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Title: |
Laboratory
Specimen Labeling |
Total Pages: 6 |
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Origination Date: |
March
1996 |
Section: |
General |
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Effective Date: |
January
2003 |
Policy No.: |
GL
15B |
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Prepared By: |
Michael
Stirewalt, MT, SC (ASCP) |
Supersedes
Procedure Dated: |
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Approved By: |
Signature on File |
Date: |
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Network Laboratory Director |
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Approved By: |
Signature on File |
Date: |
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Medical Director
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PURPOSE:
To maintain and to facilitate quality patient care as well as to fulfill safety and legal requirements of appropriate accrediting agencies in regards to specimen labeling, all specimens must be labeled with correct and adequate identifying information; otherwise, further processing and testing cannot be performed.
SCOPE All Laboratory Departments
PREPARATION AND
NOTES
Equipment and Materials:
Admission Labels
Flexilab Labels
Typenex number Label
Specimen Containers with Blank
Labels
Procedure:
This procedure is consistent with JCAHO, CAP, AABB regulations and with standard precautions.
A. All specimen labels must contain the following information:
1) Patient’s complete first and last names
2) Medical record number (Hospital number) or other unique identifying number, such as social security number, hospital account number, and/or date of birth (office chart numbers are not acceptable).
B. All specimen labels must also contain the following accurate and legible information:
1) Name, Initials, or unique identifying Flexilab User Code of individual that collected specimen
2) Date of collection
3) Time of collection
C. Labeling of all specimens requires one of the following:
1) Admissions label (contains all information in step A, above)
2) Flexilab label, (contains all information in step A, above), or
3) Complete handwritten label (in case of inpatients, appropriate with computer downtimes, see downtime procedures).
D. All labels must be compared to the patient’s armband for verification of identification and attached to the specimen at the bedside. The patient, if coherent, or a family member or nurse if the patient is not coherent, must be asked to state the name of the patient, in addition to comparing label to patient’s armband. If outpatient collection, required label information must be verified with patient or patient’s family at point of collection, and while patient is still present.
Note: Labeling of all specimens is the responsibility of the individual performing the collection procedure. Please refer to Patient Identification procedure for further detailed instructions.
E. All information contained on specimen labels must agree with accompanying requisitions; please refer to the Test Request & Outpatient Orders procedure, located in the General Lab Policy Manual, for detailed information and requirements for requisitions.
Specific Transfusion Medicine Requirements
A. If patient presents in need of emergency transfusion services (i.e., patients that are rushed to Birth Place or Cath Lab before being entered into the Hospital Admissions system), an emergency armband (Typenex) may be used. These armbands are designed to correlate positive identification of the blood sample, transfusion request form, and crossmatched units of blood when there is not time for a medical center admitting armband to be placed on the patient, or there is a discrepancy in admitting information. Labeling requirements follow:
1) Patient name, if known, or assigned name such as ‘Doe XXX’, must be clearly visible on the typenex band.
2) Record patient’s name, date, time and initials of person collecting specimen on long label near clip.
3) Remove and place this label on the blood sample tube.
4) Wrap band around patient’s wrist and firmly close clip.
5) Tear off remaining part of band and remove protective backing from the numbered end.
6) Attach typenex number to the labeled blood sample tube and deliver specimen(s) to the Blood Bank.
7) All ‘extra’ labels must be taken to Blood Bank for use on blood unit transfusion record.
8) Armband must remain on patient for duration of hospital stay.
B. Cord blood samples labeled with the mother’s name, medical record number, date, time and initials of the person collecting the specimen will be accepted if the specimen label also is visible marked as “Cord Blood”.
C. Computer printed labels are acceptable if all information is correct. If the patient’s full name does not print on the label, the name must be completed manually by the person collecting the specimen.
Special Note: Do not, under any circumstances, place more than one label on Blood Bank specimens. Blood Bank Staff may use small aliquot labels available in the lab to help with additional specimen identification, but must not cover any of the original specimen labels with these aliquot labels.
Rejection of
Specimens:
A. Unlabeled specimens, mislabeled specimens, incorrect specimen tubes or specimen containers (i.e., incorrect storage temperature, or inappropriate specimen anticoagulant) that arrive in the laboratory will be discarded, and a new collection requested, with the exception of irreplaceable fluids or tissues. Specimens will not, under any circumstance, be returned to patient care area.
NOTE: Refer to Recollection of Specimens procedure for detailed instructions regarding appropriate ordering, notification, and documentation steps surrounding requests for new collections.
B. Irreplaceable fluids or irreplaceable tissues will be dealt with on a case-by-case basis by the technologist-in-charge, resource technologist or manager-on-call.
1. For irreplaceable specimens, the ordering physician or physician responsible for the patient at the time of correction, and the collector (if not the same person) must present to appropriate Laboratory or Medical Mall to:
(a) identify specimen, and certify in writing that the specimen is irreplaceable
AND
(b) verify that the corrected information is accurate before the sample can be processed.
2. The attached Confirmation of Specimen Identification and Information Form (available in the Core Laboratory, Cape Fear Laboratory and Medical Mall) must be completed immediately before the specimen can be further processed. The form requires detailed documentation surrounding the irreplaceable specimen; it includes physician’s signature and collector’s signature sections.
NOTE: If the appropriate physician is not immediately available, the nurse directly involved with the patient’s care must obtain a verbal request from the physician to sign the form. This nurse will document the request on the patient’s chart, and complete/sign the Confirmation of Specimen Identification and Information Form in lieu of the physician’s signature.
3. After completion of the Confirmation of Specimen Identification and Identification Form, the specimen will be processed according to laboratory protocol. A comment will be attached to test results obtained on the specimen to indicate correction of specimen identification. The completed form will then be forwarded to the appropriate laboratory manager, who, after appropriate review and Quality Assurance documentation, will send the completed form to Medical Records for the actual physician’s signature.
Missing or Incomplete
Date, Time, and Initials on Specimen Label:
Missing or incomplete date, time and initials of collector on specimen labels must be obtained by laboratory staff via phone conversation, and documented using the standard Laboratory Variance Report, also attached to this procedure.
4 ATTACHMENTS
AND PROCEDURE NOTES
4.3 REFERENCES:
4.3.1 Standards
for Blood Banks and Transfusion Services. 19th Edition.1999. Pp.
56-58.
Technical Manual. 13th Edition. 1999. Pp. 376-378.
Typenex,
Fenwal Laboratories, Division of Travenol.
4.3.2
7 ATTACHMENTS
7.1 Confirmation of
Specimen Identification and Information Form
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Review Date |
Revision
Date
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Signature |
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Michael Stirewalt |
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Michael Stirewalt |
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Bessie Collins (signature on file) |
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Confirmation of Specimen Identification and Information Form
New Hanover Regional Medical Center/Cape Fear Hospital
Clinical and Anatomic Pathology Laboratories
Wilmington , NC
