In this section
This policy ensures adequate identification criteria for pathology specimens and request forms in order for them to be accepted by the laboratory for analysis.
It is the requester’s 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).
Inadequately or inaccurately labelled specimens or forms will not be accepted unless they are considered to be ‘unrepeatable’.
A classification of ‘unrepeatable’ will be on an individual basis and 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.
The MMMP will monitor the specimen acceptance policy, if the number of samples rejected is greater than 2%, an investigation will follow to so we can work with users to improve compliance.
Specimens greater than 3 days old are, in general, unacceptable. In practice some samples may be requested in advance of collection e.g. CPE ward screens. CF samples which are sent through the post are accepted up to 5 days after date of collection.
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 last name and first name.
Clinical and 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.
| 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. |
(Last reviewed March 2023)