Clin Chem Lab Med 2024; 62(9): 1787–1794

Review

Anjali Thakur, Tapasyapreeti Mukhopadhyay* and Ashok Kumar Ahirwar

Approaching sustainability in Laboratory Medicine

https://doi.org/10.1515/cclm-2023-0973 of different stakeholders’ [1]. The clinical laboratories
Received September 4, 2023; accepted March 7, 2024; in contrast are a major consumer of energy, water, and
published online April 2, 2024
hazardous chemicals, and are known to use 5 to 10 times
more energy per metre squared than a typical office [2]. The
Abstract
large and the small electrical appliances like the centrifuge,
Introduction: Clinical laboratories and the total testing ultra-low temperature freezer, auto analysers, laboratory/
process are major consumers of energy, water, and hazardous hospital information system, multiple computer systems,
chemicals, and produce significant amounts of biomedical air conditioners, water treatment plants, vacuum systems,
waste. Since the processes in the clinical laboratory and the lights and exhaust fans running 24×7 lead to the production
total testing process go hand in hand it mandates a holistic, of a substantial amount of greenhouse gases (GHG) and
and comprehensive approach towards sustainability. add to high plug load, and the carbon footprint. The need
Content: This review article identifies the various sources for controlling the temperature and humidity, and setting
and activities in Laboratory Medicine that challenge processes to meet the required air circulation per hour as
sustainability and also discusses the various approaches per the laboratory safety requirements further compromise
that can be implemented to achieve sustainability in laboratory the sustainability.
operations to reduce the negative impact on the environment. Similarly, the total testing process (TTP) starting with test
Summary: The article highlights how the integration of tech- selection to the generation of test report and specimen disposal
nological advancements, efficient resource management, staff encompass several steps that need serious evaluation for
training and sensitization, protocol development towards sustainability. Since the processes in the clinical laboratory
sustainability, and other environmental considerations con- and TTP go hand in hand, it mandates a holistic, and compre-
tributes significantly to a sustainable healthcare ecosystem. hensive approach towards sustainability. The ever-growing
Outlook: Variables and resources that negatively impact the demand for diagnostic services in patient care has propelled
environment must be identified and addressed comprehen- the need for identifying effective practices to transform clinical
sively to attain a long-lasting level of carbon neutrality. laboratories into safe and sustainable spaces.
This narrative review article identifies the various
Keywords: greenhouse gases; staff training; sustainability; sources and activities in Laboratory Medicine that challenge
technology; total testing process sustainability and also discusses the various approaches
that can be implemented to achieve sustainability in labo-
ratory operations to reduce the negative impact on the
Introduction environment (Table 1).

A sustainable space has been defined as ‘one that ensures

the preservation of resources, is practical from ecological, How to tread the path of
social, and economical perspectives, and meets the interests
sustainability in Laboratory
*Corresponding author: Assistant Professor Tapasyapreeti
Medicine?
Mukhopadhyay, MD, Department of Laboratory Medicine, Jai Prakash
Narayan Apex Trauma Centre, All India Institute Medical Sciences, New Delhi Align with the global and national movement
110029, India, Mobile: 9871593450, E-mail: [email protected]. towards sustainability
https://orcid.org/0000-0002-7616-0401
Anjali Thakur and Ashok Kumar Ahirwar, Department of Laboratory
All the United Nations Member States have adopted the 2030
Medicine, All India Institute Medical Sciences, New Delhi, India,
E-mail: [email protected] (A. Thakur), [email protected]
Agenda for Sustainable Development in 2015. Recently, the
(A.K. Ahirwar). https://orcid.org/0009-0008-0434-4843 (A. Thakur). European Federation of Clinical Chemistry and Laboratory
https://orcid.org/0000-0003-3371-378X (A.K. Ahirwar) Medicine (EFLM), has taken the lead to contribute towards
1788 Thakur et al.: Sustainability in Laboratory Medicine

