Specimen Submission Guidelines

2018 Specimen Submission Guidelines

Our laboratory has noticed an increase in the number of specimens that are submitted to our laboratory that are mislabeled, lacking patient identifiers, and/or unlabeled.

Our goal is to adhere to Joint Commission (JC) and the requirements set forth in the #1 Hospital National Patient Safety Goal (NPSG.01.01.01): Identify Patients Correctly.

This standard requires two unique patient identifiers and JC further specifies that the two identifiers be on both the requisition/order AND the specimen label.

As part of our OSF quality culture and mission, we are dedicated to following these regulations in order to ensure the highest level of safety for the patients we jointly serve.

GUIDELINES THAT MUST BE FOLLOWED WHEN SUBMITTING LAB SPECIMENS TO OSF SYSTEM LABORATORY

  • Specimen label must contain the required two, unique identifiers. The two identifiers on the label must match the corresponding identifiers on the order/requisition.
  • Label the specimen in the presence of the patient along with patient (whenever patient is capable), jointly verifying accuracy of the patient identification information.
  • Surgical pathology specimens must be labeled and requisitions prepared in the room where the surgical procedure is performed.
  • OSF requires two identifiers:  The patient name (full first and last) and patient date of birth (DOB).

Unless the specimen is deemed irretrievable by one of our pathologists/lab leadership staff, specimens lacking the two accurate identifiers on the label must be rejected.

*Irretrievable specimens are specimens that are extremely difficult or impossible to recollect due to the nature of the specimen or due to unique circumstances under which the specimen was obtained. These types of specimens are usually body fluids obtained via invasive procedures, bone, bone marrow, CSF, non-gynecological specimens obtained via invasive procedures, post-mortem specimens, synovial fluid, tissue (pathology), and cord blood. Samples such as clinical blood samples, urine, swabs, and PAP samples, are not irretrievable in nature and specimen rejection due to labeling errors must occur in order to be compliant regulations and patient safety goals.

Specimen Labeling - Best Practices

  • Whenever possible, use computer generated labels.
  • If a hand-written label is absolutely necessary, in addition to patient ID verification at the time of the draw, strongly consider having a second verification, performed by staff, of hand-written information.
  • Ensure proper placement of label on collection container. For example, for pathology specimens, do not place the label on caps/lids, as the lid is not permanently attached to the collection container and there is risk of losing the label.
  • If a surgical/pathology specimen requires documentation of collection site and/or source, carefully ensure that the specimen identifying information on collection container matches exactly with the specimen information on the order or requisition.

Please know that we must adhere to these specimen rejection guidelines in order to fully ensure patient safety.

As you may know, most laboratory errors are not analytic in nature but rather pre-analytic and often linked back to specimen labeling issues.

Your assistance in ensuring the best patient care and adherence to regulatory standards is highly appreciated.

It is always difficult to reject a specimen, yet if best labeling practices are followed, these situations should be very limited.