/ Policy Title: SPECIMEN LABELING AND
MANAGEMENT
Category: Patient Care
Number
Date Originated:
October 2013 / Effective Date:
Last Review Date:

PURPOSE:

Accurate and efficient management of patient specimens.

EQUIPMENT:

  1. Specimen container according to type of specimen ordered
  2. Patient label - Note: at PSHMC this is a regular printed patient label. At PHFH it is a printed label with a laboratory barcode and each label is matched to a specific tube type and the test(s) ordered.
  3. All specimen labels must include at least two patient identifiers AND date and time
  4. Requisition forms are required to accompany all non-blood specimens sent to the lab with the following exceptions:
  5. Infusion samples- Gentamicin and Vancomycin (HF only)
  6. Blood Bank Transfusion Requests (must use Blood Service requisition)

POLICY:

Labeling and management of specimens will comply with the following:

  1. Verify that the lab order is in the electronic system prior to sending any specimen to Lab.
  2. Identify the patient utilizing positive identification which includes 2 patient identifiers. Usually this is the patient name and one of the following: medical record number, account number or date of birth. Note: the room number is NEVER used as an identifier.
  3. Confirm correct patient by comparing the patient identifiers on the patient ID band and the label(s), and the correct specimen to be obtained prior to collecting the specimen.
  4. Staff member collecting the specimen is to note the date and time of collection on the label and place the label on the specimen container in the presence of the patient.
  5. No specimens are to leave the patient room unlabeled.
  6. Label is attached to side of the container - not on lid or Ziploc bag.
  7. A requisition must accompany all non-blood specimens.
  8. Specimen should be taken to the laboratory as soon as possible. To prevent decomposition.
  9. Avoid contaminating the outside of containers. Be sure that cap on container is tight.
  10. At time of hand off, if specimen is not collected by the end of shift, communicate in end of shift report that a specimen is still needed.
  11. Send only one patient’s specimen in each transport bag in the transportation tube.
  1. No unlabeled specimens will be accepted. Unlabeled or incorrectly labeled specimens must be recollected to assure positive specimen identification.
  2. In the case of microscopic slides, the label must be on the slide itself. It is not sufficient to label the slide holder alone.
  3. In situations where the patients’ name is not known, the staff will use the patient’s MRN number as the identifier.

NOTE: Improper management may have serious consequences for a patient. Responsibility for errors

and for actions that do not follow this policy will be progressive discipline up to and including

termination.

REVISION HISTORY
Date of Revision / Revision Explanation / Author
October 2013 / Blending of IILLC and PHS policies.