slowly, such as deterioration of a reagent or need for instrument
maintenance. A sudden shift in results may indicate a more serious A shift or trend in QC values
problem such as a malfunctioning part. Early detection of a trend is may help isolate the error.

important and allows corrective action before quality control fails.

Because some parameters reported on a complete blood cell count

are calculated from other parameters and some are analyzed on the
same instrument channels, it is important to compare failed parameters
for similarities. For example, red blood cells and platelets are usually Compare failed parameters
for similarities.
counted in the same channels on hematology analyzers. Low or
high counts on both usually indicate an analyzer problem. Figure 5
(on pages 22 and 23) contains a flow chart for troubleshooting
QC problems.

Summary
The quality control program involves carefully monitoring the perfor-
mance of the laboratory instruments and personnel by repeatedly and
regularly testing control materials. Appropriate statistical analysis
involves determining the level of random error, the standard devia-
tion, and whether the control results fall within two standard devia-
tions from the mean. Westgard® rules are used to define when the
QC test has failed. If a failure occurs, a troubleshooting plan is
implemented for isolating the error and correcting the problem.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 21

 QUALITY
CONTROL
FIGURE 5
Troubleshooting algorithm: a SUGGESTED APPROACH is shown
(also see page 23).

One level out of control

Is/Are
Reanalyze no other level(s)
QC out of = reanalyze
control patient sample
?
IN yes yes
Accept
CONTROL run Review previous Try alternative
?
data and identify to the change
no trends or shifts like different
reagent, verify
Get fresh bottle reagent is being
yes Look for any used per
of QC material changes that
and reanalyze SHIFT? manufacturer's
occurred just guidelines,
prior to shift recalibration, etc.

IN yes Discard old

CONTROL QC and use no TREND? Rerun QC
? new QC
Go to B yes
no
IN yes
Go to A Go to A CONTROL
?

no

Go to A

22 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 QUALITY
CONTROL
= reanalyze
patient sample

A
B Try to isolate problem
Rerun QC Change reagents

Rerun QC
yes IN
CONTROL
?
IN yes
no CONTROL
?
Prepare fresh QC
no

Run precision study

Rerun QC

IN no PRECISION
CONTROL WITHIN no
? SPECIFICATIONS
?
yes

Discard old QC
yes
and use new
Recalibrate

Rerun QC

IN yes
CONTROL
?

no

Probable instrument problem

Fix if possible

Rerun QC

IN yes
CONTROL
?

no

Contact technical support

gy Lab. Fundamentals

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 23

 QUALITY
CONTROL
Review Questions (II)
DIRECTIONS. Circle the letter corresponding to the correct
response in each of the following items.

1. The purpose of quality control in the laboratory is

a. to detect instrument or operator error.

b. to ensure patient results are correct and reproducible.
c. both a and b.
d. neither a nor b.

2. Which of the following correctly defines the standard deviation

as used in hematology quality control?

a. a progressive drift of control values from the mean

b. a statistical measure of the scatter of control values

around a mean

c. how closely the measured value of an analyte agrees with

its “true” value

d. the reproducibility of a test

3. Which of the following correctly defines precision as used in

hematology quality control?

a. a progressive drift of control values from the mean

b. a statistical measure of the scatter of control values around

a mean

c. how closely the measured value of an analyte agrees with

its “true” value

d. the reproducibility of a test

24 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 QUALITY
CONTROL
4. A common problem identified with controls in hematology
laboratories is not properly following the manufacturer’s
protocol for preparing the controls for sampling, leading
to errors.

a. true

b. false, laboratories should develop their own control

preparation procedures Check responses on page 41.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 25

 BASIC
HEMATOLOGY
III. BASIC HEMATOLOGY
he patients’ specimens that are collected for the hematology
T laboratory are blood samples, but the testing ordered by the
health care professional can vary widely. This is due to the variety of
cell types, proteins, metabolites, and ions in the blood, any of which
may offer clinical insight to a patient’s illness. This section describes
the cell types carried in the blood and their morphology (shape)
in health and common diseases. Also described are the diagnostic
roles of hemoglobin, a protein in red blood cells, and red blood cell
indices—measurements that describe the state of the red blood cells
in circulation.

