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