Table : Summary of strategies to achieve sustainability in clinical practices in four major areas of energy, water, waste, and use
laboratory. of hazardous chemicals in the laboratory facility.
The Centre for Sustainable Healthcare (CSH) offers
. Aligning with the global and national movement towards sustainability
consultancy and education on sustainable healthcare
. Plan a sustainable laboratory framework
– Designing a sustainable clinical laboratory at inception research and practices. It works in collaboration with both
– Prioritizing centralized laboratory facility-centralised specimen Greener National Health Service (NHS) and NHS England.
collection area, integrated testing zone The European Union Eco-Management and Audit Scheme
– Minimizing the distance between pre-analytical, analytical and (EMAS) is a national body that helps laboratories to evaluate,
post-analytical areas in the healthcare facility
report, and improve environmental performances [4]. The
. Judicious resource management pathways
– Conserve renewable energy sources
University of California Health System and Cleveland Clinic
– Adopting sustainable laboratory products and purchase process in the United States of America (USA) aim to become carbon
– Embracing sustainable technological advancements neutral by 2025, and 2027 respectively [5].
– Promoting recycling, repair, re-use, reduce and/or refuse of laboratory Similar country-specific guidelines and recommenda-
resources tions for sustainable practices, and local and state legisla-
. Sustainable total testing process (TTP)
tion could be issued that would be adopted by various
– Optimum patient preparation and judicious test ordering
– Best phlebotomy practices laboratories. Changes in the ISO 15189 document are
– Preventing and controlling errors in all phases of TTP expected in the future that would aim to improve the
– Optimizing transport methods environmental practices of the accredited laboratories.
– Optimizing specimen processing The clinical laboratories could use customised criteria
– Preferring glass containers over plastic containers
that could ease the transition of clinical laboratories to
– Incorporating quality assurance programme
– Adopting digitalization for test ordering, and report dispatch
sustainable workspaces.
– Using automation for various laboratory processes
– Functionalising integrated laboratory spaces
– Minimising use of hazardous chemicals
– Promote decentralisation by encouraging point-of-care tests
How to plan a sustainable
– Interfacing equipment with laboratory information system laboratory framework?
– Using validated auto verification algorithms for reporting
– Encouraging the use of pre-analytical module for aliquoting and post
analytical storage modules for easy sample retrieval for add-on Design a sustainable clinical laboratory at
testing, reflex testing and reflective testing inception and prioritise centralised facilities
. Capacity building, training and implementing strategies to increase
accountability
The planning process includes designing the layout of
– Establishing sustainability office
– Developing Sustainability Action Plan
the laboratory with respect to its facilities and designing the
– Targeting certification under the ISO 14001: 2015 standard core infrastructure of the building. During the layout set up,
– Implementation of sustainability service quality improvement (SusQI) one needs to prioritise easy and accessible route to the
projects laboratory for its users and its operators. The distance
– Identifying sustainability ambassadors from and between the outpatient area, wards, nearest pub-
– Training lab staff, clinicians, patients, stakeholders, administrators,
lic transport spot, parking space, patient waiting area,
medical undergrads
– Encouraging car-pooling, promoting public transport, use of electrical specimen reception area and the laboratory performing the
vehicles, choosing virtual mode over physical mode tests should be assessed thoroughly and planned such that
. Sustainable practices for biomedical waste management the movement of patients, operators and the specimens are
– Waste segregation at source minimised. Centralised specimen collection area and a core
– Adherence to local biomedical waste disposal guidelines
laboratory should be facilitated to minimise the need for
– Good autoclave practice
– Comprehensible recycling programs
non-renewable resources, buying multiple instruments,
setting multiple water harvesting plants, specimen collec-
tion containers, and manpower. By designing the laboratory
in respect to places like the canteen, meeting halls, library
sustainable environment-friendly laboratories. The guide- and lift areas in the building at the time of inception can
lines for green and sustainable laboratory under the European bring about long-lasting sustainable changes.
Green Deal (EGD) Investment Plan were published in August National policies to support the use of renewable
2022 for the Laboratory Medicine community for establishing resources in the building processes are required. The use of
‘Green labs’ in Europe and beyond [3]. It recommends good construction materials with lower GHG emissions should
 Thakur et al.: Sustainability in Laboratory Medicine 1789

