Recommendations Made By You

There have been many initiatives to improve the utilization of health care resources in general, but none have been as large or have gained as much momentum as Choosing Wisely, which began in the United States in 2012 and came to Canada in 2014. It has since expanded, spreading to other countries around the globe. For Choosing Wisely Canada (CWC), over 50 professional societies have contributed to more than 330 recommendations — and it is growing!

In 2018, the CSMLS agreed to become a campaign partner with CWC, joining other organizations such as Canadian Society for Transfusion Medicine, Canadian Association of Pathologists, Canadian Hematology Society, Canadian Agency for Drugs & Technologies in Health, Canadian Foundation for Healthcare Improvement and the University of Alberta (UofA).

The importance of CWC within the laboratory system was missing the medical laboratory professional’s voice. CSMLS and the UofA Medical Laboratory Science Division came together to create such CWC recommendations. We are pleased to present the results and recommendations of this national project to you.

Medical Laboratory Science

Seven Things Clinicians and Patients Should Question

Canadian Society for Medical Laboratory Science
Last updated: July 2020

  • Don’t collect more blood than what is needed. Use short draw tubes, consider add-on testing, and reduce or combine duplicate orders.

    Phlebotomy is not a risk-free event for the patient or the health care worker. While rare, injury from needlestick and/or pathogen exposure can occur. Cumulative blood loss due to multiple phlebotomy episodes can result in iatrogenic anemia, particularly in the elderly, children, or those with medical conditions. This anemia can lead to worsened patient outcomes. Employing mechanisms that limit the amount of blood taken has been shown to lessen the severity of iatrogenic anemia. This can range from using smaller-volume collection tubes, consulting about the possibility of add-on testing to previously drawn samples, or adopting a maximum blood volume policy. Addressing duplicate requisitions can limit a patient from being phlebotomized twice.

    • Auta A, Adewuyi EO, Tor-Anyiin A, Edor JP, Kureh GT, Khanal V, Oga E, Adeloye D.Global prevalence of percutaneous injuries among healthcare workers:a systematic review and meta-analysis.Int J Epidemiol 2018;47(6):1972-80.
    • Chandrashekar S. Hospital-Acquired anemia: A hazard of hospitalization. Glob J Transfus Med 2018;3:83-7.
    • Dale JC, Ruby SG.Specimen collection volumes for laboratory tests:A College of American Pathologists Study of 140 Laboratories.Arch Pathol Lab Med 2003;127:62-68.
    • Loh, TP, Saw S, Sethi SK.Clinical value of add-on chemistry testing in a large tertiary-care teaching hospital.Lab Med 2012;43(2):82-85.
    • Society for the Advancement of Blood Management.Anemia prevention and management program implementation guide.The Center for Hospital Innovation & Improvement 2015.Available from:
    • Whitehead N, Williams LO, Meleth S, Kennedy SM, Ubaka-Blackmoore N, Geaghan SM, et al.Interventions to prevent iatrogenic anemia:a Laboratory Medicine Best Practises systematic review.Crit Care 2019;23:278.
  • Don’t proceed with testing or reporting when sample quality or identification is suspect.

    The quality of specimens received in the laboratory is paramount to obtaining accurate results. Proceeding with testing in the presence of poor sample quality may give misleading results. This contributes to delays and unnecessary repeat examinations. Any level of error should be avoided to decrease negative impact on clinical decisions and patient care. Laboratory professionals should be proactive in ensuring that all types of specimens are collected in a high quality manner with correct identification, regardless of which health professional group is performing the act.

    • Chavan PD, Bhat VG, Polandia PP, Tiwari MR, Naresh C.Reduction in sample rejections at the pre-analytical phase – Impact of training in a tertiary care oncology center.J Lab Physicians 2019;11(3):229-33.
    • Ho J, Marks GB, Fox GJ.The impact of sputum quality on tuberculosis diagnosis:a systematic review.Int J Tuberc Lung Dis 2015;19(5):537-44.
    • Howanitz PJ, Lehman CM, Jones BA, Meier FA, Horowitz GL.Clinical laboratory quality practices when hemolysis occurs.Arch Pathol Lab Med 2015;139:901-6.
    • Lippi G, von Meyer A, Cadamuro J, Simundic AM.Blood sample quality.Diagnosis 2019;6(1):25-31.
    • O’Neill E, Richardson-Weber L, McCormack G, Uhl L, Haspel RL.Strict adherence to a blood bank specimen labeling policy by all clinical laboratories significantly reduces the incidence of “wrong blood in tube”.Am J Clin Pathol2009;132:164-8.
  • Don’t collect extra blood tubes in anticipation of test orders.

