SPECIMEN LABELING REQUIREMENTS
UC Irvine Pathology Services has established a uniform policy for specimen acceptance/rejection that:
- Has a positive impact on patient care
- Protects specimen quality
- Eliminates risk of exposure to the healthcare worker
- Complies with all accreditation standards
To protect patients from adverse errors made due to improperly labeled specimens, the laboratory policy demands that proper labeling criteria are always met. Every specimen brought to the laboratory must have a label on the container in which it is held. It is not acceptable to label only the lid, transport bag, or other container used to transport the specimen. The label must contain the following legible information:
- Patient name
- Patient medical record number, with check digit
- Patient location
- Collection date and time
- Specimen type and/or source
- Test required (note any special handling required)
- Ordering physician
When available, use the addressograph to enter all data on a prepared label being sure to fill in the additional information required that is not on the addressograph plate.
For patient safety, it is essential that the following be adhered to when submitting blood specimens for CROSSMATCHING purposes. Use special pink-top (EDTA) tubes.
- Take a Crossmatch/Transfusion form, patient printed labels with the patient's first and last name, patient file number (PF#) or medical record number (MR#), and 1 pink-top (EDTA) tube to the patient's bedside.
- Verify the patient's identity by asking the patient to state and spell his/her name, if able, while comparing the patient's identification band with the addressographed Crossmatch/Transfusion form and the patient's printed label.
- The patient's name and PF# or MR# must be obtained from the patient's identification wristband. If the patient does not have a wristband, a wristband must be obtained prior to drawing the patient's blood.
- Write the following data on the patient's printed or computer-generated gummed label at the bedside:
- Date of phlebotomy
- Time of phlebotomy
- Legibly printed last name of phlebotomist
- Affix the patient's printed gummed label to the specimen tube at the patient's bedside.
- Send the labeled specimen tube with the Crossmatch/Transfusion form to the Blood Bank.
If the Blood Bank does not have a previous ABO/Rh on file for the patient, and the patient's initial blood type is other than type O, the Blood Bank will request a second sample to be collected for an ABO/Rh confirmation.
Failure to properly label the tubes will require that the specimens be redrawn. If the patient requires blood as an emergency and another sample cannot be drawn, an Emergency Release Form must be signed for uncrossmatched group O blood.
Specimens must be accompanied with a specimen transmittal or clinic encounter form that must match the specimen label. All handwritten requisitions accompanying specimens must have the following legible information:
- Last, first, and middle name of patient
- Medical record number (8 digits)
- Patient’s date of birth
- Last and first name of ordering physician
- Nursing station or clinic originating requestTest(s) or procedure(s) requestedSpecimen source and body site
- Date and time of specimen collection
Specimens must be submitted in the correct tube type or appropriate transport material in a leak-proof container. It is the caregiver’s responsibility to understand the correct specimen and transport requirements prior to collecting specimens.
All patient specimens MUST be placed in biohazard bags for transport to the Laboratory.
Laboratory procedures will not be performed on unacceptable specimens. Specimens collected using the incorrect tube type and transport material will not be tested. Specimens received showing evidence of leakage will not be tested. The nursing station from which the specimen originated will be notified.
Specimens received unlabeled, double labeled, or with a requisition bearing a name and/or medical record number different than what is affixed to the specimen will not be tested. The patient’s nurse and/or physician will be notified to recollect the specimen.
- Any specimen is unlabeled if the container holding the specimen (test tube, urine container, surgical specimen container, etc.) does not have the patient’s first and last name, medical record number, collection date and time, specimen type, and test required on it.
- A specimen is mislabeled if it arrives in the laboratory with a requisition bearing different names on the requisition and the label OR if the name in the computer does not match the label. The laboratory will consider a mislabeled specimen an unlabeled specimen.
- Blood Bank sample labels (crossmatch or type & hold) must be handwritten. Addressograph labels must not be placed on crossmatch specimens.
A specimen is incompletely labeled if some of the required information is missing:
- If the name and the medical record number are missing, the specimen will be considered unlabeled and handled as such.
- If there is any other information missing, the location where the specimen originated will be called to supply the information.
Specimens identified as precious specimens such as ascites fluid, amniotic fluid, cerebrospinal fluid, joint fluid, pleural fluid, surgical tissue/aspirate and certain timed specimens where the specimen cannot be recollected without undue harm to the patient will be tested only if the following conditions have been satisfied:
- The patient’s physician must be notified. He/she must agree to accept responsibility for the specimen and give written authorization for testing.
- In addition, the pathologist on call must be notified. He or she must review the circumstances and give written authorization for testing.A licensed caregiver designated by the patient’s physician must identify and correctly label the specimen.
- It will be documented in the laboratory computer system that the test was performed on an unlabeled specimen so that this information appears on the preliminary and final reports.
Receipt time of the specimen in the laboratory will be the time all information is obtained, not the time the incorrectly submitted specimen was first brought to the laboratory.
The Blood Bank requires a new specimen for each unlabeled or mislabeled specimen, no exceptions.