be promoted [6, 7]. The use of solar panels, wind energy, minimize resource wastage and reduce the negative impact
planning a layout that ensures natural daylight and natural on the ecosystem.
ventilation, should always be encouraged. Incorporating Water purification plants are installed in most clinical
frameworks through ISO 14000, installing heating, ventila- laboratories. The type and the size of water plant depends on
tion, and air-conditioning (HVAC) systems using renewable the requirement of the laboratory. Purified water should be
sources of energy and including energy-efficient technolo- used only when necessary. Production of distilled water
gies such as high-performance window systems, variable- requires large amount of electricity. The reverse osmosis
air-volume (VAV) fume hoods, focussing on installing plant usually rejects 50–80 % of feed water. Preferring new
low-energy light emitting diode (LED) lighting that uses generation of reverse osmosis, using the water obtained
significantly less energy and has a longer life than incan- from the reverse osmosis plant to feed the deioniser, mini-
descent bulbs, installing heat-blocking window film, mising the need for water distillation in laboratories, are
installing censor lights in corridors are ways to ensure ways to reduce water wastage.
sustainability [8–10]. Daily energy-efficient practices include controlling
Equipment in clinical laboratories consuming high phantom power use, by turning off major and minor
energy emit large amounts of GHG. When the functionalities equipment, fume hoods, biosafety cabinets, air conditioners
of laboratories are planned, preferring the equipment with and computers when not in use. Implementing frequent and
a lower energy consumption and that automatically goes periodic cleaning and defrosting of freezers to make space
into standby mode when not in use, planning the placement for better cooling. The freezer space can also be shared
of large equipment per room well in advance, using ultra- between laboratories. Planet-friendly ‘green cleaning
low temperature freezer that consumes 50–60 % less energy products’ that are non-corrosive, phosphate and chlorine
than a standard freezer, choosing eco-friendly, reusable free should be the choice of cleaning solutions to prevent
containers, products supplied with reduced packaging, are the long-term accumulation of toxic substances. One should
other ways to bring about substantial change. minimise the use of substances threatening the environment
Resources that are used daily in the clinical laboratory like heavy metals or hydrofluoric acid, which are released
for specimen collection, transport and sample analysis may from inappropriately disposed spent batteries, mercury in
be evaluated for sustainability. Sustainable purchase pol- thermometers and fluorescence microscope bulbs in labo-
icies must be developed for both consumables and ratory equipment [12, 13].
non-consumables used in the TTP and clinical laboratories.

Adopt sustainable laboratory products and

purchase process
What are the judicious resource
management pathways in the Often when approaching sustainability in real practice, it is
anticipated that it comes with increased expenditure, buying
laboratory? a new set of equipment, and creating a different set which
appears challenging [14]. However, most practices towards
Conserve renewable energy sources sustainable growth promote minimizing resources with
minimal cost. For procuring products and collaborating with
Effective resource management is a key aspect of sustainable institutes, the laboratory could choose the one with the best
growth in medical laboratories. Whenever and wherever ethical and environmental practices. As incorporating
possible, conservation of renewable energy sources, including environmentally friendly practices is integral to sustainable
wind, solar photovoltaics, and solar thermal energy should growth, greener procurement policies should also be incor-
be prioritized. For water conservation, fixing leaky faucets, porated in tender specifications for all future procurements.
providing facility for grey water recovery, installing water- Specification can include ‘Buy back policy’ for equipment
saver fixtures like low-flow aerators in the laboratory can and waste where the seller of the goods buys back the
save thousands of gallons per year [11]. Installing closed product after use or a predetermined time frame and/or
loop recirculation equipment for cooling systems, choosing ‘Extended producer responsibility’ that is a form of reverse
new research grade autoclaves, autoclaves with water collection system ensuring recycling for end of life, post-
saving device over the traditional autoclaves, vacuum pump consumer waste.
(instead of water aspirator, wherever possible), selecting Implementing inventory control systems that consider
equipment that uses less amount of water can help to environmental impact during consumables selection and
1790 Thakur et al.: Sustainability in Laboratory Medicine

