“Blood Wastage in a Tertiary Hospital Laboratory in Tacloban City”

___________________________________________________

A Research

Submitted to the faculty of

Remedios Trinidad Romualdez Medical Foundation

Calanipawan Road, Tacloban City

____________________________________________________

In Partial Fulfillment of the

Requirements for the degree

Bachelor in Medical Laboratory Science

Ralf P. Ladrera Angel Marie A.Manalo

Nicole B. Palileo Dolores Mae A. Arga
Hyacinth Kryss G. Cabus Jeanne Kathleen R. Becious
Kaleb Josh Q. Serrano

Nicole Palileo Dolores Mae Arga

 CHAPTER 1

INTRODUCTION

Background of the Study

Unnecessary tests, inefficient ordering practices, and collection of more blood than is

required for testing contribute to iatrogenic anemia in hospitalized patients. Blood is a valuable

resource and blood wastage in a low socio-economic country could impose a very serious impact

on healthcare.^ (Kurup et.al,2016).

Physicians order blood examinations to diagnose, confirm and monitor diseases. A

pediatric patient presenting with lethargy can get a series of blood tests including vitamin b12 ,

folate level & HbA1c to confirm megaloblastic anemia. Such tests are unnecessary to some

especially if there’s no appropriate questioning of the history of the patient. According to a survey,

of the 435 ER physicians asked about the tests they order for their patients, more than 85%

admitted that in general, they call for too many tests, even if they know the results won’t really

help them decide how to treat their patients (TIME, 2015) Imagine if hospitalized patients are

drawn with blood from time to time and knowing that these tests are unnecessary, this could

imposed something negative to the patients not only that it can cause iatrogenic anemia.

A relationship between the volume of blood drawn and iatrogenic anemia was first

described in 2005, when Thavendiranathan et al3 found that in adult patients on general medicine

floors, the volume of blood drawn strongly predicted decreased hemoglobin and hematocrit levels.

For every 100 mL of blood drawn, hemoglobin levels fell by an average of 0.7 g/dL, and 13.9%

of the patients in the study had iron studies and fecal occult blood tests performed to investigate

anemia. Kurniali et al reported that during an average admission, 65% of patients experienced a
drop in hemoglobin of 1.0 g/dL or more, and 49% developed anemia. Iatrogenic anemia from

blood draws is common, serious, and unnecessary. Salisbury et al, in 2011, studied 17,676 patients

with acute myocardial infarction across 57 centers and found a correlation between the volume of

blood taken and the development of anemia. On average, for every 50 mL of blood drawn, the risk

of moderate to severe iatrogenic anemia increased by 18%. They also found significant variation

in blood loss from testing in patients who developed moderate or severe anemia. The authors

believed this indicated that moderate to severe anemia was more frequent at centers with higher

than average diagnostic blood loss.5This relationship has also been described in patients in

intensive care, where it contributes to anemia of chronic disease. While anemia of critical illness

is multifactorial, phlebotomy contributes to anemia in both short- and long-term stays in the

intensive care unit.^ (Lutz et. al, 2016)

In the laboratory setting, not all blood that is being drawn from the patients are

used. Only small amount of blood is needed for examinations especially that machines nowadays

have grown more sophisticated. These excess blood are not used anymore leading to wastage.

Research Objectives:

The reasearch aims to document occurrence of “Blood wastage in a Tertiary Hospital

Laboratory in Tacloban City” This intends to answer the following;

1. To determine the volume of blood used and the volume extracted in the desired

laboratory procedures in a clinical laboratory.

2. To identify percent wastage of blood.

3. To describe how excess blood are disposed.

 4. To identify factors leading to wastage of blood product.

Theoretical and Conceptual Framework:

Record the incidences of sample

INPUT
wastage(blood)in hospitals and
*Volume Extracted laboratories in Tacloban City.
Questionnaire Identify the factors that leads to
*Volume Used sample wastage and the ways
Conducted Survey
sample are discarded.
* Factors that lead to blood
wastage

* Waste of disposing blood

Significance of the Study

The findings which this study will reveal, may benefit certain groups and the benefits they

may be able to gain are as follows:

Future researchers. The results of this study will serve as an initial data for further studies on the

impact of blood wastage on the patients.

Clinical laboratories. With the results of this study, it may help hospitals and/or laboratories on

improving their policies, guidelines and protocols specifically on the area of blood extraction.

