This policy defines labeling requirements for acceptance of samples by laboratory personnel and defines criteria for rejection of samples in the routine setting.
Sample Labeling Requirements
Before collecting/labeling the sample, the patient identity must be confirmed. If any discrepancy in patient identification exists, it must be resolved before collecting the sample. Confirm identity by either:
Inpatients, Emergency, Surgery: Comparing the computer generated label, or requisition to the patient wristband.
Outpatients: Having the patient state his/her name and DOB.
- Label the sample in the presence of the patient with complete patient identification by either:
Manually labeling the sample container with:
Full Legal Name (last name, first name)
DOB or Medical Record Number
Source/Site – if required, see below.
Applying a computer generated bar-coded sample accession label after comparing the label to the wristband or confirming with the patient verbally. The date and time of sample collection and initials of the individual collecting the sample must be indicated on the large label. Include site/source if required, see below.
- Sample Source/Site- For most routine venipuncture blood samples it is not necessary to indicate the source or anatomic site of the collection. In general, it is assumed that the source is venous blood and collection site is peripheral venipuncture. For some samples, the source is implied in the pre-printed label order, such as urinalysis, urine for drugs of abuse, CSF culture, etc. If the source cannot be implied or assumed the sample source/site must be written on the container label and indicated on the request form. Some examples of this include:Blood collections from arterial, capillary, indwelling catheters (example: arterial line)
- Blood samples for renin studies collected from specific anatomical sites (right renal artery, left renal artery, etc.)
- Blood cultures
- Body fluid samples (example: right pleural, left pleural, peritoneal, pericardial, synovial, CSF, etc.)
- Tissue, needle aspirates, swabs for microbiology, culture and/or anatomic pathology.
- Urine for culture or cytology – specify collection method (midstream, clean catch, catheter, cytoscopic, or suprapubic).
Additional Labeling Requirements
Samples for blood bank testing including: Type & Screen, PAT Type & Screen, RHIG Workup, Crossmatch, BB Hold, or BB Specimen Hold; require an additional labeling protocol.
- Obtain a Blood Bank identification band.
- Verify the patient’s identity by checking a standard wristband AND, when possible, asking the patient to state full name and DOB.
- Write the patient’s last name, first name, unique identifying number (date of birth and/or medical record number), date/time and phlebotomist’s initials on the Blood Bank identification band. Use a ball point pen.
- Place the identification band in the red Blood Bank band sleeve.
- Loosely wrap the band once around the patient’s wrist (dominant hand preferred), number side out, and place the tab in the clip. Firmly close the clip. Cut off remaining section of sleeve and discard.
- Instruct the patient to keep this Blood Bank identification band on during the entire admission.
Perform the venipuncture on the patient. Apply barcode label or manually label.
- NOTE: If the Blood Bank identification band is missing or illegible, the patient must be re-banded and new samples must be collected for the Blood Bank.
Remove a small Blood Bank identification number from the Blood Bank identification band/label form, and place it on the tube of blood. Put date, time and initials on the label. The person performing the venipuncture MUST label the sample.
Complete the “Blood Bank Identification Form”
Anatomic Pathology Samples
- NOTE: If a subsequent Blood Bank is collected during the patient’s admission, write the Blood Bank identification number (letters and numbers) from the patient’s Blood Bank identification band on the sample barcode label (do not obscure the barcode or patient information).
Sample source/site information – For pathology samples it is important to identify the exact anatomical site of collection on the sample container (not the lid). It is not acceptable to merely label a sample as “lesion”, “tumor,” “metastasis” or “leg.” Give the specific source (such as liver, lymph node, skin or soft tissue) and further clarify the site if possible (such as right lobe of liver, right cervical lymph node, skin left cheek or soft tissue right calf). Indication of the procedure may also be warranted (e.g. biopsy, excision, incision, LEEP, partial resection, total resection). The sample source must be clear and include laterality (right versus left). This information serves as an additional safety check regarding prevention of wrong site surgeries.
- If multiple samples, label with numbers (preferable) or letters
- If the source is lengthy, use a number or letter with an abbreviated source on the container (e.g. 1. skin, right leg) and put the full source on the requisition (e.g. 1. skin, right leg popliteal fossa)
Slides for Microscopic Examination
- Name – Last name, First name
- Identifying number – medical record number or date of birth
- If multiple slides are submitted, put source on slide
Requisition Requirements and Clinical Information
Paper requisitions are required for all samples except for those ordered in Cerner Millennium (ERNE) or Cerner Classic LIS.
- Full Legal Name (last name, first name) – must match sample
- DOB or Medical Record Number – must match sample
- Source/Site – except for routine venipuncture
- Patient Location
- Date and Time of Sample Collection
- Initials of individual collecting sample
- Provider ordering test
- Pertinent Clinical information
All samples for surgical pathology, and cytology must have detailed clinical information indicating the reason for the procedure and the clinician’s impression. This information includes signs/symptoms and specific questions that need to be addressed. A simple “rule out ___” statement is not adequate clinical history for processing a sample. The signs/symptoms should precede any “rule out” statements.
Exception Handling & Criteria for Rejection of Samples
The classification of a sample being replaceable or irreplaceable is defined below. Exceptions to this should be made at the discretion of the ordering provider in conjunction with the laboratory supervisor, charge person and/or on-call pathologist.
Replaceable samples - Blood, urine and gynecologic cytology samples (Pap smears)
Irreplaceable samples - Tissue, non-gynecologic cytology samples, body fluids, CSF and some timed blood/urine samples
The following are criteria for rejection of samples:
- Not labeled with a minimum of Full Patient Name, and identifying number (DOB or MRN);
- Sample has exceeded established time limits for preservation;
- Sample has been collected in an inappropriate container, preservative or anticoagulant;
- Sample has been collected in an inappropriate manner (i.e. tube improperly filled or clotted samples in anticoagulant tubes);
- Sample is in a sample container that is broken or leaking.
When unacceptable samples are received, laboratory personnel will notify the ordering provider of the rejection.
- Replaceable samples will then be discarded.
- Irreplaceable samples - laboratory personnel will notify the ordering provider and request an appropriate individual to come to the laboratory to identify the sample and correctly label the sample. This individual will be required to complete and sign an Identification of Irreplaceable Specimen form. If the provider is off-site, the sample, requisition and an Identification of Irreplaceable Specimen form will be sent back to the provider.
Samples Missing Other Required Information
Samples that are missing other information (other than missing and/or discrepant patient identifiers) will be held and NOT PROCESSED until the appropriate information is obtained from the ordering provider or appropriate clinical staff. Samples that are missing required information may incur delays in processing and reporting until the required information is obtained. Some sample processing delays may result in the sample not being able to be processed if it exceeds established time limit for preservation.
Examples of this missing information may include:
- Not accompanied by a complete written request or computerized request;
- Missing initials of the collector;
- Missing collection date and time on the sample container/request
- Missing source/site information when required
- Missing required clinical information when required