Hematology SOP (Free PDF Download)

Hematology Standard Operating Procedure (Free PDF Download)

A complete, ready-to-customize standard operating procedure template for clinical laboratory hematology testing — covering sample collection and labeling, analyzer operation and quality control, result validation, critical (panic) value reporting, biosafety and waste handling. Adapt the bracketed fields to [Laboratory Name] and adopt it as your hematology bench procedure.

1. Purpose

To standardize hematology testing at [Laboratory Name] so that every sample is collected, analyzed, validated and reported accurately, with quality control performed on schedule and critical results communicated to clinicians without delay.

2. Scope

Applies to all phlebotomists, medical laboratory technologists, the hematology section supervisor and the pathologist at [Laboratory Name], [Address]. Covers complete blood counts, differentials, coagulation tests and any other hematology assays performed in-house.

3. Background and Standards

• Hematology testing supports the diagnosis and monitoring of anemia, infection, coagulation disorders and hematologic malignancies; unreliable results can directly affect patient care, so documented quality control is essential.
• Run manufacturer and laboratory-defined quality controls at the frequency your accreditation requires — confirm QC frequency and acceptance criteria with your accreditation body and the analyzer manufacturer.
• Reference ranges and critical (panic) value limits must be approved by your medical director or pathologist — confirm the current critical value list with them before use; never invent limits.
• Biosafety practices for blood handling follow universal precautions; confirm your jurisdiction's occupational biosafety requirements with the relevant authority.

4. Responsibilities

5. Procedure

5.1 Sample collection and labeling

1. Verify patient identity with two identifiers before collection; label tubes at the bedside with patient name, ID number, date and time of collection, and collector initials — never label before or after leaving the patient.
2. Collect in the correct anticoagulant tube (EDTA for CBC and differential; citrate for coagulation) following the accepted order of draw.
3. Fill tubes to the indicated volume; underfilled citrate tubes are rejected for coagulation testing.
4. Transport samples to the laboratory promptly and analyze within the stability window the analyzer manufacturer specifies.

5.2 Analyzer operation and quality control

1. Perform start-up, calibration and maintenance exactly per the analyzer manufacturer's instructions; log all maintenance in the [Analyzer Name] maintenance records.
2. Run QC material at each level at the start of every shift (or at the frequency your accreditation requires) and document results before reporting patient samples.
3. Apply your laboratory's QC rules (for example Westgard rules); if QC fails, stop reporting, troubleshoot, repeat QC, and document the corrective action.
4. Participate in external quality assessment (proficiency testing) as required and review the results with the section supervisor.

5.3 Result validation

1. Review every result for delta-check failures (a significant change from the patient's previous result), critical flags and instrument alarms before release.
2. Verify abnormal or first-time critical results by repeat analysis or smear review per your laboratory's review criteria.
3. Release validated results to the ordering clinician within the turnaround time defined in [Laboratory Name]'s service policy.

5.4 Critical (panic) values

1. On detecting a critical value, notify the ordering clinician or covering provider immediately by direct phone call — never by message or report comment alone.
2. Read back the result to confirm receipt; document the value, time of notification, person notified and your name in the critical value log.
3. Escalate to the pathologist if the clinician cannot be reached within [Escalation Timeframe].

5.5 Biosafety and waste

1. Treat all blood samples as potentially infectious; wear gloves, lab coat and eye protection, and use biological safety practices for aerosol-generating steps.
2. Decontaminate benches and equipment after spills with an approved disinfectant; report exposures per your occupational health procedure.
3. Dispose of sharps in puncture-proof containers and blood-contaminated waste in biohazard bags for licensed disposal — confirm disposal requirements with your environmental authority.

6. Pro Tips

• Label at the bedside. Every mislabeled sample is a potential wrong-patient result; labeling at the patient's side eliminates the most common pre-analytical error.
• Never report through failed QC. One failed control invalidates the whole run — stop, fix, repeat, document.
• Respect the delta check. A hemoglobin that drops 4 g/dL overnight is either a bleed or a wrong tube; investigate before you release.
• Phone critical values, always. A critical platelet count sitting unread in an inbox helps no one; call, read back, log.
• Keep the maintenance log honest. Skipped maintenance voids the analyzer warranty and undermines your QC story during accreditation visits.

7. Frequently Asked Questions

Q1: Which tube is used for a complete blood count? A: An EDTA (lavender-top) tube, filled to the indicated volume and labeled at the bedside with two patient identifiers, collection date and time, and collector initials.

Q2: How often is quality control run on the hematology analyzer? A: QC material at each level is run at the start of every shift before patient samples are reported, or at the frequency your accreditation requires — confirm QC frequency with your accreditation body.

Q3: What are critical (panic) values? A: Results indicating potentially life-threatening conditions, such as critically low hemoglobin or platelet counts, that require immediate clinician notification; the exact limits must be approved by your medical director — never invent them.

Q4: What is a delta check? A: A comparison of the current result against the patient's previous result; a change beyond the laboratory's defined limit triggers review before release, catching sample mix-ups and genuine clinical changes alike.

Q5: How are critical values communicated? A: By direct phone call to the ordering clinician with read-back confirmation, documented in the critical value log with the value, time, person notified and notifier name — escalate to the pathologist if the clinician cannot be reached within [Escalation Timeframe].

Q6: How is hematology laboratory waste disposed of? A: Sharps go into puncture-proof containers and blood-contaminated waste into biohazard bags for licensed disposal — confirm disposal requirements with your environmental authority.