Medical Technologists. This study may help in giving knowledge or information to the medical

technologists about factors leading to wastage of blood samples and give them ideas on an

estimated amount of blood to be extracted to prevent wastage.

Patients. The results of the study may help minimize or lessen the incidences of unnecessary

excess blood extraction which will benefit patients in a way that they may be able to prevent

diseases or disorders related to too much blood loss.

Scope and Limitation

This study aims to confirm incidences regarding blood wastage in a hospital laboratory in

Tacloban City.

Medical Laboratory Technicians/Phlebotomists will be asked through conducted survey to

determine the factors that lead to sample wastage and the different ways excess samples are

disposed of. Printed questionnaires would be the basis for this study so as to have uniformity. The
researchers only obtain information from subjects who were able, willing, and qualified to

complete the questionnaires and participate in the study.

This research study is limited only within the school year 2018-2019.

Definition of Terms:

Clinical Laboratory -a laboratory where tests are usually done on specimens in order to obtain

information about the health of a patient as pertaining to the diagnosis, treatment and prevention

of disease.

Tertiary Laboratory- sophisticated laboratory with fully automated machine

Tertiary Hospital – a major hospital that usually has a full complement of services including

pediatrics, obstetrics, general medicine, gynecology, various branches of surgery and psychiatry.

Blood Wastage – refers to any blood component or product which is discarded rather than use

for testing
 CHAPTER 2

REVIEW OF RELATED LITERATURE

This chapter presents readings on concepts and studies that serve as basis in the conduct of

the present study. Discussion focuses on resources that gave further insights into what have been

done and still need to be done relative to the present investigation.

Related Literature

Blood is an essential component of every mortal. It has vital functions which are needed

for a person to subsist. This sticky fluid transports oxygen from the lungs to the cells of the body,

where it is needed for metabolism, and provides the cells with nutrients, transports hormones and

removes waste. Blood maintains homeostatic balance, it makes sure that the right body temperature

is maintained. It also protects blood vessel when damaged, certain parts of the blood clot together

very quickly and make sure that a scrape, for instance, stops bleeding. With all these significant

functions of the blood, it is then important to monitor and maintain its good condition by doing

laboratory procedures. Laboratory tests/procedures are important to diagnose diseases. Doctors

often request laboratory test before concluding that a patient is suffering from a specific disease.

Effective use of basic laboratory tests at primary health care level significantly improves diagnosis

and patient treatment.

According to a study conducted by Carter et.al, Laboratory tests were ordered on 704

(62.1%) patients. Diagnosis and treatment were changed in 45% of tested patients who returned

with laboratory results (21% of all patients attending the clinics). 166 (23.5%) patients did not
return to the clinician for a final diagnosis and management decision after laboratory testing. Blood

slide examination for malaria parasites, wet preparations, urine microscopy and stool microscopy

resulted in most changes to diagnosis. There was no significant change in drug costs after

laboratory testing. The greatest changes in numbers of recorded diseases following laboratory

testing was for intestinal worms (53%) and malaria (21%). This study showed that laboratory test

has a significant function in the diagnosis of disease and patient treatment.

The most commonly used sample in the laboratory is blood specifically serum. Commonly

requested blood test includes full blood count, renal profile, liver profile, lipid profile, blood

glucose, antibodies test, urines test, infectious disease screening, cancer test, heart test-cardiac

test,.( Door 2 Door Doctor, 2015). Full blood count contains complete blood count,one of the most

commonly ordered blood tests. It is the calculation of the cellular (formed elements) of blood.

These calculations are generally determined by special machines that analyze the different

components of blood in less than a minute. Vol of blood needed: 0.5 ml in EDTA, Vol of blood

extracted: 3 or 5 cc syringe is used. Renal profile give us a snapshot of your kidneys health. This

profile will include Blood Urea Nitrogen and Creatinine which is a by-product of protein

metabolism and is eliminated through the kidneys. This shows us how well your kidneys are

functioning and alerts us if there is any kidney failure. Among the electrolytes that are tested are

Sodium which is One of the major salts in the body fluid, sodium is important in the body’s water

balance and the electrical activity of nerves and muscles; Potassium helps to control the nerves

and muscles; and Chloride which helps to maintain the body’s electrolyte balance. Volume

extracted 90.5 ml, needed .3 ml. Serum is the preferred specimen. Liver Function Tests are one of

the more extensive screening profiles due to the vast number of functions that the liver performs.