Learning Objectives
1. Describe the importance of differential cell counts.

2. Describe red blood cells’ function and the importance of

measured laboratory findings about red blood cells.

3. Describe the role of automated hematology analyzers in red

blood cell analysis.

4. Broadly describe the function of white blood cells and list the
particular types.

5. Describe platelets and their function in the body.

Key Concepts
1. Blood cell formation is influenced by many stimuli in the
body, including disease conditions. Analyzing blood
cell types can give important diagnostic information to
health care providers.

2. Red blood cells deliver oxygen to the tissues and remove

carbon dioxide, a cellular waste product. The number, size,
shape, hemoglobin content, and hemoglobin concentration are

26 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 BASIC
HEMATOLOGY
all important indicators in many conditions. One such condi-
tion is anemia, in which low oxygen delivery is due to too few
red cells per volume of blood or too little normal hemoglobin.

3. Automated hematology analyzers measure or derive important

descriptive information about a patient’s red blood cells.
These objective measurements are called indices, and give
quantitative descriptions about the size and hemoglobin
amounts in the cells. The laboratory should have a plan for
when to manually analyze blood smears to verify abnormal
test results.

4. White blood cells function in immune responses against

foreign substances. The circulating white blood cells are
monocytes, lymphocytes, and granulocytes. There are three
kinds of granulocytes: neutrophils, eosinophils, and basophils.

5. Platelets prevent blood loss by forming clots in response to

blood vessel injury. They also nurture and maintain the cells
lining the blood vessels. Low platelet counts can lead to
excess bleeding.

A. Overview of Blood
The functions of the blood in serving the whole body make it a
prime candidate for revealing improper organ functioning, immune
disorders, and infection, along with an enormous list of illnesses
that affect blood cells themselves. This part of Section III gives an
overview of blood functions, components, cellular formation, and
normal test values. It also introduces the potential diagnostic
benefits of blood tests and the importance of properly handling
blood samples.

1. Major Functions. Blood circulates throughout the body, carrying Blood functions in oxygen
delivery, waste removal,
oxygen, nutrients, waste products, carbon dioxide, hormones, and
immune responses,
other products. The delivery or removal of these substances is and clotting.
essential for keeping the body’s cells alive and functioning properly.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 27

 BASIC
HEMATOLOGY
Blood is a suspension of
cells in a protein-salt solution.
The cellular components
of blood are RBCs, WBCs,
and platelets.
Normal hematology values
are the expected values
in healthy individuals.
28 • HEMATOLOGY LABORATORY FUNDAMENTALS
Blood also carries white blood cells and other components of the
immune system, which fight infections. Other components of the
blood regulate the formation of blood clots while preventing bleeding.
Blood circulation also helps maintain body temperature. Sweating
and more circulation of blood near the skin dissipate body heat; the
opposite prevents excess loss of body heat.
2. Noncellular and Cellular Components. Blood is a suspension
of cells in a protein-salt solution. This noncellular solution is known
as plasma and contains proteins that are involved in clotting of the
blood. When blood clots or coagulates, these proteins are removed.
The noncellular component of the blood is then called serum.
[Pickard, 1989, 41] Centrifuging clotted or unclotted blood can
separate the blood cells from the serum or plasma. Uncentrifuged
(nonseparated) blood is called whole blood.
plasma serum noncellular
and
cellular
red clotted red
blood cells blood cells
anticoagulated coagulated whole
blood blood blood
The major cellular components in blood are red blood cells (RBCs),
lymphocytes, granulocytes (neutrophils, eosinophils, and basophils),
monocytes, and platelets. Lymphocytes, granulocytes, and monocytes
are collectively called white blood cells (WBCs) or leukocytes.
3. Normal Values. Studies have been performed on different age
groups to determine the expected concentrations of cellular compo-
nents in blood of healthy individuals. These values are called normal
values or reference ranges. Normal values for adults for complete
blood cell counts and differentials are provided in Table 2. [Finnegan,
1998, 869]
PN 69968-101
 BASIC
HEMATOLOGY
Test Adult Male Adult Female
White Blood Cell (WBC) (x 103/µL*) 3.9–10.6 3.5–11.0
Red Blood Cell (RBC) (x 106/µL) 4.4–5.9 3.8–5.2
Hemoglobin (Hb) (g/dL) 13.3–17.7 11.7–15.7
Hematocrit (Hct) (%) 40–52 35–47
Mean cell volume (MCV) (fL**) 80–100 80–100
Mean cell hemoglobin (MCH) (pg***) 27–34 27–34
Mean cell hemoglobin concentration 31–36 31–36
(MCHC) (g/dL) TABLE 2
Red cell distribution width (RDW) (%) 11.5–14.5 11.5–14.5 Normal reference values for
hematology: normal RBC count,
Platelet (x 103/µL) 150–400 150–400 hemoglobin concentration,
Mean platelet volume (MPV) (fL) 7.4–10.4 7.4–10.4 and hematocrit vary by gender.
(Adapted with permission from:
Band (%) 0–5 0–5 Finnegan K. Hematopoiesis.
Neutrophil (%) 54–62 55–62 In: Lehmann CA, ed. Saunders
Manual of Clinical Laboratory
Lymphocyte (%) 20–40 20–40 Science. Philadelphia, PA: W. B.
Monocyte (%) 4–10 4–10 Saunders Company; 1998:869.)

