For patient safety, each specimen container must have a label firmly affixed
to the container, not the container lid or biohazard specimen transport bag,
that contains the following minimum information:
- Patient’s full name (last name, first name);
- Patient’s medical record number;
- Date of specimen collection;
- Time of specimen collection (time sensitive specimens); and
- Specimen description or anatomic site of the specimen (non-blood body fluids,
microbiology, cytology and surgical tissue specimens).
Properly labeled specimen(s) must be accompanied by a laboratory requisition
(lab tag or electronic order) containing the following information:
- Patient’s full name (last name, first name);
- Patient’s medical record number;
- Date and time of specimen collection;
- Source or site of specimen (non-blood body fluids, microbiology, cytology,
and surgical tissue specimens);
- Preoperative and postoperative diagnosis and clinical history (cytology
and surgical tissue specimens);
- Test(s) requested;
- Collector identification;
- Patient location;
- Ordering physician name and doctor code (senior staff only); and
- ICD diagnostic code (OPD charges and IPD professional charges).
The person that collects a specimen from a patient for laboratory analysis
is responsible for establishing the identity of both the patient and the specimen(s)
at the time of collection. Patient identification must be verified immediately
before any specimen collection procedure using two patient identifiers. Specimens MUST be labeled in the presence of the patient.
- Patients with ID bands will be identified by comparing the name and MRN on the ID band to
the specimen label or requisition.
- Patients who are not required to wear an ID band will be identified by
asking the patient to state their first name, last name and date of birth.
Specimens submitted to the laboratory without the required information will
not be accepted for processing. Unlabeled blood and urine specimens will not
be accepted for testing and may require recollection. Although extenuating circumstances
may exist and some information may be retrievable after specimen receipt by
the laboratory, this will require the licensed caregiver, physician or nurse,
to come to the laboratory to provide the missing information and sign a Specimen
Labeling Resolution form, accepting responsibility for the accuracy of post-collection
labeling. Post-collection labeling (rehabilitation) will be permitted under
the following circumstances only:
- The test is a Vital Value and delay resulting from recollection could compromise
care;
- Clinical reasons exist for avoiding recollection (requires approval of pathologist/division
head, laboratory supervisor, or designee); or
- The patient is unavailable for recollection (requires approval of pathologist/division
head, laboratory supervisor, or designee).
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