purchase in supplier evaluation checklist are other ways How to develop a sustainable total
that contribute to sustainable resource management.
Leveraging data analytics can help laboratories identify and testing process?
address inefficiencies in resource allocation.
Promote judicious test ordering, best
phlebotomy practices, preventing errors,
optimizing transport methods, replacing
Embrace sustainable technological
paper with digitalization, promotion of
advancements
integration and automation of laboratory
Telelaboratory services, telecommunication by video call, processes
telephone, and mobile applications make laboratory ser-
vices and report delivery more accessible without compro- The TTP is largely resource intensive and a consensus on the
mising quality and patient safety [15, 16]. Data mining, online targetable steps to achieve sustainable TTP is not available
data storage, and inter-operator data sharing decrease the yet [1]. Embracing sustainability for the processes across
hosting requirement and thus control the carbon and water the TTP helps the laboratory to be better placed amongst
footprints [1]. its users and positively impacts the status symbol of the
laboratories as the lab appears to be environmentally and
socially more responsible. The potential modifications in
the TTP for achieving sustainability are enlisted below
Promote recycling, repair, re-use, reduce and summarised in Figure 1.
and/or refuse of laboratory resources – Test ordering is the first step of the TTP. Application of
correct and comprehensive knowledge while ordering
A lot of resources go into making products for a clinical laboratory tests contributes to judicious resource
laboratory setup. Assessing the products for their repairability utilisation. Adequate patient preparation, correct test
and the potential to be recycled must be considered before selection, correct patient identification should be
the purchase. Promotion of repair, reconditioning, refurbish- targeted and can be achieved by increasing awareness of
ing of laboratory equipment, reselling of laboratory resources users (clinicians and patients) by regular training, or by
to ones who need and cannot afford first-hand equipment, making amends in the electronic ordering systems [17].
establishing ‘Reagent-sharing programs’ are ways to decrease – Best phlebotomy practices ensure the right site prepa-
laboratory carbon footprint. ration, selection of the correct blood collection container
Reducing and refusing the use of single use plastic, filled in the right sequence up till the recommended
cellotape, plastic packaging, bubble wrap not only has finan- volume with adequate mixing [18, 19]. A good quality
cial benefits but also reduce the need for new production. blood sample would not only produce correct result that
Disposing them off outrightly creates waste. Laboratories can will correctly correlate clinically, it would also decrease
enrol in ‘Lab plastic recycling programs’. Maintaining daily the need for repeated blood withdrawal, retesting,
statistics on laboratory production of plastic can identify patient travelling for submission and report collection,
sources and aid in planning strategies to use plastic in a more thus decreasing the laboratory carbon footprint [20].
efficient manner. – The frequency of specimen transport from collection
Waste solvent recycling decreases the final volume of area to the testing laboratory, the transport route, the
hazardous waste as well as decreases the prospective ill transport duration, quality and components of spec-
effect to the environment. ‘Solvent recovery programs’ and imen packaging and number of samples collected in a
use of ‘Solvent Recyclers’ ensure recycling of hazardous batch for transport also determine a substantial fraction
chemicals like xylene, formalin, alcohol. of the carbon footprint contributed in the TTP. Pneu-
‘Vendor take back programs can help the used resources matic tube sample transfer system, drones and electrical
and the waste generated to reach the site of recycling in vehicles should be preferred for specimen transport as
a more systematic manner. Reusing packaging material, per the local conditions.
cold packs and transport boxes are sustainable options. – Errors in the pre-analytical phase are reported to be the
Used paper can be collected in separate bins for the purpose highest and frequently lead to specimen rejection [21].
of recycling. Electronic or CD versions of catalogues can Mislabelling, choice of a wrong vial, insufficient spec-
be used to reduce paper use.’ imen volume, are one of the many reasons that lead to
 Thakur et al.: Sustainability in Laboratory Medicine 1791