Eosinophil (%) 1–3 1–3

Basophil (%) 0–1 0–1

*µL = microliter, or 10–6 Liter. **fL = femtoliter, or 10–15 Liter. ***pg = picogram,
or 10–12 gram.

Laboratory standards require that normal values be established or

Laboratories must use
verified for different ages and sexes in the geographic area in which normal values established or
the laboratory is located. This is necessary because environmental verified in a geographically
local population…
conditions may influence cellular concentrations. For example,
healthy long-time residents of Denver (higher elevation) will have
higher concentrations of red blood cells than healthy long-time
residents of New Orleans (sea level). It is also important that the
laboratory develop a list of elevated and decreased test results that
indicate life-threatening situations for the patient. These values
are called critical or panic values and require that the physician
…and develop a list of
be notified immediately so the patient can be treated. Critical panic values.
values should be developed in consultation with the medical staff.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 29

 BASIC
HEMATOLOGY
Many CBCs are done as
routine screens.
The different blood cell
types, and common diseases
that affect them are
described in more detail in
Section III-B–D.
Anticoagulated whole blood
is needed for many hema-
tology tests.
30 • HEMATOLOGY LABORATORY FUNDAMENTALS
4. Why Differentiate and Count Cell Types? By measuring and
visually examining the different cellular components, it is possible
to detect the existence of different disease states in the patient and to
monitor treatments. Measurement of the different cellular components
is called a complete blood cell count (CBC). The CBC is probably
the most widely requested and single most important lab test on
blood. Many CBCs are done as routine screens— tests that provide
general information about the patient’s status. Most CBCs include
the following values:
• RBC count
• WBC count
• WBC differential
—3-part: lymphocytes, monocytes (sometimes substituted
by MID cells, which include additional cell types),
granulocytes
—5-part: lymphocytes, monocytes, neutrophils, eosinophils,
basophils
• RBC indices
• hemoglobin concentration (Hb)
• hematocrit (Hct)
• platelet count
5. Sample Handling Requirements. An anticoagulated whole
blood specimen is required to perform blood cell counts, identify
the different types of white blood cells present, and review cellular
morphology. An anticoagulated specimen is one in which the clotting
process has been inhibited by adding a chemical compound. The
anticoagulant of choice for hematology testing is EDTA (ethylene-
diamine tetraacetic acid). EDTA eliminates the formation of artifacts
when microscopically viewing blood cells and prevents platelet
clumping. EDTA samples are stable for making blood smears for
2 to 3 hours and for cell counting for 24 hours when refrigerated.
[Nelson, 1984, 580] For automated analyzers, samples older than
8 hours or newer than 20 minutes are not recommended. Whether
PN 69968-101
 BASIC
HEMATOLOGY
for blood smears or autoanalysis, refrigerated blood must be warmed
to room temperature and then mixed well before sampling to avoid
errors caused by inadequate mixing. All samples must be well mixed
before sampling.