These tests include: Protein is a measure of the state of nutrition in the body. Albumin in one of
the major proteins in the blood and a reflection of the general state of nutrition. Globulin is a major

group of proteins in the blood comprising the infection fighting antibodies. Bilirubin, chemical

involved with liver functions and is involved in digestion of fat. High concentrations may result in

jaundice which is a yellowish discolouration of skin and whites of the eyes. There are three major

liver enzymes which are Alkaline Phosphatase is a body protein important in diagnosing proper

bone and liver functions and can be raised if there is a obstruction of the billiary system; Aspartate

Aminotransferase (AST or SGOT)an enzyme found in skeletal and heart muscle, liver and other

organs. Abnormalities may represent liver disease; and Alanine Aminotransferase (ALT or SGPT)

an enzyme found primarily in the liver. Abnormalities may represent liver disease. Volume

extracted, 2 ml, minimum volume used 0.5 ml. Serum is the preferred specimen. Cholesterol Test

– Lipid Profile Test is a group of simple blood tests that reveal important information about the

types, amount and distribution of the various types of fats (lipids) in the bloodstream. Includes

Total Cholesterol, HDL (good) Cholesterol, LDL (bad) Cholesterol, Risk Ratio (good to total),

and Triglycerides. Too much cholesterol in the blood is a major cause of heart disease and blood

vessel disease. The high-density lipoprotein (HDL) cholesterol, which is referred to as the “good”

cholesterol because of its ability to take cholesterol and remove it from the arteries. The low-

density lipoprotein (LDL) cholesterol, or the “bad” cholesterol, which builds up and clogs the

arteries. Volume extracted, 1 ml, minimum volume used o.5 ml. Serum is the preferred specimen.

Blood Glucose Test , also known as A1c, HbA1c, Glycohemoglobin, or Glycated hemoglobin,

indicates how well you have controlled your diabetes over the last few months. Even though you

may have some very high or very low blood glucose values, Hemoglobin A1C will give you a

picture of the average amount of glucose in your blood over that time period. While the

Hemoglobin A1C is the standard tool to determine blood sugar control for patients with diabetes,
it is not a substitute for daily, routine blood glucose testing. Volume extracted, 1 ml, minimum

volume used 0.5 ml. Serum is the preferred specimen. Antibodies Test – Rheumatoid Factor is an

antibody that is measurable in the blood. Rheumatoid factor is actually an antibody that can bind

to other antibodies. Antibodies are normal proteins in our blood that are important parts of our

immune system. Rheumatoid factor is an antibody that is not usually present in the normal

individual. Most commonly, rheumatoid factor is used as a blood test for the diagnosis of

rheumatoid arthritis. Volume extracted, 4 ml, minimum volume used 1 ml. Whole blood is the

preferred specimen. Urine test Type of Blood Test - cancer test A routine urinalysis can tell your

doctor a great deal. Diabetes, urinary tract infections and kidney problems are among the many

medical conditions that can be detected by routine urinalysis results. Very often, a routine

urinalysis is part of a general physical exam. A routine urinalysis does not detect drugs of abuse.

A special drugs-of-abuse screening test is used to detect the presence of those substances. Volume

extracted, 4 ml, minimum volume used 1 ml. Serum is the preferred specimen. Infectious Disease

Screening Type of Blood Test - infectious diseases can be transmitted in a number of ways. If

you’ve been exposed, you want to know quickly, as diagnosis and treatment can help prevent

further transmission. Symptoms can indicate a disease, but lab tests for infection are the only way

to confirm a diagnosis Among Diseases that are commonly tested are HIV, Hepatitis, Influenza

and H-Pylori. Volume extracted, 1ml, minimum volume used 0.5 ml. Serum is the preferred

specimen. Cancer Test – Tumor markers detect the presence of certain types of cancer in the body,

and to monitor the progress of cancer treatment. Some examples of common tumor markers

include: CA15-3 is a sensitive tumor marker for breast cancer. CA19-9 antigen has been shown to

be elevated in the blood of some patients with gastrointestinal tumors. CA-125 is a useful marker

for monitoring disease progression in ovarian cancers. PSA is a useful marker for monitoring
disease progression in prostate cancers. CEA (carcinoembryonic antigen) is useful in monitoring

patients with various types of malignancies, such as gastrointestinal, pancreatic, breast, and lung

cancers. Volume extracted, 0.8ml, minimum volume used 0.3ml. Serum is the preferred specimen.

