Clinical Laboratory Services


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  • Specimen Acceptability

    Department of Pathology

    Division of Clinical Laboratory Medicine

    University of Mississippi Medical Center

    Prepared and written by:Marilyn B. Bray, BS MT (ASCP), Director of Laboratory Services
    Effective Date:January 1, 2013
    Approved:Bradley Brimhall, MD, MPH, Director of Clinical Pathology
    Purpose:  

     This policy defines the requirements for specimen labeling and laboratory acceptability. The policy also defines the process used when a specimen submitted to the laboratory does not meet the established requirements.

     All specimens must be labeled with the patient's first and last name - no nicknames - and a unique numeric identifier. For inpatients, the numeric identifier is the University of Mississippi Medical Center Medical Record Number that is assigned to a patient at their first visit to the Medical Center. For outpatients, the numeric identifier is the UMMC medical record number or the date of birth. For emergency admission, a special number is given which is then replaced with the permanent MRN. Testing will not be performed on specimens that are not labeled as described. The specimen will be rejected by the laboratory and the test request will be credited.

     The University of Mississippi Medical Center Laboratory system does recognize and permit the re-labeling of the following irretrievable specimens:
     > Blood Gases
     > Neonatal Specimens
     > Body Fluids including Spinal, Peritoneal, Amniotic, etc.
     > Bone Marrow
     > Needle aspirates
     > Timed blood and urine specimens
     > Pap Smears
     > Tissue/Biopsy
     > Microbiology specimens collected through invasive procedures

     However, the individual relabeling the specimen will take full responsibility for confirming the identification of the patient and will be responsible for signing the Specimen Exception Form. No exception will be accepted for labeling without this form.

    Responsibility/Scope

     Individuals employed and deemed competent to draw or collect, submit or receive test specimens must follow this procedure.

    Procedure:
    Requisition Requirements
     All test requests coming to the laboratory must contain the following information:
    1.Patient's complete first and last name - no nicknames
    2.Patient's UMMC MRN or date of birth is also required
    3.Name of the ordering physician
    4.Name of the test ordered
    5.Specimen collection date and time
    6.Location of specimen collection (floor or clinic)
    7.Requisitions submitted for testing on outpatients must include a description of the patient diagnosis or applicable ICD-9 code.
    Specimen Labeling Requirements
    1.

    If the test is ordered in the Epic System, a bar-coded Epic label will be printed at the time the specimen is accessioned. If an Epic label is unavailable, then the EpiCare admission label may be used. The label contains the following information:

     A.Patient's complete first and last name - no nicknames
     B.Patient's unique UMMC MRN
     C.Specimen collection date and time
     D.Test Name
     E.Specimen Requirements: tube type
     F.Accession or order number
     G.Container identification
     H.Collection Date and Time
    2.The label must be placed on the tube length-wise with the bar-code nearest the cap.
    3.If the test is not ordered in the hospital information system, a legible handwritten or typed label must be placed on the specimen. The label must contain the following information:
     A.Patient's complete first and last name.
     B.Patient's medical record number or DOB.
    4.Special labeling situations include the following:
     A.Specimens submitted for type and screen or cross-match.
     B.Specimens submitted for Cytology require the first and last name or unique numeric identifier on the slide or specimen container.
    Specimen Assessment
    1.

    The laboratory staff will not accept syringes with needles attached, or remove a needle from any specimen. In these situations, the laboratory staff will contact staff in the area that collected the specimen and request that they come to the laboratory to remove the needle.

    2.

    Specimens that are leaking from their containers will not be accepted. These specimens will be discarded. In these instances, laboratory staff will credit the test and document the reason for discard in the laboratory system.

    3.

    At the time of specimen arrival in the laboratory, the laboratory staff will compare the identification on the specimen to the identification on the requisition - whether a hand-written procedure or electronic procedure from the LIS.

    4.The patient's name and Medical Record number or DOB on the specimen MUST be the same as the information on the requisition and in the laboratory information system.
    5.If there is a discrepancy, the specimen must be relabeled or recollected. A discussion will follow as to the possibility of relabeling a specimen versus recollection.
    Specimen Relabeling
    1.Irretrievable specimens may be relabeled. Irretrievable specimens include the following:
     > Blood gases
     > Neonatal specimens
     > All fluids (CSF, amniotic fluid, peritoneal)
     > Bone Marrow
     > Needle Aspirates
     > Times Blood or urine specimens
     > Tissue specimens
     > PAP smears
     > Microbiology specimens collected through invasive procedures
    2.Laboratory Staff will verbally notify staff at the collection location of the receipt of an irretrievable specimen. Staff at the location may re-label the specimen. The individual that takes that responsibility must complete the Specimen Exception Form and take full responsibility for properly identifying and re-labeling the specimen. The label used to re-label the specimen must meet the criteria listed above in Step 1.
    3.Laboratory Staff will make an order entry comment in the BEAKER system when a specimen is relabeled.
    4.The laboratory staff will not allow a mislabeled specimen to be relabeled if, in their professional opinion, the correct identification of the specimen is in doubt.
    Completion of the Specimen/Requisition Exception Form
     Staff identifying a mislabeled specimen or requisition must complete a Specimen/Requisition Exception Form:
    Specimen/Requisition Exception Form.