B. Terminology and Cell Function

Complete blood count reports include information about these three
formed elements: erythrocytes (red blood cells), leukocytes (white
blood cells), and platelets, or thrombocytes (see Figure 6).

A FIGURE 6
Red and white blood cells and
platelets: the cell types have
distinct morphologies (shapes).
A = erythrocytes;
B B = lymphocytes;
C = neutrophils;
D = eosinophil,
C E = monocyte;
F = basophil;
G = platelets.
C

E B

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 31

 BASIC
HEMATOLOGY
The following terms are used in hematology laboratory reports:

WBC: White blood cell is any of the nucleated cells from one of
the following subpopulations:

LYM: Lymphocytes— WBCs whose key role is

producing antibodies

MID cells: includes less frequently occurring cells, such as:

Monocytes— WBCs whose main function is phago-

cytosis (engulfment of foreign bodies)

Eosinophils—WBCs whose major role is in controlling

parasitic infections and in hypersensitivity reactions

Basophils—WBCs whose most important function is

their role in immediate hypersensitivity reactions

GRAN: Granulocytes— WBCs whose main function is

phagocytosis

RBC: Red blood cell—erythrocyte

HGB: Hemoglobin—oxygen-carrying component of an RBC

HCT: Hematocrit— volume % of RBCs in a blood sample

MCV: Mean corpuscular volume— volume of average RBC

MCH: Mean corpuscular hemoglobin— HGB content of

average RBC

MCHC: Mean corpuscular hemoglobin concentration—concen-

tration of the HGB in the RBC mass

RDW: Red cell distribution width—the coefficient of variation of

the RBC size distribution

PLT: Platelet— thrombocyte, which aids in coagulation

(blood clotting)

MPV: Mean platelet volume— average volume of a PLT

32 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 BASIC
HEMATOLOGY
Histograms: As shown in Figure 7, histograms are used to
graphically show the following:

• average size of cells within a specific cell population

• distribution of the size of cells around the mean
• presence of significant subpopulations

FIGURE 7
NORMAL WBC HISTOGRAM
Histograms for WBCs, RBCs,
and PLTs: the measured values
(size in these cases) is shown on
the X axis and the concentration
of cells is shown on the Y axis.

WBC

50 100 150 200 250 300

NORMAL RBC HISTOGRAM

RBC

50 100 150 200 250

NORMAL PLT HISTOGRAM

PLT

2 5 10 15 20 25 30

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 33

 BASIC
HEMATOLOGY
RBC indices provide clues
to underlying pathology.
The RBC indices are MCHC,
MCV, MCH, and RDW.
The normal reference
values for the red blood
cell indices are shown in
Table 2, in Section III-A.
MCHC is the average hemo-
globin concentration in RBCs.
MCV is the average volume
of RBCs.
MCH is the weight of
hemoglobin per RBC.
34 • HEMATOLOGY LABORATORY FUNDAMENTALS
Histograms provide additional information about specimen results.
When specimens have flagged results (abnormal size distribution),
reviewing the histogram gives the technologist another valuable
interpretative tool.
C. Red Blood Cell Indices
Measures that are derived from automated analyzers or calculated
from other automated analyzer values provide objective information
about a patient’s RBCs. These measures, or indices, may be used
alone or with a technologist’s examination of red cell morphology on
a blood smear to find clues to the underlying pathology.
1. What Are Indices and Why Are They Important? The red
blood cell indices consist of the mean cell hemoglobin concentration
(MCHC), mean cell volume (MCV), mean cell hemoglobin (MCH),
and the RBC distribution width (RDW). The indices are used to give
general insight into the differential diagnosis of anemia. [Glassman,
1997, 74]
a. MCHC. The average concentration of hemoglobin in the
RBCs is called the mean cell hemoglobin concentration and is cal-
culated from the hemoglobin and hematocrit. [Kube, 1998, 947]
MCHC = (hemoglobin x 100)/hematocrit
The results are expressed in g/dL.
b. MCV. The MCV is the average volume of RBCs and may
be directly measured on an instrument or calculated from the
hematocrit or packed cell volume: [Kube, 1998, 947]
MCV = (hematocrit x 10)/RBC count
c. MCH. The hemoglobin content of the cell is called the
MCH (mean cell hemoglobin) and is the weight of hemoglobin
in the average cell. It is calculated from the hemoglobin and
RBC counts. [Kube, 1998, 947]
PN 69968-101
 BASIC
HEMATOLOGY
MCH = (hemoglobin x 10 )/RBC count

d. RDW. Another measurement that has become available

on automated hematology analyzers is the red cell distribution
width. The RDW is an index of the variation in cell volume
within the red cell population. Mathematically, it is the RDW is the CV of RBC size
distribution.
coefficient of variation: [Cornell, 1997]

