Page 1 of 2 DESCRIPTION/OVERVIEW Laboratory Specimens must ...

Applies To: All HSC Hospitals
Component(s):
Responsible Department: Laboratory
Title: Specimen Labeling
Procedure
Patient Age Group: ( ) N/A (X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult
DESCRIPTION/OVERVIEW
Laboratory Specimens must be labeled correctly to ensure proper patient identification as well as
the safe handling and processing of the specimen.
REFERENCES
UNMH Patient Identification Procedure
CAP GEN.41096 regarding reporting time and date of specimen collection
CAP GEN.40490 regarding patient identification
CAP GEN.40491 regarding mislabeled specimens
CAP GEN.40496 regarding collectors initials
CAP GEN.40750 regarding specimen label elements
AREAS OF RESPONSIBILITY
Lab responsible for reporting mislabels
Nurses, physicians, aides, techs, paramedics, etc. responsible for making sure procedure is
followed and label has correct elements.
PROCEDURE
1. Properly identify patient at the bedside by performing a pre- collection comparison of the
armband and the label/requisition. Verify that all identification elements match. This includes
patient name, medical record number and date of birth.
1.1. If the patient is not wearing an armband or the information on the armband has a
Discrepancy, do not collect the specimen until information is updated/corrected.
2. Obtain specimen using proper technique and label immediately at the bedside.
3. Perform a post collection comparison of the armband and the label/requisition. Verify
that all identification pieces match. This includes patient name, medical record number
and date of birth.
4. If able, show patient their labeled specimen and ask them to verify name and date of birth
on the labeled specimen.
5. A properly completed specimen label contains five information elements:
5.1. Patient Name
5.2. Medical Record Number or Date of Birth
5.3. Date of Collection (must be on the label)
5.4. Time of Collection (must be on the label)
5.5. Collector’s initials (must be on the label).
6. Ensure all identification pieces on requisition match specimen. This included patient name,
medical record number and /or date of birth.
7. For any body fluid (other than blood),microbiology or surgical pathology specimen, indicate
specimen source/type on label.
_________________________________________________________________________________________________________________
Title: Specimen Labeling
Owner: Executive Director of Diagnostic Services
Effective Date: 9/5/07
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8. Place specimen and requisition in plastic bag.
8.1.Use red bag is STAT specimen.
8.2.Use clear bag with orange biohazard label is ASAP, Routine or Timed Study specimens.
9. Deliver specimen to the laboratory.
10. If one or more of the five required information elements are missing from the label, the
specimen is considered mislabeled. The collector will then be notified to recollect the
specimen and a variance report via Patient Safety Net will be completed by the laboratory
within twelve hours of the incident.
CRITERIA FOR SPECIMEN REJECTION:
1. Specimen and requisition match but do not match in the hospital information system and/or
laboratory information system.
2. No label affixed to specimen,
3. Label affixed incorrectly on the specimen. An example of an improperly labeled specimen
would be a urine container where a label has been affixed to the lid, instead of the container
itself.
4. Plastic bag or requisition labeled with patient information, but specimen inside bag is not
labeled.
5. Specimen label is missing any one of the five required data elements.
6. Labeled specimen does not match requisition.
RESOURCES/TRAINING
Resource/Dept
Internet/Link
DOCUMENT APPROVAL & TRACKING
Item Contact Date Approval
Owner
Executive Director, Diagnostic Services
Consultant(s)
Steve Crabb, Project Consultant
Committee(s)
Education Council
Nurse Practice Council
Clinical Operations PP&G Committee
Y
Nursing Practice Counsel
Nursing Officer [Name], Chief Nursing Officer [Y or N/A]
Medical Director/Officer [Name, Department (or Chief Medical Officer)] [Y or N/A]
Human Resources [Name], HR Administrator, [UNMH or UNM] [Y or N/A]
Finance [Name, Title], [UNMH or HSC] [Y or N/A]
Legal [Name, Title], [UNMH or HSC] [Y or N/A]
Official Approver Amy S. Boule, Administrator, Professional Services Y
Official Signature 9/5/07
2 nd Approver (Optional)
Signature
[Day/Mo/Year]
Effective Date 9/5/07
Origination Date
[Month/Year]
Issue Date
Clinical Operations Policy Coordinator
_________________________________________________________________________________________________________________
Title: Specimen Labeling
Owner: Executive Director of Diagnostic Services
Effective Date: 9/5/07
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