subsequent retesting and thus impacting the labo- – Integration of space and testing areas promotes sus-
ratory’s carbon footprint. Likewise, reducing errors in tainability. The laboratory tests under various disci-
all phases of the testing processes is critical for reducing plines can now be performed using integrated
the need for resources. Action plans to prevent repeated autoanalysers placed in integrated testing zones [24].
blood withdrawals, retesting, patient travel for testing This automatically decreases the requirement of multi-
and report collection can make the TTP sustainable [22]. ple blood collection tubes, infrastructure, reagents,
– Digitalization in laboratory processes besides enhancing plastic and other consumables, major and minor
process efficiency, minimizing human error, and equipment used for testing and the need for energy,
decreasing the turnaround time for test results, makes water, light. This also hugely impacts the quantum of
record keeping paperless, subsequently decreases the biomedical waste generation.
waste generation and the functional cost substantially – Devoting in internal and external quality control pro-
[23]. Some of the patient care practices like patient gram under quality assurance programme not only
registration, test request generation, and test report verify the analytical process for its reliability and
generation can all be digitalized to decrease the envi- accuracy but also decrease the need for re-collection
ronmental carbon footprint. Since the laboratory test and retesting for accurate clinical correlations [25].
reports will be easily accessible to both clinicians – Laboratory automation can potentially bring in
and patients, it will potentially decrease the use of sustainability in TTP. The pre-analytical automated
non-renewable resources like fuel, electricity and wa- modules available for aliquoting and the refrigerated
ter required to commute to the laboratories. Online sample storage module in post-analytical system greatly
maintenance of staff attendance, controlling footfall reduce the need for resampling in case of add-on testing
inside laboratory premises by incorporating biometrics or reflective testing. Also the aliquoting could be done in
at the doors of the laboratory and in the specimen glass tubes instead of plastic tubes. Likewise, a large
collection areas, managing laboratory inventory, amount of water used in operating a clinical chemistry
recording the various laboratory census, recording the section could be avoided using the principle of dry
daily laboratory quality system procedures, documenting chemistry. The improved laboratory information man-
and sharing the laboratory quality control activities with agement systems (LIMS) interfaced to the equipment,
the stakeholders using computer software are some of and artificial intelligence-based algorithms used for
the potential target areas to achieve sustainability in auto verification of test results, reporting of critical
the laboratories. values, not only improve turnaround time, and decrease

Figure 1: Potential targets to achieve sustainability in the total testing process.

1792 Thakur et al.: Sustainability in Laboratory Medicine

errors but also decrease the need for non-renewables an additional way to assure sustainability in laboratory
sources of energy like water and electricity [26, 27]. practice [34]. Studies to identify and quantify the carbon
Also, it prospectively reduces the use of unsustainable intensity of various laboratory processes can be planned and
plastics and generation of waste as these steps also conducted. The results will aid to frame guidelines for their
minimise the requirement of resampling, and re-testing. usage and disposal. The Laboratory Efficiency Assessment
– The tests done using point-of-care (POC) devices are like Framework (LEAF) by University College London guides
double edge sword with respect to sustainability. On users through sustainability actions to save resources in
one hand it promotes decentralization to make tests their laboratory. It also offers workshops for laboratory
affordable, and accessible reducing the hospital or staff and students [35].