Heart Test – Cardiac Markers,elevated homo cysteine levels have a much greater risk of heart

attack or stroke than those with average levels. This can lead to heart attack, strokes, and blood

vessel blockages in any part of the body.Highly Selective C-Reactive Protein levels seem to be

correlated with levels of heart disease risk as well. Volume extracted, 1 ml, minimum volume used

0.5 ml. Serum is the preferred specimen. (Labcorp.com. Too much blood extraction can cause

iatrogenic or hospital aquired anemia to the patient.

Hospital‐acquired anemia (HAA) is the occurrence of below normal hemoglobin (Hgb) in

an inpatient with normal Hgb on admission. While HAA is often multifactorial, phlebotomy losses,

especially in critically ill patients, is a major and potentially avoidable cause. As early as 1971,

Buckley‐Sharp showed that the hematocrit of hospitalized patients decreased proportionally to the

volume of blood collected for laboratory testing. Multiple studies report that HAA continues to be

a problem many decades later. For example, in a study including every adult admission at a large

academic center, 74% of patients developed HAA. When studying specific patient populations

such as those with renal impairment, in the intensive care unit (ICU), or hospitalized post‐trauma,

the incidence of HAA ranged from 20% to 70%. Salisbury et al. estimated that the risk of HAA

increased by 20% with each 50 mL of blood loss. In a recent editorial, Stefanini questioned the

need for the usual apparently excessive volume of blood requested for testing. It has also been

reported that laboratory testing and the corresponding blood volumes being collected are

increasing, without a corresponding increase in the quality of care or improvement in patient

outcomes. In one study, inappropriate laboratory testing was estimated to be as much as 50%.In
the Choosing Wisely campaign of the American Board of Internal Medicine (ABIM) Foundation,

several societies have included in their lists, the recommendation of avoiding laboratory tests at

regular intervals without a change in the patient's clinical status. At the same time, some authors

have challenged the notion that laboratory tests are a major cause of HAA. They propose that the

volume collected for tests is determined by the patient's severity of illness and ability to produce

RBCs to compensate for the lost blood. While a healthy person is expected to replace 1%, or about

50 mL of his/her total blood volume (TBV) per day, this capacity is impaired in hospitalized

individuals, lowering their threshold of tolerable blood loss. (Mann et.al, 2017)

CHAPTER 3

METHODOLOGY
 This chapter presents the research design, description of the respondents, the research

instrument used, data gathering procedure, and the statistical treatment of the data gathered.

Research Design

This study utilized the descriptive – survey in order to achieve the purpose of this study-

which is to record sample wastage among clinical laboratories in Tacloban City area. It is

descriptive in a sense that the data were collected without changing the environment in which

nothing was manipulated. The information collected concerns about the occurrence of blood

wastage in clinical laboratories within hospitals and methods involved survey which describes the

status quo and investigates the relationship between variables.

Research Respondents

Medical Technologists are health professionals that analyze and test body fluids

(specifically blood) and tissues. They are knowledgeable about the tests and/or amount of blood

needed for these tests.

Research Instrument
 The researchers used a survey questionnaire as their tool in this study, comprising two

parts.

Part I of the survey questionnaire provides the name of the Hospital (optional due to the

ethical issues), the type of the hospital which is either public or private and also the level of their

service provided whether it is a primary, secondary or a tertiary hospital. Followed by the different

laboratory sections whether it’s Hematology, Clinical Microscopy, Clinical Chemistry,

Histopathology, Microbiology, Blood Banking or Serology .In part I the respondents will react by

checking the box of the appropriate answer beside each given option for each item.

Part II of the survey questionnaire elicited the different blood tests that are used in each lab

sections that are commonly achieved after obtaining the sample from the patient.There are 2

columns that the respondents need to answer, the volume extracted and volume used.

Part III of the survey requires the respondents to answer two the questions. First questions

is all about the factors that lead to blood wastage with six choices. Second question is all about the

ways of disposing blood with two choices. These two questions can be answered by checking the

choices.

Research Locale

This study will be conducted in Tacloban City for the following reasons; (1) there are

significant numbers of clinical laboratories in the city (2) there are different types/level of service

of clinical laboratories (3) feasible for the researchers.

