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Licensed Unlicensed Requires Authentication Published by De Gruyter December 1, 2021

Policies and practices in the field of laboratory hematology in Croatia – a current overview and call for improvement

  • Vanja Radišić Biljak , Ivana Lapić ORCID logo EMAIL logo , Valentina Vidranski , Ivona Herceg , Franciska Tomić , Brankica Šimac , Martina Horvat , Helena Čičak , Dora Vuljanić , Adrijana Dorotić and Ana Nikler



In 2019 The Croatian Working Group for Laboratory Hematology, on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine, wanted to explore the background in field of laboratory hematology routine practice among Croatian laboratories in order to develop future strategies for producing national recommendations, if needed.


During April and May 2019, a comprehensive survey covering all main parts of the total testing process within the field of laboratory hematology among Croatian medical laboratories was conducted. The survey comprised 49 inquiries. Data was collected using Survey Monkey (Palo Alto, CA, USA). All collected data was anonymized.


The response rate was 72%. There is still a substantial number of laboratories that have only three-part differential hematology analyzers (9%). Furthermore, a very high number of laboratories did not perform analyzer verification prior to implementation into routine work (31%). Out of those who have verified their analyzers, a diversity of guidelines and recommendations were used. Nearly 10% of the laboratories do not have a defined policy regarding specimen rejection. The majority of the participants perform internal quality control daily (83%), however, only 51% of respondents evaluate the agreement between different hematology analyzers on daily basis. Although more than 90% of Croatian laboratories have a defined policy regarding specimen rejection, only 61% of respondents continuously monitor quality indicators in routine practice.


The survey revealed substantial differences in all aspects of laboratory hematology practices among Croatian medical laboratories, indicating the need for universal recommendations at the national level.

Corresponding author: Ivana Lapić, Working Group for Laboratory Hematology of the Croatian Society of Medical Biochemistry and Laboratory Medicine, Zagreb, Croatia; and Department of Laboratory Diagnostics, University Hospital Center Zagreb, Kišpatićeva 12, 10000 Zagreb, Croatia, Phone: +385981767367, E-mail:
Vanja Radišić Biljak and Ivana Lapić contributed equally to this work.
  1. Research funding: None declared.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Participants were notified of research and future data publishing and by completing the survey, implicitly granted their informed consent.

  5. Ethical approval: The local Institutional Review Board deemed the study exempt from review.


1. Horton, S, Fleming, KA, Kuti, M, Looi, LM, Pai, SA, Sayed, S, et al.. The top 25 laboratory tests by volume and revenue in five different countries. Am J Clin Pathol 2019;151:446–51. in Google Scholar PubMed

2. Buoro, S, Lippi, G. Harmonization of laboratory hematology: a long and winding journey. Clin Chem Lab Med 2018;56:1575–8. in Google Scholar PubMed

3. De la Salle, B. Pre- and postanalytical errors in haematology. Int J Lab Hematol 2019;41:170–6. in Google Scholar PubMed

4. Hoffmann, JJ. Laboratory hematology in the history of clinical chemistry and laboratory medicine. Clin Chem Lab Med 2013;51:119–27. in Google Scholar PubMed

5. Plebani, M. Harmonization in laboratory medicine: more than clinical chemistry? Clin Chem Lab Med 2018;56:1579–86. in Google Scholar PubMed

6. Comar, SR, Malvezzi, M, Pasquini, R. Are the review criteria for automated complete blood counts of the International Society of Laboratory Hematology suitable for all hematology laboratories? Rev Bras Hematol Hemoter 2014;36:219–25. in Google Scholar PubMed PubMed Central

7. Comar, SR, Malvezzi, M, Pasquini, R. To follow or not to follow the recommendations regarding microscopic analysis of the Clinical and Laboratory Standards Institute H20-A2 to validate the criteria for blood smear review? Rev Bras Hematol Hemoter 2015;37:69–70. in Google Scholar PubMed PubMed Central

8. Barnes, PW, Mcfadden, SL, Machin, SJ, Simson, E. The international consensus group for hematology review: suggested criteria for action following automated CBC and WBC differential analysis. Lab Hematol 2005;11:83–90. in Google Scholar PubMed

9. Buttarello, M, Plebani, M. Automated blood cell counts: state of the art. Am J Clin Pathol 2008;130:104–16. in Google Scholar