    Frequently called “just-in-case,” “rainbow draws,” or simply “extra tubes,” blood collected before tests are ordered is frequently unused and ultimately discarded. This represents a waste of laboratory resources and a challenge for specimen management. Excessive phlebotomy is a recognized contributor to iatrogenic anemia, which is linked to worsened patient outcomes.

    • Gray A. Drawing extra blood tubes in the ED.Med Lab Observer [online] 2012.Available from:
    • Humble RM, Hounkponou HG, Krasowski MD.The “Rainbow” of extra blood tubes – Useful or wasteful practise?JAMA Int Med 2017:177(1):128-9.
    • Loh TP, Saw S, Sethi SK.Extra blood tubes – an affordable excess? [letter].Clin Chim Acta 2010:411:1544-5.
    • Snozek CLH, Hernandez JS, Traub SJ.“Rainbow Draws” in the emergency department:clinical utility and staff perceptions.J Appl Lab Med 2019:4(2);229-234.
  • Don’t support repeat test ordering (re-testing) at a frequency that is not backed by evidence.

    Many analytes have known stability profiles or minimum retesting intervals. In most cases, values will not change during this time. These intervals may be longer than traditional or historical test repeat ordering frequency. Ordering tests more frequently is unlikely to provide clinically meaningful results, and may contribute to iatrogenic anemia. Iatrogenic anemia can worsen patient outcomes. Laboratorians can play an active role in drawing awareness to and/or acting to reduce these types of orders.

    • Chami N, Simons JE, Sweetman A, Don-Wauchope AC.Rates of inappropriate laboratory test utilization in Ontario.Clin Bioch 2017:50;822-7.
    • Compton M, Szklarski P, Booth G.Duplicate type and screen testing waste in the clinical laboratory.Arch Path Lab Med 2018; 142(3):358-63.
    • Eaton K, Levy K, Soong C, et al.Evidence-based guidelines to eliminate repetitive laboratory testing.JAMA Int Med 2017:177(12);1833-9.
    • Lang T, Croal B.National minimum retesting intervals in pathology.A final report detailing consensus recommendations for minimum retesting intervals for use in pathology.2015.Report by The Royal College of Pathologists.Available from:
    • Tchou MJ, Girdwood ST, Wormser B, Poole M, David-Rodriguez S, Caldwell JT, et al.Reducing electrolyte testing in hospitalized children by using quality improvement methods.Pediatrics 2018:141(5):e20173187.
  • Don’t routinely repeat critical results for most common analytes before reporting.

    With modern instrumentation, analytical precision is very high when the result is within the reportable range and no delta checks have failed. Providing that sample integrity and performance validity has been confirmed, repeating critical values rarely changes the result. However, turnaround time is significantly increased. This can delay clinical action, negatively impact patient care, and increase the likelihood of unnecessary investigations.

    • Lehman CM, Howanitz PJ, Souers R, Karcher DS.Utility of repeat testing of critical values.A Q-probes analysis of 86 clinical laboratories.Arch Pathol Lab Med 2014:138:788-93.
    • Motie PB, Zare-Mirzaie A, Kadivar M.Does routine repeat testing of critical laboratory values improve their accuracy?Med J Islam Repub Iran 2015;29:176.
    • Onyenekwu CP, Hudson CL, Zemlin AE, Erasmus RT.The impact of repeat-testing of common chemistry analytes at critical concentrations.Clin Chem Lab Med 2014;52(12):1739-45.
    • Sun SP, Garcia J, Hayden JA.Repeating critical hematology and coagulation values wastes resources, lengthens turnaround time, and delays clinical action.Am J Clin Path 2018:149;247-52.
  • Don’t support ordering system mechanisms that contribute to over-testing. Encourage the development of an evidence-based utilization management program that may include interventions such as unbundling order sets, reflex testing algorithms, and decision-support technology.