Size and Sample

 The researchers used Total enumeration to determine the population of interest wherein

data are collected from all elements of the population. Total enumeration is used since intensive

investigation is needed and the number of members in the population is not large. This method is

expected to yield an accurate information since it measures the specific characteristics of the

respondents.

Data Gathering Procedure

The researchers will make a letter for the approval to conduct the study in a Clinical

Laboratory within hospital. After which, the researchers will go to the clinical laboratoriy to

personally distribute the questionnaire to the medical practitioners who has the knowledge or

familiarity about the laboratory procedures. The questionnaire would help in determining if there

is blood wastage occurring in clinical laboratories. The questionnaire will be tallied and tabulated.

Data Analysis Used

The data gathered from the questionnaire were analyzed according to their corresponding

quantitative equivalents. The responses were also categorized according to the nature of the

specified questions asked. Total enumeration was used for the profile of the respondents.

To compute for the mean for the responses of the respondents about the sample wastage

among clinical laboratories the following formula was used:

∑𝑥
𝑋̅ =
𝑛
Where: 𝑋̅ – Mean

∑𝑥 – Summation of possible scores

n – total number of items

CHAPTER 4
 PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA

This chapter presents the data gathered, the results of the statistical analysis done and

interpretation of findings. These are presented in tables and graphs following the sequence of

specific research problem regarding “Blood Wastage in a Tertiary Hospital Laboratory in

Tacloban City “.

Laboratory procedures that uses blood includes; haematology and coagulation, chemistry,

microbiology, transfusion and serologic tests. Haematology and coagulation tests have six specific

haematological tests and all are available in the hospital. Chemistry test have eight specific tests

but only seven are available . Microbiology and transfusion have four specific tests and all are

available. Serologic tests have eleven specific test but only three are available. A total of twelve

respondents answered the survey questionnaire and the mean response is showed in table 1 below.

Table 1.

Percent wasted of blood used in the different lab procedures

Test Used Mean Standard Dispense Volume Percent

Volume volume of difference Wastage
extracted use

(x)

A. Hematology
& Coagulation
CBC w/ or w/o 1.95 ml 0.5 ml 0.4 ml 1.55ml 79.5%
differential &
platelet count
Haematocrit or 1.6 ml 0.5 ml 0.2 ml 1.4 ml 88%
Hemoglobin or
both
1.8 ml 0.5ml 0.4 ml 1.4 ml 78%
WBC count w/
or w/o
differential 1.6 ml 0.5 ml 0.3 ml 1.3ml 81%
Platelet count
only 2.0 ml 1.8ml 0.5 ml 1.5ml 75%
PT and PTT, or
if ordered
singly

B. Chemistry
Tests
Individual 3 ml 0.6 ml 0.5 ml 2.5ml 83%
chemistry
analytes
Chem 10 panel 3 ml 0.6 ml 0.9 ml 2.1ml 70%
Met B panel 3 ml 0.6 ml 0.7 ml 2.3ml 77%
Met C panel 4 ml 1.2 ml 0.8 ml 3.2ml 80%
Lipid Profile 3 ml 0.6 ml 0.6 ml 2.4ml 80%
Chem 23 panel 4 ml 1.2 ml 3 ml 1 ml 25%
+ Lactate on
ice 4 ml 1.2 ml 0.8 ml 3.2ml 80%
Met C panel +
Lipid Panel +
CRP

C.
Microbiology
and 3.5 ml 1.0 ml 1.5 ml 2 ml 57%
Transfusion 3 ml 1.0 ml 1.3 ml 1.7ml 57%
Blood Culture
ABO Rh only 3 ml 1.5 ml 0.7 ml 2.3ml 77%
(Transfusion)
Type and 2.6 ml 0.5 ml 0.5 ml 2.1ml 81%
Screen (&ABO
Rh)
Blood Type
verification
 D. Serologic
Tests
Syphilis 2.6 ml 1 ml 0.5 ml 2.1ml 81%
(Treponema
Pallidum)
Hepatitis B 2.6 ml 1 ml 0.3 ml 2.3ml 88%
Hepatitis C 2.3 ml 1 ml 0.4 ml 1.9ml 83%

This table presents the laboratory procedures, volume extracted, standard volume use,
dispensed blood, volume difference between the volume extracted and dispensed blood, and the
precent wastage.