RDW = (Standard deviation of red cell volume ÷

mean cell volume) x 100

This measurement is derived from a histogram of size distribu-

tion of the RBCs. Histograms graphically show the average size
of cells within a specific cell population, the distribution of the
size of cells around the mean, and the presence of significant
subpopulations.

D. Common Disease States

Analysis of blood cell numbers and morphologies helps physicians
diagnose, treat, or monitor diseases.

1. Disorders of Red Blood Cells. Common disorders of RBCs can

be broadly categorized into two groups: anemia and polycythemia.
Anemia indicates a deficiency of RBCs, while polycythemia is the Anemia is a deficiency of
RBCs, while polycythemia
opposite of anemia; the term literally means “many cells in the is an overabundance.
blood.” Anemia can be caused by insufficient or abnormal hemoglobin
production. A common problem is an inadequate supply of iron for
hemoglobin formation. Terms used to describe changes in RBCs are:

• Chromic—change in color generally associated with

hemoglobin content. Commonly associated with the
prefixes “normo” for normal color and “hypo” for less than
normal color.

• Macrocytic—larger than normal RBCs

• Microcytic—smaller than normal RBCs

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 35

 BASIC
HEMATOLOGY
Slightly cooled RBCs clump
when agglutinins are present.
Common WBC disorders
involve unregulated or
cancerous WBC growth
and WBC deficiencies or
overproduction.
Platelet disorders can be a
side effect of another disorder.
Flagged samples warrant
examination of the
blood smear.
36 • HEMATOLOGY LABORATORY FUNDAMENTALS
Cold agglutination is a disorder in which RBCs clump together in
response to slight cooling (below 86° F). The clumping is caused by
a group of antibodies called agglutinins.
2. Disorders of White Blood Cells. Common disorders of WBCs
generally affect the development or function of WBCs. They include:
• Lymphomas— cancers involving the lymphatic system,
including Hodgkin’s and non-Hodgkin’s lymphoma
• Leukemia—cancer of the blood-forming tissues (marrow);
types of leukemia are identified by the dominant cells
involved and can be associated with any of the white
blood cells
• Leukopenia, neutropenia, granulocytopenia—depression in
the amount of produced cells; increases susceptibility to
serious bacterial or fungal infection
• Leukocytosis—increase in the total WBC count for any reason
• Lymphocytosis—increase in the number of lymphocytes in the
blood; may occur in infectious mononucleosis
3. Disorders of Platelets. Common disorders of platelets can
broadly be categorized into two groups: thrombocytopenia and
thrombocytosis. Thrombocytopenia is a reduced platelet count, and
thrombocytosis is an elevated platelet count. Platelet disorders gener-
ally involve the body’s ability to stop or contain bleeding and can be
a side effect of another disorder, such as cancer.
E. Hematology Evaluation Process
When automated hematology analyzers are used, laboratories develop
a system for when to analyze the blood microscopically. Certain
values are “flags” that trigger the instrument to alert the technologist
that the sample may have a significant abnormality. When a
sample is flagged, the routine technologist analyzes a blood smear.
PN 69968-101
 BASIC
HEMATOLOGY
If uncommon red or white blood cell abnormalities are discovered,
the technologist refers the sample to the senior technologist, who has
more experience and training. If noteworthy features are found,
e.g., those that may lead to a definitive diagnosis, then the senior
technologist alerts the physician who directs the laboratory to review
the smear. An example of this analysis process is shown in Figure 8.