laboratory visits [28]. On the other hand since most of In order to reduce laboratory resource consumption,
the POC devices are manufactured from unsustainable behavioural change of the laboratory staff and users of
polymeric materials like thermoplastic and elastomers, lab services is required. Individuals should be motivated
it increases the environmental burden [29].In the to strive to achieve long-term carbon dioxide reduction
absence of a government regulatory framework, their targets. The laboratory staff should be routinely and
use and disposal are posing a serious threat to the frequently trained for phlebotomy, and about the variables
environment by adding to the plastic waste generation leading to errors in laboratory results. Recognizing and
[30]. Since the COVID-19 pandemic, the usage of POC promoting the value of sustainable growth by introducing
devices has considerably increased [31]. The increased action plans, guidelines and policy approaches towards
demand has led to the increased production of POC sustainability, encouraging laboratory professionals to
devices globally. Strict regulation on the choice of implement sustainability measures, executing effective
material, setting national and global guidelines for POC training and the engagement of staff are essential for
device disposal, and providing national and interna- sustainable growth. The laboratory staff could be encouraged
tional subsidies to sustainable manufacturers can by awarding ‘Green badges’ monthly for their action towards
restrict the irrational use of POC devices. sustainability. Further promotions can be done by desig-
nating a few laboratory personnel, who are active in the field
of laboratory sustainability as ‘Sustainability ambassadors’,
which would improve accountability.
Training for sustainability should not just be limited to
How to ensure the application and the laboratory personnel, but also involve stakeholders,
sustenance of sustainable policymakers, and administration to bring in any long-
lasting change. The clinicians and laboratory physicians
laboratory facility and TTP? could also review the annual volume of inappropriate test
requests and errors due to poor patient preparation and
Capacity building, staff training and make necessary amends in strategies to optimise test
implementing strategies to increase ordering for patient care [36]. Introducing the concept of
accountability sustainability in clinical laboratories and healthcare early
on in the under-graduation curriculum can prove beneficial
Setting up a ‘Sustainability office’ with dedicated work force [37]. Encouraging participation for public activities that
in these green spaces to develop sustainability action plan promote the idea of sustainability like practicing Earth
can make the transition easy and ensure consistency in Hour, spreading awareness by inviting staff for poster pre-
the practices. The team can focus on activities like releasing sentations, and guest lectures on the relevant topics should
‘Green research newsletters’ and conducting ‘Green be encouraged. Promoting the use of reusable mugs and cups
research events’ [32]. By improving the sustainable practices instead of disposables in gatherings, and staff canteen are
further, the clinical laboratories can get certified under the ways to supplement the movement towards a sustainable
ISO 14001: 2015 standard for environmental management laboratory space.
[33]. It has a potential to improve the laboratory budget, The daily commuting of staff to-and-from the laboratory
besides adding ethical importance to the daily practices. for routine work or for various meetings, attending work-
Implementation of environmentally lean practices in shops and conferences outside the laboratory also adds to
sustainability service quality improvement (SusQI) projects the greenhouse gas emissions. Incorporating environmen-
that aim to reduce laboratory waste, water use, plastic use tally friendly practices is an integral part of sustainable
and electricity consumption in the clinical laboratory is growth. Estimating the annual quantum of carbon
 Thakur et al.: Sustainability in Laboratory Medicine 1793