10. Leung, E, Johnston, A, Olsen, B, Chang, H, Martin, T, Wizniak, M, et al.. Laboratory practices for manual blood film review: results of an IQMH patterns of practice survey. Int J Lab Hematol 2021;43:184–90. in Google Scholar PubMed

11. Palmer, L, Briggs, C, McFadden, S, Zini, G, Burthem, J, Rozenberg, G, et al.. ICSH recommendations for the standardization of nomenclature and grading of peripheral blood cell morphological features. Int J Lab Hematol 2015;37:287–303. in Google Scholar PubMed

12. Kozanoğlu, İ, Patıroğlu, T, Dalva, K, Yanıkkaya Demirel, G, Soysal, T, Demir, M. Results of the hematology laboratory survey: what has changed in eight years? Turk J Haematol 2018;3:215–6. in Google Scholar PubMed PubMed Central

13. Bunyaratvej, A, Tatsumi, N, Funahara, Y. Hematology laboratory standardization: a plan for harmonization in Asia. Southeast Asian J Trop Med Publ Health 1999;30:182–4.Search in Google Scholar

14. Charuruks, N, Vanavanitkun, Y, Seublinvong, T, Werawatanakumpa, S, Eiam-Oung, S, Jindamaporn, A, et al.. Situation of laboratory service and instruments in Thailand: a descriptive study from questionnaires. J Med Assoc Thai 2002;85:253–61.Search in Google Scholar

15. Hrvatska komora medicinskih biokemičara. Preporuke povjerenstva za stručna pitanja. Pohrana i priprava uzoraka (minimalni uvjeti). PPSP-ZK 2.0 – 2012. (in Croatian). [Accessed 5 Sep 2021].Search in Google Scholar

16. Piva, E, Brugnara, C, Spolaore, F, Plebani, M. Clinical utility of reticulocyte parameters. Clin Lab Med 2015;35:133–63. in Google Scholar PubMed

17. Lapić, I, Padoan, A, Bozzato, D, Plebani, M. Erythrocyte sedimentation rate and C-reactive protein in acute inflammation. Am J Clin Pathol 2020;153:14–29. in Google Scholar PubMed

18. Kratz, A, Plebani, M, Peng, M, Lee, YK, McCafferty, R, Machin, SJ, et al.. ICSH recommendations for modified and alternate methods measuring the erythrocyte sedimentation rate. Int J Lab Hematol 2017;39:448–57. in Google Scholar PubMed

19. CLSI GP 39-A6 Guideline. Tubes and additives for venous and capillary blood specimen collection, 6th ed. Wayne, PA, USA: Approved Standard. CLSI Documentation; 2010.Search in Google Scholar

20. International Council for Standardization in Haematology. Recommendations of international council for standardization in haematology for ethylenediaminetetraacetic acid anticoagulation of blood cell counting and sizing. Am J Clin Pathol 1993;100:371–2. in Google Scholar PubMed

21. Clinical and Laboratory Standards Institute (CLSI). Validation and verification of tubes for venous and capillary blood specimen collection; approved guideline. Wayne, PA: Clinical and Laboratory Standards Institute; 2010. CLSI document GP34-A.Search in Google Scholar

22. Lippi, G, Cornes, MP, Grankvist, K, Nybo, M. Simundic AM; Working Group for Preanalytical Phase (WG-PRE); European Federation of Clinical Chemistry and Laboratory Medicine (EFLM). EFLM WG-preanalytical phase opinion paper: local validation of blood collection tubes in clinical laboratories. Clin Chem Lab Med 2016;54:755–60. in Google Scholar PubMed

23. Vis, JY, Huisman, A. Verification and quality control of routine hematology analyzers. Int J Lab Hematol 2016;38:100–9. in Google Scholar PubMed

24. Sciacovelli, L, Lippi, G, Sumarac, Z, Del Pino Castro, IG, Ivanov, A, De Guire, V, et al.. Working Group “Laboratory Errors and Patient Safety” of International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). Pre-analytical quality indicators in laboratory medicine: performance of laboratories participating in the IFCC Working Group “Laboratory Errors and Patient Safety” project. Clin Chim Acta 2019;497:35–40. in Google Scholar PubMed

25. Zandecki, M, Genevieve, F, Gerard, J, Godon, A. Spurious counts and spurious results on haematology analysers: a review. Part II: white blood cells, red blood cells, haemoglobin, red cell indices and reticulocytes. Int J Lab Hematol 2007;29:21–41. in Google Scholar PubMed

