Department of Pathology

VISION & MISSION

 The Department of Pathology & Laboratory Medicine of the International Islamic University Malaysia was established in 2015. It is responsible for academic training in basic medical sciences, clinical and allied health sciences for a broad spectrum of undergraduate and postgraduate students at IIUM. The department is providing medical laboratory services which form an integral part of its activities to IIUMMC. The department also fosters basic sciences, clinical and translational research through multidisciplinary collaborations with the clinical as well as other departments.

 VISION

To be recognized for excellence in pathology education, diagnostic pathology services and research.

MISSION

The mission of the department is to strive to: 1. Provide outstanding undergraduate and postgraduate education in the fields of pathology. 2. Provide highest quality of laboratory medicine services. 3. Lead and support scientific research. 4. Integrate Islamic values in all activities in order to promote personal and professional development of our staff.

 CORE VALUES

 We uphold steadfastly the core values that form the pinnacle of our work ethics at Department of Pathology and Laboratory Medicine which are Quality, Professionalism, Team work, Leadership and Accountability

GENERAL OPERATING POLICIES FOR CLINICAL LABORATORY SERVICES

• INTRODUCTION
• QUALITY ACTIVITIES
• We also take into account the following (as listed below) for quality improvement purposes:
• SERVICES
• PRE-ANALYTICAL REQUIREMENT:
• MEDICO LEGAL CASES
• REJECTION CRITERIA
• OUTSOURCED TEST
• TESTS REQUIRING PRIOR APPOINTMENT.
  • For tests requiring prior appointment, the doctor in-charge needs to contact the unit/laboratory to make arrangement.
  • Tests that need prior appointment include:

The Pathology and Laboratory Medicine Department, International Islamic University Malaysia (IIUM) Medical Centre provides diagnostic laboratory service beginning August 2016.

There are eight (8) unit (laboratories) within the department: Integrated laboratory; Chemical Pathology; Haematology; Microbiology; Transfusion Services Laboratory; Histopathology; Cytology; Medical Genetic laboratory and Biobank. The department also coordinates the management of Specimen Collection Centre and Forensic Unit with other departments in IIUMMC. We are committed to provide the highest quality of laboratory medicine diagnostic services in line with MS ISO 15189 accreditation requirement. The department aims for MS ISO 15189 accreditation in five years from its establishment. In the early phase of its service provision, some laboratory tests will be outsourced.

It is our policy to provide accurate, reliable and timely results to our customers through continuous improvement of the quality system. 3.1 Quality improvement activities: Pathology Department participates in many quality improvement activities such as:

• Internal Quality Control Monitoring
• ii. External Quality Assurance Programme for almost all tests offered.
• iii. Monitoring of turn-around time (TAT) for urgent and routine tests.

• Customer complaints
• Customer satisfaction survey
• Incident reporting iv. Internal Audit Exercise and Management Review Meeting
• Corrective and Preventative Actions

The department provides diagnostic and consultancy services in the following disciplines:

• Chemical pathology
• Haematology
• Microbiology
• Immunology
• Blood transfusion
• Histopathology
• Cytopathology
• Medical genetics Handbook of Diagnostic Laboratory Services, 1st Edition 2017

a. For all requests, patients’ particulars must be completed as stipulated.

b. To eliminate the risk of cross contamination and to reduce the risk of clotted specimens, listed below are the correct order of containers for placing drawn blood specimen for multiple testing:

• Blood culture tube
• Sodium citrate tube
• Plain gel tube
• Heparin gel tube
• EDTA tube
• Fluoride tube

c. For tests by appointment, the request should be made by the doctor incharge.

 d. All requests should be accompanied by relevant clinical information.

 e. For urgent tests, the requests must be justified.

 f. Priority of testing will be given to requests of laboratory tests from critical units/departments. g. Requests of laboratory test made maybe modified upon consultation with the relevant parties. h. Repeated request of similar test for a patient maybe cancelled upon consultation.

(SPECIMEN TRANSPORT / COLLECTION)

a. Specimens should be sealed and sent directly to the respective laboratories.

b. Specimens should be sent to the laboratory by designated personnel.

 c. Chain of custody should be maintained at all times and record book should accompany the samples.

d. Infectious waste shall be discarded into clearly identifiable containers or plastic bags (biohazard plastics) that are leak-proof and punctureresistant and the containers shall be marked with the universal symbol for biological hazards.

e. Non-infectious waste shall be handled in accordance with good safety practice and written law relating to handling of such waste. Handbook of Diagnostic Laboratory Services, 1st Edition 2017.

Samples that do not fulfil laboratory requirement will be rejected.

Criteria for rejection include:

• Leaking specimen/specimen not seal
• Wrong tube/container
• Specimen not label
• Specimen insufficient / unsatisfactory
• Specimen clotted or haemolysed
• Incorrect blood to anticoagulant ratio
• Patient identification not properly written/incomplete
• No doctor’s name or official stamp
• No clinical summary
• Wrong transportation procedure
• Request form is not accompanied with specimen
• Specimen sent is not suitable for the test requested xiii. Information of patient does not match the label on the specimen container

• Some laboratory tests (normally specialised tests) will be outsourced to the external laboratory.
• Specimens for outsourced tests will be collected from the Integrated Laboratory Counter by the personnel of the external laboratory two times in a day, i.e. 10.00 AM and 3.00 PM respectively.
• Pathology department has the right to reject any request if the testing requirements are not fulfilled.
• The results/reports of laboratory tests issued by the external laboratory will be managed by the Department of Pathology & Laboratory Medicine.
• Any critical results will be conveyed to the respective staff via phone and e-mail as soon as the results are available.
• The work-flow for specimen collection and post-analytical results are shown in Figure 2 and 3 respectively, as in the appendix. Handbook of Diagnostic Laboratory Services, 1st Edition 2017

• Frozen section (Histopathology lab)
• Fine Needle Aspiration cytology (Cytology lab)
• Bone Marrow Aspiration and Trephine Biopsy (Haematology lab)
• iv. Any other tests specified in this handbook as by appointment
  •  For critical specimens (i.e. plasma ammonia & CSF), inform the relevant laboratory before sending the specimen.

10.  RESULTS

Dedicated staff:

Consultant of Pathologist: (Kulliyyah of Medicine)

Scientific officer:

Medical Laboratory Technologist (MLT):