generation, and setting up rationale targets to control or environment need to be identified and addressed in a
decrease the carbon footprint by encouraging car-pooling, comprehensive manner to attain a long-lasting level of car-
promoting public transport, use of electrical vehicles, bon neutrality.
choosing virtual mode over physical mode for conducting
meetings/conferences, and developing a sustainable travel Research ethics: Not applicable.
policy for the working staff talks volume about the Informed consent: Not applicable.
commitment of the laboratory towards sustainability. Author contributions: The authors have accepted respon-
sibility for the entire content of this manuscript and
approved its submission.
Can the biomedical waste Competing interests: The authors state no conflict of
management in clinical interest.
Research funding: None declared.
laboratories be sustainable? Data availability: Not applicable.

Waste segregation at source, proper waste

disposal, and by participating in References
comprehensible recycling programs
1. Molero A, Calabrò M, Vignes M, Gouget B, Gruson D. Sustainability in
The clinical laboratories are a major producer of biomedical healthcare: perspectives and reflections regarding laboratory
medicine. Ann Lab Med 2021;41:139–44.
waste. Of all the medical waste composition, 60 % is
2. Prowler D. Laboratories for the 21st century: an introduction to
contributed by blood collection kits and 5–20 % by gloves, lab
low-energy design; federal energy management program (FEMP)
wears, single use plastic pipette tips. Meticulous waste brochure. Book, August 22, 2000; Golden, CO. Available from:
segregation at the site of generation and following the https://www.osti.gov/servlets/purl/764569 [Accessed 12 Oct
national and international guidelines for safe waste 2023].
management have the potential to reduce the burden of 3. European Federation of Clinical Chemistry and Laboratory Medicine.
EFLM guidelines for green and sustainable medical laboratories
biomedical waste [38, 39]. Recent guidelines have banned the
[Online]; 2022. Available from: https://www.eflm.eu/upload/docs/
use of chlorinated plastic bags to collect waste so as to EFLM-GREEN-LAB-BOOKLET.pdf [Accessed 12 Oct 2023].
decrease the hazardous fumes released during incineration. 4. Directorate-General for Environment of the European Commission.
The wide use of single-use plastics for specimen collection, Guide for sustainable waste management in the healthcare sector
transport, aliquoting, sample storage, and retesting is posing [Online]. Available from: https://webgate.ec.europa.eu/life/
publicWebsite/project/LIFE04-ENV-GR-000114/emas-and-information-
a serious impact on the environment. Improperly inciner-
technology-in-hospitals [Accessed 12 Oct 2023].
ated plastics further generate toxic pollutants and thus the
5. Gammie AJ, Lopez JB, Scott S. Imperative: reducing the environmental
unchecked use should be avoided. Autoclaving practices impact of clinical laboratories. Clin Chem Lab Med 2023;61:634–7.
should be optimised. To ensure it is only operated when full, 6. Darko A, Chan AP, Yang Y, Shan M, He BJ, Gou Z. Influences of barriers,
multiple laboratories can come together and schedule the drivers, and promotion strategies on green building technologies
process. Corrosive liquids used in laboratories should be neu- adoption in developing countries: the Ghanaian case. J Clean Prod
2018;200:687–703.
tralised before pouring down in drains. To decrease laboratory
7. Samari M, Godrati N, Esmaeilifar R, Olfat P, Shafiei MW. The
waste further, the laboratory should incorporate ‘compre- investigation of the barriers in developing green building in Malaysia.
hensible recycling programs’ for non-hazardous biomedical Mod Appl Sci 2013;7:1.
waste that would positively impact the environment. 8. EERE Group. High performance window systems [Online]. Available
To conclude, embedding sustainability in the field of from: https://basc.pnnl.gov/building-science-measures/high-
performance-window-system [Accessed 12 Oct 2023].
Laboratory Medicine requires a multi-faceted approach
9. ICAP Group. Convert fume hoods from CAV to VAV [Online]. Available
encompassing sustainable designing at inception of the
from: https://icap.sustainability.illinois.edu/project/convert-fume-
laboratory space, incorporating technological advance- hoods-cav-vav [Accessed 12 Oct 2023].
ments, judicious resource management, effective staff 10. Asim N, Badiei M, Mohammad M, Razali H, Rajabi A, Haw CL, et al.
training, and by taking measures to reduce and prevent er- Sustainability of heating, ventilation and air-conditioning (HVAC) systems
rors in the TTP. These individual components have an in buildings-an overview. Int J Environ Res Public Health 2022;19:1–16.
11. Umesh V, Sitaram N. Hydraulic performance of faucet aerator as water
unrealised potential to build green laboratory spaces and
saving device and suggestion for its improvements. Int J Res Eng
process, that together can make a huge positive impact on Technol 2014;3:243–7.
the environment. The variables and resources in laboratory 12. Rowdhwal SS, Chen J. Toxic effects of di-2-ethylhexyl phthalate: an
and the testing process that negatively impact the overview. Biomed Res Int 2018;2018:1750368.
1794 Thakur et al.: Sustainability in Laboratory Medicine