    Over-testing is a recognized problem, and evidence supports multi-faceted interventions that capitalize on advances in computer-based ordering technology. Bundling of tests may provide results that are not necessary for the ordering professional and may lead to duplication of testing or unnecessary follow-up. Order sets should be regularly reviewed. Research supports increased collaboration of all health care providers, including laboratory personnel, in combating over-testing. Laboratory professionals can be involved at all stages of interventions from problem recognition, feedback provision, to participation in the creation of supportive education materials and ordering guidelines.

    • Ferraro S, Panteghini M.The role of the laboratory in ensuring appropriate test requests.Clin Bioch 2017;50(10-11):555-61.
    • Jackups R, Szymanski J, Persaud S.Clinical decision support for hematology laboratory test utilization.Int J Lab Hem 2017;39:128-35.
    • Krasowski M, Chudzik D, Dolezal A, Steussy B, Gailey M, Koch B, et al.Promoting improved utilization of laboratory testing through changes in an electronic medical record:Experience at an academic medical center.BMC Med Inform Decision 2015;15(1):11.
    • Rubinstein M, Hirsch R, Cornish N.Effectiveness of practises to support appropriate laboratory test utilization.A laboratory medicine best practises systematic review and meta-analysis.Am J Clin Path 2018;149(30):197-221.
    • NazerianP, Vannit S, Fanelli A, Fallai L, Duranti C, Ognibene A, et al.Appropriate use of laboratory test requests in the emergency department:a multilevel intervention.Eur J Emerg Med 2019;26(3):205-11.
  • Don’t allow standing orders for repeat testing without a stop or review date.

    Standing orders without an expiry or review date allow testing to be performed repetitively for extended periods of time. This type of testing is rarely clinically necessary without regularly reviewing the validity of the order. This contributes to overutilization of laboratory tests, and may exacerbate the development of iatrogenic anemia.

    • Raad S, Elliot R, Dickerson E, Khan B, Diab K.Reduction of laboratory utilization in the intensive care unit.J Int Care Med 2017:32(8);500-7.
    • Studnicki J, Bradham D, Marshburn J, Foulis P, Straumfjord J.Measuring the impact of standing orders on laboratory utilization.Lab Med 1992:23(1);24-8.
    • Wertheim B, Aguirre A, Bhattacharyya R, Chorba J, Jadhav A, Kerry V, et al.An educational and administrative intervention to promote rational laboratory test ordering on an academic general medicine service.Am J Med 2017:130(10);47-53.
    • Iturrate E, Jubelt L, Volpicelli F, Hochman K.Optimize your electronic medical record to increase value:Reducing laboratory overutilization.Am J Med 2016;129(2):215-20.

How the List was Created

Project leadership was established as a team of individuals from the Canadian Society of Medical Laboratory Science (CSMLS) and the Medical Laboratory Science program at the University of Alberta. A working group (herein referred to as the “Expert Panel”) of experienced medical laboratory professionals (MLPs) from across Canada were recruited through advertisement by the CSMLS. Expert Panel members were selected based on maximal representation of geography, years and variety of working experience, and professional designation. All traditional disciplines of medical laboratory science (chemistry, hematology, blood bank, microbiology, and histology) were represented by at least two members. There were five virtual synchronous meetings as well as asynchronous technology-enabled discussions over approximately one year. Potential CWC list items were generated through Expert Panel members, a national CSMLS survey, and a meeting at the 2019 CSMLS annual convention. A modified Delphi process was used to reduce a long list to a short list of items. We used scoping reviews to generate evidence for items on the short list. Items with the strongest evidence were sent to the CSMLS Board of Directors for approval.

About the Canadian Society for Medical Laboratory Science

The Canadian Society for Medical Laboratory Science is the national certifying body for medical laboratory technologists and medical laboratory assistants, and the national professional society for Canada’s medical laboratory professionals. Our purpose is to: 1) promote and maintain a nationally accepted standard of medical laboratory technology by which other health professionals and the public are assured of effective and economical laboratory services, and 2) promote, maintain and protect the professional identity and interests of the medical laboratory professional and of the profession.

Our members practice in hospital laboratories, private medical laboratories, public health laboratories, government laboratories, research and educational institutions. Incorporated in 1937 as the Canadian Society of Laboratory Technologists, the society has over 14,500 members in Canada and in countries around the world.

To understand the collected evidence that supports these recommendations, please see our searchable recommendation database.

Do you have questions on how the recommendation validation process was conducted? Contact for more information. You can also find general information in the volunteer presentation.