Hematology and Coagulation. Significant percent wastage for all the tests can be
observed in the table. Haematocrit and Hemoglobin or both has the highest wastage with 88%
followed by platelet count only. CBC with or without differential and platelet count comes next
with 79.5% and then WBC count with or without differential at 78%. PT and APTT or if ordered
singly the least among them with 75% of wastage.

Chemistry. Chem panle 23 + Lactate on ice is the only tests where there is minimum
blood wastage compared to all the other test procedures with high percent wastage ranging from
70-80%.

Microbiology and Transfusion. Blood culture and ABO Rh and Transfusion has the
minimal blood wastage of 57%. Blood Type Verification and Type and Screen has a higher
percentage of blood wastage between 77-78%.

Serologic. There are three tests available in serology section. All test showed a highly
significant increase in blood wastage with minor differences form 81-88%.

Table 2.

Factors the lead to blood wastage

 Factors Frequency Percent

Blood returned after 30 2 17%

minutes

Out of controlled temperature 0 0%

storage

Time Expiry 4 33%

Waste Imports 0 0%

Medically ordered but not 2 17%

used

Hemolyzed 4 33%

Total 12 100%

Blood Returned after 3o minutes and medically ordered but not used got the same
percent for about 17%.
Time expiry and Hemolysis got the highest responses for about 33%. This confirms that
the common factor that lead blood to wastage are due to time expiry and hemolysis.
Out of controlled temperature storage and wasted imports are not common factors that lead
blood sample to wastage.
Table 3: Ways of disposing blood

Ways of disposing blood Frequency Percent

Treating with incineration 9 75%
Directly disposing to landfills 3 25%
Total 12 100%

Treating with incineration is the most common way of disposing blood according the
mean responses for about 75%.
 CHAPTER 5

CONCLUSION, INTERPRETATION AND DISCUSSION

Conclusion

From the data gathered, it was found out that sample wastage of blood happens in the

laboratory. The standard volume for extraction and the volume dispensed clearly showed a

significant difference resulting to an increase percent wastage for almost all the laboratory

procedures.

For hematology and coagulation, the volume for extraction ranges from 1 ml to 2 ml and

the dispensed from 00.2ml to 0.5 ml. CBC with of without differential & platelet count has the

highest percent wastage of 88%.

Chemistry require a significant amount of blood so the volume of extraction is much higher

than the others. It ranges from 3 ml to 4ml and dispensed blood from 0.5ml to 3ml. Individual

chemistry anlaytes has the highest percent wastage of 83%. Chem 23+ panel+lactate on ice got

the lowest percent wastage of only 25%.

Microbiology and transfusion also require a significant amount of blood so a large volume

of sample is being drawn from a patient. The volume for extraction ranges from 2ml to 4 ml and

volume dispensed from 1ml to 2 ml. Compare to other laboratory procedures, microbio has lower

percent wastage. Blood type verification got the highest percent wastage of 81%.
 Samples for serological testing are usually drawn together with chemistry examinations

making almost the same amount for volume of extraction. Sample wastage can be observed form

all the tests. Hepatitis B being the highest at 88%.

In general, hematology and serology laboratory procedures has the highest mean percent

wastage. Hematology at 80% and Serology at 84%. Sample wastage that can lead to more volume

of extraction may cause iatrogenic anemia in in-patients. As the study of Thavendiranathan et. al

suggest that the volume of blood draw strongly predicted decrease haemoglobin and haematocrit

levels. Before ordering blood request, physicians must always discern if it is necessary or not.

Blood wastage maybe due to many reasons. Time expiry and hemolysis are the common

reasons why blood sample is turned into waste according to the results that we have gathered.

Hemolysed and expired blood are not accepted in laboratory examinations because it causes false

results. Blood returned after 30 minutes and medically ordered but not used also contribute to

wastage of blood but not significantly.

Blood waste must be properly disposed. Blood is an infectious fluid that can cause serious

illnesses. Many ways of properly disposing blood can be done by correct personnel. Treating with

incineration is the most common way according to the results that we have gathered followed by

direct disposing to landfills.

RECCOMENDATIONS:

If feasible, conduct the research in many hospital laboratories not just one.

Use standards specifically from our own country like from RITM or DOH.

Conduct the research with more respondents.

Use other instruments aside from survey questionnaires.

Go experimental with this kind of research.

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