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. 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 unnecessarily be delayed.
- All test requests ordered on the HIVE Electronic Patient Record (EPR) system must have a request form print out submitted with the sample.
- For non- HIVE requests or paper requests raised during HIVE down time see acceptance criteria below.
The following mandatory information must be provided for us to accept the specimen:
Essential Patient Identifiers:
- Surname
- Forename
- Unique identification number – NHS number, MRN number, external reference
- Date of birth
- Address
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
N.B The only exception to the above policy is donor cornea samples from an Eyebank. When these are sent for investigations for quality assurance purposes only we do not require all the information above. In these circumstances the unique donor number, donation number and D.O.B will be accepted.
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/MRN 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. HIVE generates histology labels for both the requisition form and each sample pot each pot. 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.
Unlike some of the other pathology disciplines, Ophthalmic Pathology still require a request form for all specimens requested on HIVE.
All samples for ophthalmic pathology must be ordered on Hive using ophthalmic pathology or adult histology selection and not paediatric histology or cytology.
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.
Specimen storage
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.
| Specimen | Storage |
| Formalin | Room temperature |
| Dry unfixed | Fridge |
| Transport medium | Fridge |
Dry/unfixed samples such as Vitreous/aqueous specimens and frozen sections must be brought immediately to the Adult histology specimen reception urgently.
Specimens for immunofluorescence that are in transport medium such as zeus or Michel’s medium must be brought to the department as soon as possible but it will not be an issue if they are received 1-2 days after being taken.
Transport of specimens
All specimens should be transported in the relevant fixative or transport medium. All specimen pots should be tightly sealed and transported using specimen bags, where appropriate.
The request card/HIVE request 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 MFT theatres and clinics from internal departments samples will be signed for. For samples from external users any confirmation of receipt forms will be filled in and faxed back.
Please can all HSC and 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 delayed 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 zeus for immunofluorescence specimens should be made to Adult histopathology specimen reception on 0161 276 8808 (68808 internal).
Formalin spillages
Formalin should be handled with care and sent in appropriately sized containers with secure lids to minimise the risk of a spillage. Specimen pots should be secured in a sealable plastic specimen bag.
Each sender who handles formalin should have their own policy or procedure and equipment for handling formalin and dealing with a spill, and should have sourced from a reputable supplier. Spillages should be dealt with as soon as it safe to do so. Salvage of any specimen should be of the highest importance as it is likely to not be repeatable. Specimens must not be discarded.
The sender must inform the laboratory of any spillage where the specimen may have been lost, partially lost or its integrity compromised. This should be reported as an incident and the sending clinician should be informed as soon as possible.
In the event of a spillage please follow local spillage protocols. The Histology laboratory can be contacted for advice Mon-Fri 07:00-17:00 on 0161 276 8806
Our formalin supplier, CellSolv, has issued the following guidance on spillages.
Spillage volumes:
- Minor spillages (up to 200ml) – usually can be dealt with by 1 or 2 staff using simple procedures
- Large spillages (200ml – 5 litres) – require the use of a formaldehyde spillage kit
- Major Spillages (over 5 litres) – should be dealt with by Fire Service
For more information on Formalin and spillages please see Adult Histopathology
(Last reviewed August 2024)