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. Due to the difficulty in repeating a tissue specimen, different criteria are used in Adult Histopathology.
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 to determine the length of fixation of the tissue specimen.
Specimen Acceptance Policy
All Ophthalmic specimens sent for histology and /or cytology must comply with our specimen acceptance requirements. If the correct information is not present then the specimen may be unnecessarily be delayed. All fields on the Ophthalmic Pathology request card/ICE request should be completed to ensure efficient and effective investigation of the specimen.
The following mandatory information must be provided for us to accept the specimen:
Essential Patient Identifiers:
- Unique identification number – district for Central site, EMPI for Trafford, NHS or external hospital number for external cases
- Date of birth
Essential Clinical Details:
- High risk status – to ensure health and safety of all staff
- Specimen site – must match on specimen pot and request card
- Relevant clinical information
- Reconstruction date if urgent processing required
- Date/time taken – essential to ensure proper fixation of high risk specimens
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 – for verbal reports, and frozen section
Each specimen container, no matter how small, must also be labelled with the appropriate patient identification data (minimum of 3 identifiers e.g. first and last name, date of birth/age, gender and preferably patient’s NHS/Hospital No). The information must be consistent with the request form, to prevent errors in specimen and patient identification. Multiple specimens from the same patient should also identify the specimen type/site.
Specimens that do not contain the required information or have discrepancies between the request card and specimen pot will not be processed in the laboratory until the necessary information has been obtained. The sender will be contacted to attend the laboratory to complete any missing information or correct any mistakes. The person correcting the patient or specimen details should be of appropriate seniority and able to take responsibility for the labelling of the specimen. This will result in a delay to specimen processing and reporting.
For some external users we will accept corrections to patient detail discrepancies via email.
Prior to transport to the laboratory, it may be necessary to temporarily store specimens. All specimens that are placed into Formalin should be kept at room temperature until transported to the laboratory. Specimens in Formalin should not be placed into the fridge as this will have a negative impact on fixation and therefore preservation of the tissue.
|Gel transport medium||Fridge|
All dry specimens and specimens in gel transport medium ideally should be
transported to the laboratory immediately. Where this is not possible, these specimens should be stored in the fridge.
Transport of specimens
All specimens should be transported in the relevant fixative or transport medium as indicated below in section 5. All specimen pots should be tightly sealed and transported using specimen bags, where appropriate. The request card should be placed in the pocket of the specimen bag, and the pot inside the sealed bag to ensure the safety of all staff.
Specimens can be delivered to the Adult histopathology specimen reception throughout the day.
If a porter brings specimens from the theatres and clinics from the Royal Eye Hospital the samples will be signed for. For samples from other organisations any confirmation of receipt forms will be filled in and faxed back.
Please can all urgent specimens be clearly labelled as such to ensure that they are dealt with in the appropriate manner. This is particularly important for temporal arteries and specimens requiring urgent processing for reconstruction.
All specimens sent in the post should 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.
Requesting Formalin pots/gel tubes
Any requests for formalin pots or gel tubes for immunofluorescence specimens should be made to Adult histopathology specimen reception on 0161 276 8808 (68808 internal).
The department uses 10% neutral buffered Formalin (4% formaldehyde) and this should be handled with care at all times.
Acute Toxicity Category 4 – Harmful if inhaled
Skin Sensitizer Category 1 – May cause an allergic reaction
Carcinogen Category – 1B May cause cancer
Mutagen Category 2 – Suspected of causing genetic defects
All solutions containing formalin are suspected carcinogens, mutagens and sensitisers. The solutions should be handled with care, minimising skin contact. Safety equipment including gloves should be worn and any spill on the skin should be washed as soon as possible.
In general, formalin solution, like any other chemical should be treated with respect. Handle with care and avoid any situations which could potentially result in formalin spillage.
Formalin can be disposed of down a sink suitable for clinical waste with copious amounts of running water in a well-ventilated room.
In a hospital environment formalin is mostly handled in very small containers with less than 100ml of 10% formalin solution. A spill of this size is unlikely to contaminate the air to dangerous levels if dealt with promptly. The spill can be wiped up with absorbent material by staff members wearing suitable impervious gloves such as nitrile gloves. The contaminated material should be sealed in plastic bags for disposal and removed from the room as soon as possible. It is important not to simply dispose of the contaminated material in an open bin as the formaldehyde will continue to contaminate the air. The area should be rinsed with water.
For more information on Formalin and spillages please see Adult Histopathology
(Last reviewed February 2019)