HIERARCHICAL HEMATOLOGY EVALUATION FIGURE 8

Automated to manual analysis:
EXAMINER DIFFERENTIATION the hierarchy of who should
examine flagged samples is
shown. (Reprinted with
Analyzer Flagged Normal permission from: Koepke JA.
Specimen flagging. In:
Zacharia M, ed. Tips on
Hematology. Montvale, NJ:
Medical Economics; 1996;11.)
? abnormal RBC •common RBC abnormality
Routine ? atypical mononuclear WBC •granulocyte left shift
technologist •atypical (variant) lymphocytes
•normoblasts

? blasts •myelocytes
? organisms •plasma cells
Senior •Döhle bodies
technologist •Targets
•Auer rods

Physician Diagnostic
Cells

Report Report Report Report

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 37

 BASIC
HEMATOLOGY
Summary
The hematology laboratory analyzes the cellular and noncellular
components of the blood to provide important diagnostic information
to health care providers. Blood is a suspension of cells in a protein-
salt solution. The major formed elements in blood cell types are
red blood cells (RBCs), white blood cells (WBCs), and platelets.

RBCs contain hemoglobin, an oxygen-carrying protein. WBCs are

the granulocytes (neutrophils, eosinophils, basophils), lymphocytes,
and monocytes. These cells function in the immune responses,
e.g., phagocytosis of microbes and production of antibodies against
infectious agents. Platelets prevent excess blood loss by forming clots.

Measurements that describe the state of red blood cells (RBCs) are
highly important in the differential diagnosis of anemia. These
measurements are called red blood cell indices and consist of the
mean cell volume (MCV), mean cell hemoglobin (MCH), mean cell
hemoglobin concentration (MCHC), and red blood cell distribution
width (RDW). Except for the RDW, their values are calculated from
hemoglobin, hematocrit, and red blood cell count measurements.
The RDW is determined from the RBC histogram that plots cell sizes
for a sample of cells against the frequency of each size’s occurrence.
The indices give information about cell size and chromicity, which
are used to narrow the range of possible pathologies.

The indices are generated by automated hematology analyzers, which

also produce information about white blood cells, platelets, and other
blood component values. Therefore, to have reliable information
from the autoanalyzers, laboratories need a system for when to verify
the instruments’ results by analysis of blood smears. Flagged samples
that raise any questions should be analyzed by more experienced
laboratory workers, with the most difficult or noteworthy samples
reviewed by the laboratory director.

38 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 BASIC
HEMATOLOGY
Review Questions (III)
DIRECTIONS. Circle the letter corresponding to the correct
response in each of the following items.

1. Red blood cells from a patient with anemia due to insufficient

hemoglobin production would likely appear

a. agglutinated.
b. coagulated.
c. hypochromic.
d. macrocytic.

2. Which of the following is the correct calculation for the mean

cell volume?

a. (hematocrit x 10)/RBC count

b. (hemoglobin x 10)/RBC count
c. (hemoglobin x 100)/hematocrit
d. (MCV x RBC count)/10

3. Neutropenia is a condition characterized by

a. a cancerous change in neutrophils.

b. an abnormally high number of granulocytes.
c. increased susceptibility to bacterial infections.
d. leukocytosis.

4. Who should first examine a blood smear corresponding to a

flagged sample by an automated hematology analyzer?

a. a laboratory director
b. a routine technologist
c. a senior technologist
d. the patient’s physician Check responses on page 41.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 39

 INTEGRATIVE
SUMMARY
Integrative Summary
erforming laboratory testing accurately, efficiently, promptly, and
P with expertise is a critical component in the care of the patient.
Panels of experts have developed guidelines for good laboratory
practices to ensure that accurate test results are provided to the
physician in a timely manner. The Clinical Laboratory Improve-
ment Amendments of 1988 (CLIA ’88) are the minimum guidelines
established as law by Congress. Congress charged the Centers for
Medicare and Medicaid Services (CMS) with overseeing adherence
to the CLIA ’88 regulations. Certain other agencies also perform
laboratory inspections, such as the College of American Pathologists
(CAP), the Commission on Office Laboratory Accreditation (COLA),
and the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO).

