Policies and Procedures

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Collection and Handling Procedures

Division of Clinical Pathology Laboratory Medicine

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

This procedure manual, “Collection and Handling Procedures," has been developed to provide laboratory, nursing or other collection personnel with guidelines pertaining to the procedures and policies associated with the collection and handling of laboratory specimens. These procedures will ensure that regulatory guidelines are met and a proper specimen is submitted to provide quality results for our patients and clients. Information provided in this document may change to reflect new policies or changes in techniques.

Proper patient identification

 Because positive patient identification is such a crucial aspect of the blood collection process, the collector of a specimen for laboratory testing must insure the specimen is positively identified. In accordance with the College of American Pathologists and the Joint Commission on Accreditation of Healthcare Organizations guidelines, the laboratory has developed a set of policies and procedures to ensure the positive identification of all patient specimens, specimen types and aliquots. Each specimen container submitted for laboratory testing must identify the patient uniquely. All primary collection containers and aliquots will display a unique label which will allow an audit back to the specifics of each submitted specimen. Information necessary on all patient specimen containers submitted for testing are: patients full name, University of Mississippi Medical Center's unique Medical Record Number, collection date/time and initials of collector. Other data may include test name, specimen accession number, date of birth, gender, etc., depending on the test request. Emergency admissions will be covered in a separate policy. 
 Responsibility for this procedure will be directed to all staff collecting patient specimens submitted to the laboratory system of the University of Mississippi Medical Center for testing.
 Specimens included in this policy will include all blood, body fluids and tissue specimens submitted by phlebotomists, nursing staff, physicians and other healthcare workers deemed collection personnel by the University of Mississippi Medical Center.
 Labels generated by the Epic system are the preferred method for labeling specimens. This label will incorporate all identifying information. Check labels against the patient's armband. 
B.Labeling Procedure
 This procedure is specific for patients who have been successfully admitted to the University of Mississippi Medical Center for in-house treatment or admitted as a University of Mississippi Medical Center out-patient receiving treatment from a UMMC based physician.
1.Labeling of specimens must occur in the presence of the patient, at the bedside.
2.Regardless of the label used, after a successful phlebotomy procedure, the healthcare worker collecting the sample must note their initials, time and date of collection on each label. The sample will be discarded if information is not available on each specimen container submitted to the laboratory.
3.All labels used must be legible, each with required 2 unique identifiers corresponding to the information on the physicians order. Unique identifiers acceptable by the University of Mississippi Medical Center for labeling on submitted specimens for testing are Patient's name and UMMC Medical Record Number.
4.When affixing the labels, labels must be straight and smooth to allow for reading of the bar-code.
5.Apply only one (1) label to each tube or container.
6.Tube should be appropriately filled.
7.Use added care when affixing labels to Microtainer tubes.
8.In addition to required information on labels, Microbiology specimen labels must contain the specimen source.
9.Ensure tube is shipped following laboratory guidelines, i.e., ice, etc. Place the specimen in a zip-lock specimen transport bag. Bags should contain specimens from 1 patient only. Any unused labels should be sent to the laboratory in the outside pouch of the zip-lock bag.
 Specimens may be submitted to the laboratory through the tube system, hand or courier delivered. Spinal fluids, stool specimens, blood cultures or other microbiology test requests, urines and surgical specimens should be hand delivered. When in doubt, do not tube and call the laboratory at 5-9777 for correct delivery information.
10.Labels for routine draws are printed to the phlebotomy area 30 minutes before each scheduled regular phlebotomy round. Test requests must be completed and released for these labels to print to the laboratory for “laboratory-collect”. 
 Patients coming for diagnostic testing only.
1.Patients presenting to the outpatient laboratories of the UMMC laboratory system must have a written order from the referring physician. The two forms of ID acceptable on this request are the patient's name and date of birth. The unique UMMC MRN will be given during the registration process at which time other pertinent information may be required of the patient.
2.After the registration process is complete, the procedure for labeling patient specimens submitted for laboratory testing will be identical to the in-patient procedure.
3.Specimens sent to the laboratory for reference testing by previously approved clients/customers will be required to contain the patient's name and date of birth. These patients will be given an account number that will follow the patient through the testing process.

Reduce results wait if you get your label straight!
Correctly labeled tube!