13. World Health Organisation. Replacement of mercury thermometers change value (RCV) based autoverification on turnaround time and
and sphygmomanometers in health care: technical guidance[Online]; physician satisfaction. Biochem Med 2017;27:342–9.
2011. Available from: https://www3.paho.org/hq/dmdocuments/2013/ 27. Torke N, Boral L, Nguyen T, Perri A, Chakrin A. Process improvement
Replacement-of-Mercury-Thermometers-and-sphygmomanometers. and operational efficiency through test result autoverification. Clin
pdf [Accessed 12 Oct 2023]. Chem 2005;51:2406–8.
14. Ekins P, Zenghelis D. The costs and benefits of environmental 28. Nichols JH, Ali M, Anetor JI, Chen LS, Chen Y, Collins S, et al. AACC
sustainability. Sustain Sci 2021;16:949–65. guidance document on the use of point-of-care testing in fertility and
15. Karah N, Antypas K, Al-Toutanji A, Suveyd U, Rafei R, Haraoui LP, et al. reproduction. J Appl Lab Med 2022;7:1202–36.
Teleclinical microbiology: an innovative approach to providing web- 29. Glover RT, Connelly J, Gammie A, Kilcoyne J, Ozben T, Santos A,
enabled diagnostic laboratory services in Syria. Am J Clin Pathol 2022; Wiencek JR. Sustainability in laboratory medicine. Clin Chem 2023;69:
157:554–60. 1212–9.
16. Dunn BE, Choi H, Almagro UA, Recla DL. Combined robotic and 30. Ongaro AE, Ndlovu Z, Sollier E, Otieno C, Ondoa P, Street A, et al.
nonrobotic telepathology as an integral service component of a Engineering a sustainable future for point-of-care diagnostics and
geographically dispersed laboratory network. Hum Pathol 2001;32: single-use microfluidic devices. Lab Chip 2022;22:3122–37.
1300–3. 31. World Health Organization. Global analysis of health care waste in the
17. Bejjanki H, Mramba LK, Beal SG, Radhakrishnan N, Bishnoi R, Shah C, context of COVID-19: status, impacts and recommendations [Online];
et al. The role of a best practice alert in the electronic medical record in 2022. Available from: https://www.who.int/publications/i/item/
reducing repetitive lab tests. Outcomes Res 2018;8:611–8. 9789240039612 [Accessed 12 Oct 2023].
18. Bölenius K, Lindkvist M, Brulin C, Grankvist K, Nilsson K, Söderberg J. 32. Scott S. Embedding education into clinical laboratory professional
Impact of a large-scale educational intervention program on venous training to foster sustainable development and greener practice. Clin
blood specimen collection practices. BMC Health Serv Res 2013;13:463. Chem Lab Med 2023;61:638–41.
19. Cadamuro J, von Meyer A, Wiedemann H, Klaus Felder T, Moser F, 33. Lopez JB, Jackson D, Gammie A, Badrick T. Reducing the environmental
Kipman U, et al. Hemolysis rates in blood samples: differences between impact of clinical laboratories. Clin Biochem Rev 2017;38:3–11.
blood collected by clinicians and nurses and the effect of phlebotomy 34. Ross J, Penesis J, Badrick T. Improving laboratory economic and
training. Clin Chem Lab Med 2016;54:1987–92. environmental performance by the implementation of an
20. Eaton KP, Levy K, Soong C, Pahwa AK, Petrilli C, Ziemba JB, et al. environmental management system. Accred Qual Assur 2019;24:
Evidence-based guidelines to eliminate repetitive laboratory testing. 319–27.
Intern Med 2017;177:1833–9. 35. UCL Group. LEAF - laboratory efficiency assessment framework
21. Lippi G, Chance JJ, Church S, Dazzi P, Fontana R, Giavarina D, et al. [Online]. Available from: https://www.ucl.ac.uk/sustainable/leaf-
Preanalytical quality improvement: from dream to reality. Clin Chem laboratory-efficiency-assessment-framework [Accessed 12 Oct 2023].
Lab Med 2011;49:1113–26. 36. Bindraban RS, Ten Berg MJ, Naaktgeboren CA, Kramer MHH,
22. McAlister S, Barratt AL, Bell KJ, McGain F. The carbon footprint Van Solinge WW, Nanayakkara PWB. Reducing test utilization in
ofpathology testing. Med J Aust 2020;212:377–82. hospital settings: a narrative review. Ann Lab Med 2018;38:402–12.
23. Fragão-Marques M, Ozben T. Digital transformation and sustainability 37. Clery P, d’Arch Smith S, Marsden O, Leedham-Green K. Sustainability in
in healthcare and clinical laboratories. Clin Chem Lab Med 2023;61: quality improvement (SusQI): a case-study in undergraduate medical
627–33. education. BMC Med Educ 2021;21:425.
24. Ebubekir B, Nurinnisa O, Nurcan KB. Automation in the clinical 38. Central Pollution Control Board. Guidelines for management of healthcare
laboratory: integration of several analytical and intralaboratory pre- waste as per biomedical waste management rules [Online]; 2016.
and post-analytical systems. Turk J Biochem 2017;42:1–3. Available from: https://cpcb.nic.in/uploads/Projects/Bio-Medical-Waste/
25. Ozben T. SMART and GREEN LABORATORIES. How to implement IVDR, Guidelines_healthcare_June_2018.pdf [Accessed 12 Oct 2023].
emerging technologies and sustainable practices in medical 39. World Health Organisation. Safe management of wastes from health
laboratories? Clin Chem Lab Med 2023;61:531–4. care activities [Online]; 2014. Available from: https://iris.who.int/
26. Fernández-Grande E, Varela-Rodriguez C, Sáenz-Mateos L, Sastre- bitstream/handle/10665/85349/9789241548564_eng.pdf?sequence=1
Gómez A, García-Chico P, Palomino-Muñoz TJ. Impact of reference [Accessed 12 Oct 2023].