In this section
The Division of Laboratory Medicine (DLM) guidelines for specimen acceptance must be followed to ensure that all samples are correctly and unambiguously identified. The policy provides an overarching process to specimen rejection to help balance the requirement to process against the risk to patient safety. Clinical governance issues may arise from errors in specimen identification and/or insufficient clinical information being given with a specimen. To ensure that specimens are linked to the correct patient, adequate identifiers are essential.
Labelling multiple samples from the same patient:
If there are multiple samples from the same patient from different sample sites or multiple samples from the same site:
- Ensure each sample is collected in the appropriate sample collection pot (see section 7.2)
- Ensure each pot is fully labelled with all the appropriate patient demographic information (see section 4.1) – for HIVE orders each pot should have a unique sample label generated
- Ensure each pot is labelled with the specific sample source location i.e. left knee
- If there is more than 1 aspiration for a specific sample location (i.e. 2 aspirations of left knee) these should be collected into the same sample pot where possible and labelled with sample source. Alternatively, you may use another pot if the volume of the sample exceeds the pot size. Please indicate the number of aspirations for that site on either the sample pot or provided with the request.
All urgent and specimens on a cancer tracking pathway (HSC205) should be clearly labelled as such. The date and time the specimen was taken is important information that should be included on all requests.
Specimen acceptance policy
Each specimen must be accompanied by a completed and matching Synovial fluid cytology request form. Please ensure all fields of request forms are completed. See instructions on completing synovial fluid cytology request form. Alternatively, we can supply bulk forms on request.
Please note samples received into this department will only be used for cytology. If additional tests are requested to be done by other departments, each department must be sent a separate sample.
For test requests ordered on the Hive Electronic Patient Record (EPR) system an order requisition printout must be submitted with the request.
For non-Hive requests or paper requests raised during Hive downtime see sample acceptance criteria below for more information.
The following mandatory information must be provided for us to accept the specimen:
All specimen containers must be clearly labelled with:
- Patient’s full name
- Date of Birth
- NHS &/or Hospital number
- Aspiration site
Essential Patient Identifiers:
- Surname
- Forename
- Unique identification number – Medical Record Number (MRN), NHS or external hospital number for external cases
- Date of birth
- Address – for GP or external locations
Essential clinical information – sample site MUST be listed on the sample pot/request form for the sample to be accepted
Essential Sender Details:
- Ward/department – required for return of reports
- Consultant or GP – required for return of reports and contact in case of any errors/discrepancies
- Contact number/bleep – if urgent preliminary report required
It is recognised that samples are sometimes not repeatable therefore the department has protocols in place to deal with specimens and accompanied request forms that do not meet the specimen acceptance criteria. A final report will not be issued until such details have been corrected.
As far as is reasonably practicable, when the sample is being processed on the same hospital site as it was taken, the requesting clinician will be required to attend the Laboratory to make any necessary amendments or verify the patient details / source of the sample.
For MFT cases, where it is not possible for the requesting clinician to attend, they, and / or the person raising the order will be contacted by electronic communication (email / HIVE chat as appropriate) and an audit trail will be established to verify the patient details / source of the sample.
For samples from General Practitioners or external clinics we will accept corrections to patient detail discrepancies via email.
All specimen and/or request form amendments will need to have a specimen amendment form completed and / or a printout of the correction email.
If the request form requires edit, either a new form is submitted, or the request form can be edited to represent the amendment in the margin on the form with the initials and date of the individual who collated the information. If amendments are not addressed within seven calendar days, then an incident will be raised in Ulysses.
Any high-risk specimens should be highlighted on the specimen request form and for MFT orders, on the HIVE request.
Request cards
All paper request cards should be completed in full (see above), and all information provided should be clearly legible. Any missing information or errors will result in a delay to specimen processing and reporting.
Correct patient and specimen information is vital for us to provide a quality service to our users. Any specimens deemed to be high risk or potentially high risk should be clearly labelled as such to protect the health and safety of all staff.
As we provide our service to a range of service users, please also state the type of unique patient identification number given, e.g. NHS, district, MRN. Please also indicate whether the patient is an NHS, private or waiting list initiative patient.
Hive requests
Unlike some of the other pathology disciplines, Cellular Pathology (Cytology) still require a request card for all specimens requested on HIVE.
For test requests ordered on the Hive Electronic Patient Record (EPR) system an order requisition printout must be submitted with the request
HIVE generates specimen labels for both the requisition printout and each sample pot created as part of the order entry. Please ensure the correct label is attached to the correct container. HIVE labels must be attached to the specimen container and not to the lid of the container.
Package and transportation of samples
Samples taken at central site must be sent with the porter and not via the pneumatic tube.
Synovial fluid samples requiring transport on the public road must be packaged and transported in compliance with “The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations (ADR Regulations) 2011”. Specimens must be packaged according to P650 instructions with a UN3373 diamond point label – Biological Substance, Category B.
Please note instructions P650 requires three layers of packaging:
- Primary container (e.g. universal tube, vial)
- Secondary container (e.g. specimen bag)
- Outer packaging (e.g. rigid transport box).
The primary sample must be individually bagged in a secondary bag and sealed. If the sample is liquid, enough absorbent material must be added to the secondary bag to absorb a potential spillage of the sample. The request form must be placed in the specimen bag’s separate pouch.
Specimens must then be placed in a rigid box and closed. The box must comply with Transport Regulations. The outside must be clearly labelled Biological Substance Category B, with a UN3373 diamond label. The laboratory address should be clearly written.
- If a sample is sent by post via Royal Mail, please adhere to the packaging guidance available on the Royal Mail website. It is the responsibility of the sender to ensure that specimens are appropriately labelled and packaged and:
- Are sent by first class post or Special Delivery and to inland addresses only.
- The packet is marked with the sender’s name, telephone number and address.
Specimens must be delivered to the laboratory within 24 hours. If there is unavoidable delay in sending the specimen, please keep it refrigerated at 4°C
If possible, send specimens on the first 4 working days of the week as the laboratory is not open at weekends.
All samples must arrive before 13:30hrs to be processed on the same day.
Specimen tracking
Many of our service users have systems in place to track specimens. If specimen acceptance criteria are applied at the time of tracked receipt, the specimen can be returned to the sender quickly should any discrepancy be identified.
Appropriate action in the event of a specimen acceptance failure involving an Urgent / HSC 205 sample is decided at the discretion of the reporting pathologist. The decision to accept and process pending confirmation may be taken based on a dynamic risk assessment to determine potential harm to the patient.
If a specimen has been requested using HIVE, the sender can use HIVE to check whether the specimen has been received.
(Last reviewed February 2025)