Specimen Identification Policy
Implemented: May 1, 2000 Revised: June 29, 2010
All patient care departments who submit specimens to the Clinical Laboratory.
To define criteria for identification of specimens to be processed in the Clinical Laboratory.
The Clinical Laboratory will ensure that the following criteria regarding specimen identification be met to assure optimal test accuracy.
A. Each and every specimen container submitted to the Laboratory for analysis must have on the container (not on the lid since it can be removed for processing) the following information:
Patient last name, first name
Medical Record Number
Date and Time of Collection (unless noted on the requisition)
Collectorís initials (unless noted on the requisition)
If the specimen submitted does not meet the requirements listed
above, the following steps will be taken:
1. The requesting physician or the patientís primary nurse will be contacted to define the problem.
2. A specimen with the correct patientís name and medical record number but other information lacking or incomplete may be corrected only by the collector of the specimen.
3. Unlabeled or mislabeled specimens cannot be accepted. The patient care unit will need to recollect unacceptable specimens prior to processing by the Laboratory. Collectors will not be allowed to re-label a specimen that has been discovered to be mislabeled.
4. Exceptions to this policy will be made for the following irreplaceable critical specimens: cerebrospinal fluid, normally sterile body fluids, bone marrow, needle aspirates, tissue/biopsy, surgically obtained specimens, bronchaveolar lavage.
5. If an above-mentioned critical specimen is received, the individual who collected the specimen must personally identify the specimen and sign a witnessed voucher (see attachment 1). If the issue cannot be resolved, the manager on call (688-6135) will be notified and will contact the submitting nurse or physician.
C. Once a non-lab generated labeled specimen is received in the lab, laboratory generated labels are attached by laboratory personnel to the hospital patient label on the tube/container after verifying the name and MRN on the tube match the request form ID. Labeling personnel must include their initials on the tube/container they are labeling. All aliquot lab generated labels must be verified to assure that the aliquot label matches the name, MRN and accession number of the original tube and must include the initials of the person pouring the aliquot. Non-compliance may result in disciplinary action.
D. In the event that a specimen is found to be mislabeled or improperly collected, the section finding the error will review the ordering screen and notify all other sections that may have samples collected at the same time.
**Policy review date and signatures are available and on file in the Laboratory.
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