In this section
The laboratory considers the best interests of the patient in receiving care. Poor specimen collection, labelling and transport can lead to repeat collection, delayed testing, with potential delays in diagnosis and treatment. This policy aims to reduce risks to patient care in the pre- examination process, the policy ensures adequate identification criteria for Pathology specimens and request forms for them to be accepted by the laboratory for analysis. It is the requesters responsibility to ensure that all details are correct, clearly written and that the specimen details match those on the form and patient wrist band (if applicable).
| ORC Mandatory Labelling Requirement | Action by Laboratory if requirement not met |
Samples MUST be labelled with 4 unique identifiers which are as follows:
The request form (if required) data MUST match the above information on the sample. Multiple samples taken at different times on a patient MUST be labelled on the sample container with the time (24 hr clock) when the sample is taken. |
No analysis will be performed. The event will be reported as an incident on Ulysses if appropriate.
Where the sample is repeatable/reproducible, no analysis will be performed and the sample will be discarded. Where the sample is unrepeatable/unreproducible, the risk to the patient of rejection of the sample must be weighed against the risk of acceptance of a wrongly labelled sample, local procedures will be followed. Laboratory Medicine will accept no responsibility for samples analysed which initially failed to meet the acceptance criteria and will issue a disclaimer on such reports.
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If a request form is required then the request form data MUST match the above sample information
Request forms SHOULD also contain:
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A lack of patient or sample information may result in the laboratory not conducting the analysis/examination.
Examples could include:
It may not be possible to issue a report or to interpret results. Appropriate comments will be made on the report where this can be issued. |
Inadequately or inaccurately labelled specimens or forms will not be accepted unless they are considered to be ‘unrepeatable’ (e.g. a CSF or BAL sample). In these exceptions, the risk of accepting the sample against the risk of not accepting the sample has been considered. In these cases the requester may be required to come to the laboratory to amend their request information and to document that they have done so. Any labelling discrepancy will be included on the pathology report. Inadequate or Inaccurate labelling results in delays before pathology results are available and hence affects patient care.
Specimens greater than 3 days old are, in general, unacceptable. Do not request a test in advance of sample collection. The laboratory uses the collection date to determine how old the sample is on arrival at the laboratory. If the recorded date of collection is a day or two before the actual collection, then the laboratory may not accept or test the sample because it is too old. CF samples which are sent through the post are accepted up to 5 days after the date of collection.
When a compromised clinically critical or irreplaceable sample is accepted, after consideration of the risk to patient safety, the final report will indicate the nature of the problem and where applicable, advising caution when interpreting results that can be affected.
Remember One Bag One Patient
Where multiple patient samples are received in one bag samples will be rejected, as we cannot ensure that the samples were collected correctly and are from the right patient.
Any samples that require testing in multiple departments must be separated and transported in separate specimen bags. The pathology departments are not joint and are spread over three buildings so putting Biochemisty, Cytology and Microbiology samples in one bag will lead to a delay in processing the patient sample.
Please use one patient specimen, one test per bag.
Anonymous/uniquely identified specimens and requests
In certain circumstances, patient identification details are intentionally hidden or substituted with particular ID numbers (eg. Sexual Health, Clinical trials, donor specimens), in such instances, a properly coded identifier must be used in place of the patient lastname & firstname.
Clinical & epidemiological information
To ensure samples can be safely and appropriately tested in the laboratory, information including details of foreign travel, symptoms and known or suspected contact with other patients known to have communicable disease is important.
For example, samples likely to contain high risk pathogens [as described by the Advisory Committee for Dangerous Pathogens] are handled at a higher containment level to safeguard both laboratory staff and other downstream workers.
The information is also of benefit to the patient ensuring that appropriate testing is performed to safeguard the patient and benefit their patient journey.
To ensure safe, accurate and clinically appropriate collection and pre-examination storage, the laboratory provides instructions for the;
- verification of the identity of the patient from whom a primary sample is
- verification, where relevant, that the patient meets pre-examination requirements [e.g., fasting status, medication status, (time of last dose, cessation), sample collection at predetermined time or time intervals, etc.].
- collection of primary samples, with descriptions of the primary sample containers and any necessary additives, as well as the order of sample collection where relevant.
- labelling of primary samples in a manner that provides an unequivocal link with the patients from whom they are collected.
- recording of the identity of the person collecting the primary sample and the collection date, and, when needed, recording of the collection time.
- requirements for separating or dividing the primary sample when
- stabilisation and proper storage conditions before collected samples are delivered to the laboratory.
- Safe disposal of materials used in the collection
(Last updated November 2024)