26. Banfi, G, Germagnoli, L. Preanalytical phase in hematology. J Med Biochem 2008;27:348–53. in Google Scholar

27. Zeng, SG, Zeng, TT, Jiang, H, Wang, LL, Tang, SQ, Sun, YM, et al.. A simple, fast correction method of triglyceride interference in blood hemoglobin automated measurement. J Clin Lab Anal 2013;27:341–5. in Google Scholar PubMed PubMed Central

28. Sun, SP, Garcia, J, Hayden, JA. Repeating critical hematology and coagulation values wastes resources, lengthens turnaround time, and delays clinical action. Am J Clin Pathol 2018;149:247–52. in Google Scholar PubMed

29. Schoorl, M, Schoorl, M, Oomes, J, van Pelt, J. New fluorescent method (PLT-F) on Sysmex XN2000 hematology analyzer achieved higher accuracy in low platelet counting. Am J Clin Pathol 2013;140:495–9. in Google Scholar

30. Lippi, G, Plebani, M. EDTA-dependent pseudothrombocytopenia:further insights and recommendations for prevention of a clinically threatening artifact. Clin Chem Lab Med 2012;50:1281–5. in Google Scholar PubMed

31. Zandecki, M, Genevieve, F, Gerard, J, Godon, A. Spurious counts and spurious results on haematology analysers: a review. Part I: platelets. Int J Lab Hematol 2007;29:4–20. in Google Scholar PubMed

32. Wu, DW, Li, YM, Wang, F. How long can we store blood samples: a systematic review and meta-analysis. EBioMedicine 2017;24:277–85. in Google Scholar PubMed PubMed Central

33. Vidali, M, Carobene, A, Apassiti Esposito, S, Napolitano, G, Caracciolo, A, Seghezzi, M, et al.. Standardization and harmonization in hematology: instrument alignment, quality control materials, and commutability issue. Int J Lab Hematol 2021;43:364–71. in Google Scholar PubMed

34. Sioufi, J, Badrick, T, Sinclair, L, Marsden, K. Full blood count – internal QC protocol: a review by the Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP) Pty Ltd – Haematology. Int J Lab Hematol 2017;39:84–94. in Google Scholar PubMed

35. Plebani, M, Sciacovelli, L, Aita, A. Quality indicators for the total testing process. Clin Lab Med 2017;37:187–205. in Google Scholar PubMed

36. Rimac, V, Jokic, A, Podolar, S, Vlasic Tanaskovic, J, Honovic, L, Lenicek Krleza, J. General position of Croatian medical biochemistry laboratories on autovalidation: survey of the working group for post-analytics of the Croatian Society of Medical Biochemistry and Laboratory Medicine. Biochem Med 2020;30:020702. in Google Scholar PubMed PubMed Central

37. Buoro, S, Apassiti Esposito, S, Balboni, F, Da Rin, G, Di Fabio, A, Fanelli, A, et al.. Stato dell’arte della diagnostica ematologica nei servizi di Medicina di Laboratorio in Italia. Biochim Clin 2015;39:25–40.Search in Google Scholar

38. Buoro, S, Da Rin, G, Fanelli, A, Lippi, G. Harmonization of interpretative comments in laboratory hematology reporting: the recommendations of the Working Group on Diagnostic Hematology of the Italian Society of Clinical Chemistry and Clinical Molecular Biology (WGDH-SIBioC). Clin Chem Lab Med 2018;57:66–77. in Google Scholar PubMed

39. Hrvatska komora medicinskih biokemičara. Preporuke povjerenstva za stručna pitanja. Kritične vrijednosti laboratorijskih nalaza i izvještavanje o kritičnim vrijednostima. PPSP-ZK 8.2 – 2016. (in Croatian). [Accessed 5 Sep 2021].Search in Google Scholar

40. Hrvatska komora medicinskih biokemičara. Harmonizacija laboratorijskih nalaza u području opće, specijalne i visokodiferentne medicinske biokemije. (in Croatian). Zagreb: Medicinska naklada; 2007.Search in Google Scholar

Received: 2021-09-20
Accepted: 2021-11-18
Published Online: 2021-12-01
Published in Print: 2022-01-27

© 2021 Walter de Gruyter GmbH, Berlin/Boston

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