Good laboratory practices require the laboratory to have a statistical

quality control (QC) program to evaluate laboratory testing. The
key components of the hematology laboratory’s QC program are
calibration and analysis of manufacturer-prepared controls. Quality
control is used to identify potential problems early before testing is
affected. All laboratories are inspected to ensure that a quality
control program exists and is effective.

A commonly performed hematology test is a complete blood cell

count (CBC) with differential and is used to assess many body
systems. The cellular components measured in a CBC and differential
are influenced by many stimuli in the body and in the environment.
Important information and diagnosis of diseases can be obtained by
quantifying the cellular components and reviewing their morphology.
Red blood cell indices are calculated or measured by automated
hematology analyzers. These indices are used in the differential
diagnosis of anemia. Abnormal results are verified by reviewing
stained smears.

40 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 ANSWERS TO
REVIEW QUESTIONS
Answers to Review Questions
I. 1. b
2. c
3. c
4. a

II. 1. c
2. b
3. d
4. a

III. 1. c
2. a
3. c
4. b

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 41

 BIBLIOGRAPHY

Bibliography
Centers for Disease Control. Division of Laboratory Systems.
Clinical Laboratory Improvement Amendments. Subpart K.
Available at: http://www.phppo.cdc.gov/clia/regs/subpart_k.asp/.
Accessed June 3, 2002.

Centers for Medicare & Medicaid Services (CMS). CLIA—

General program description. CMS website. Available at:
http://cms.hhs.gov/clia/progdesc.asp. Accessed May 31, 2002.

Clinical Laboratory Improvement Amendments (CLIA) Home Page.

Food and Drug Administration web site. Available at:
http://www.fda.gov/cdrh/clia/. Accessed May 31, 2002.

Cornell University College of Veterinary Medicine. Clinical

Pathology Modules. Red cell distribution width. Available at:
http://web.vet.cornell.edu/public/popmed/clinpath/CPmodules/
hemogram/rdw.htm. Accessed July 8, 2002.

Finnegan K. Hematopoiesis. In: Lehmann CA, ed. Saunders

Manual of Clinical Laboratory Science. Philadelphia, PA:
WB Saunders Company; 1998:833–870.

Glassman AB. Anemia: Diagnosis and Clinical Considerations. In:

Harmening DM, ed. Clinical Hematology and Fundamentals of
Hemostasis. 3rd ed. Philadelphia, PA: FA Davis Company;
1997:71–79.

Kube BT. Hematology procedures. In: Lehmann CA, ed. Saunders

Manual of Clinical Laboratory Science. Philadelphia, PA:
WB Saunders Company; 1998:943–958.

Nelson DA, Morris MW. Basic methodology. In: Henry JB, ed.
Clinical Diagnosis and Management by Laboratory Methods.
Philadelphia, PA: WB Saunders Company; 1984:578–625.

Pickard NA. Collection and handling of patient specimens. In:

Kaplan L, Pesce A, eds. Clinical Chemistry Theory, analysis,
and correlation. 2nd ed. St. Louis, MO: CV Mosby Company;
1984;41.

Westgard JO. QC The Chances of Rejection. Madison, WI:

Westgard QC Inc; 2000. Available at: http://www.westgard.
com/lesson15.htm. Accessed June 3, 2002.
42 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101
 SELF-ASSESSMENT
POST-TEST
Self-assessment Post-test
DIRECTIONS. Circle the letter corresponding to the correct
response in each of the following items.

1. The CLIA ’88 laboratory testing guidelines regulate how the

test is performed and how timely the reporting is, but do not
assess the qualifications of the laboratory personnel.

a. true

b. false, the regulations assess whether the personnel are

qualified

c. false, the timeliness of the reporting is not part of the

guidelines

2. Which of the following best describes the CLIA ’88

regulations?

a. a voluntary set of laboratory guidelines agreed upon by

pathologists

b. guidelines that apply only to large centralized laboratories

c. laboratory guidelines that by law must be adhered to

d. standards that define the required maximum quality

control

3. Laboratory inspectors will ask for documentation that

laboratory reagents are

a. correctly labeled for identification.

b. not used past their expiration date.
c. stored properly.
d. all of the above.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 43

 SELF-ASSESSMENT
POST-TEST
4. During a scheduled laboratory inspection, which of the
following documentation will be reviewed?

a. maintenance logs
b. patient testing logs
c. quality control records
d. all of the above

5. A laboratory that fails the inspection due to severe noncompli-

ance may have to stop testing until compliance is achieved.

a. true

b. false, a period of nonsuspended testing is always the

first action

c. false, no laboratory fails, corrections are made during the

inspection

6. Statistical measures that are useful in quality control include

a. CO.
b. CV.
c. PT.
d. both CV and SD.

7. Precision is the same as

a. accuracy.
b. reproducibility.
c. validity.
d. variability.

8. By convention, testing results that fall within ____ standard

deviation(s) are considered valid.

a. 1
b. 2
c. 3
d. all of the above

44 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 SELF-ASSESSMENT
POST-TEST
9. Which of the following are the two primary components of
hematology laboratory quality control programs?

a. calibration of the analyzer and running daily quality

control materials

b. high- and low-value control materials

c. patient identification and test reporting

d. red and white blood cell counts

10. Which of the following correctly describes commercial

hematology controls?

a. as physically and chemically similar to patient samples

as possible

b. fresh blood samples that must be used on the day

of arrival

c. marked with an expiration date based on assumed day

of opening

d. all of the above

11. Levey-Jennings™ graphs show where the quality control data

are in relation to the mean and standard deviations over time.

a. true

b. false, they specifically show data generated by systematic

errors

c. false, QC data are plotted relative to other certified labora-

tories’ quality control data

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 45

 SELF-ASSESSMENT
POST-TEST
12. The term granulocytes applies to all of the following, except

a. basophils.
b. eosinophils.
c. lymphocytes.
d. neutrophils.

13. In hematology, a “differential” involves which of the

following?

a. counting the different types of white blood cells

b. assessing all of the red blood cell indices
c. measuring hemoglobin and hematocrit
d. counting red and white blood cells and platelets

14. Which of the following statements correctly describes

platelets?

a. They carry oxygen to the tissues.

b. They clump rapidly in non-anticoagulated blood.
c. They form platelet plugs to keep blood in the fluid state.
d. They produce antibodies as part of an immune response.

15. Which of the following is used in the equation for calculating

the mean cell hemoglobin?

a. hematocrit and CBC count

b. hematocrit and RBC count
c. hemoglobin and hematocrit
d. hemoglobin and RBC count

16. One of the most common types of anemia is due to

a. hemoglobin overproduction.
b. iron deficiency.
c. lack of oxygen at high altitudes.
d. WBC underproduction.

46 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 SELF-ASSESSMENT
POST-TEST
17. An increased number of WBCs is called

a. leukocytosis.
b. neutropenia.
c. polycythemia.
d. thrombocytosis.

18. Which of the following is likely to cause an abundant increase

in circulating lymphocytes?

a. allergic or hypersensitivity reactions

b. collagen vascular diseases
c. Hodgkin’s disease
d. infectious mononucleosis Check responses on page 48.

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 47

 ANSWERS TO
POST-TEST
Answers to Self-Assessment
Post-test
1. b
(page 8, paragraph 1)
2. c
(page 8, paragraph 2)
3. d
(page 10, paragraph 4, bullet 1; page 11, bullets 1 and 3)
4. d
(page 12, paragraph 1)
5. a
(page 12, paragraph 2)
6. d
(page 16, paragraph 3; page 17, paragraph 2; page 18,
paragraph 1)
7. b (page 17, paragraph 1)
8. b (page 17, paragraph 2)
9. a (page 19, paragraph 1)
10. a (page 19, paragraph 3)
11. a (page 20, paragraph 3 and Figure 4 legend)
12. c (page 28, paragraph 3)
13. a (page 30, paragraph 1, bullet 3)
14. b (page 30, paragraph 2; page 32, term 12)
15. d (page 34, paragraph 7)
16. b (page 35, paragraph 5)
17. a (page 36, paragraph 2, bullet 4)
18. d (page 36, paragraph 2, bullet 5)

48 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101

 NOTES

PN 69968-101 HEMATOLOGY LABORATORY FUNDAMENTALS • 49

 NOTES

50 • HEMATOLOGY LABORATORY FUNDAMENTALS PN 69968-101