Specimen Acceptance Policy - MMMP
This policy ensures adequate identification criteria for
pathology specimens and request forms in order for them to be
accepted by the laboratory for analysis.
It is the requester's responsibility to ensure that all details
are correct, clearly written and that the specimen details match
those on the form and patient wrist band (if applicable).
Inadequately or inaccurately labelled specimens or forms will
not be accepted unless they are considered to be
A classification of 'unrepeatable' will be on an individual
basis and in these cases the requester may be required to come to
the laboratory to amend their request information and to document
that they have done so.
Any labelling discrepancy will be included on the pathology
report. Inadequate or inaccurate labelling results in delays before
pathology results are available and hence affects patient care.
|CENTRAL SITE Mandatory Labelling
||Action by Laboratory if requirement not
Samples MUST be labelled with 4 unique
identifiers which are as follows:
- District number
- Date of birth
The request form (if required) data
MUST match the above information on the
Multiple samples taken at different times on a
patient MUST be labelled on the sample container
with the time (24 hr clock) when the sample is taken.
No analysis will be performed. The event will be reported as an
incident on Ulysses if appropriate.
Where the sample is repeatable/reproducible, no analysis will be
performed and the sample will be discarded.
Where the sample is unrepeatable/unreproducible, the risk to the
patient of rejection of the sample must be weighed against the risk
of acceptance of a wrongly labelled sample, local procedures will
Laboratory Medicine will accept no responsibility for samples
analysed which initially failed to meet the acceptance criteria and
will issue a disclaimer on such reports.
If a request form is required then the request form data
MUST match the above sample information
- District number
- Date of birth
Request forms SHOULD also contain:
- The patient's location/destination for the report (or a
- Tests required
- Name of consultant or GP
- Name of the requester and contact number (bleep or
- Patient gender
- Date and time of sample collection
- Anatomical site and type of sample (where relevant)
- All relevant clinical information
- Patient address for GP requests
- For Blood Transfusion - forms MUST be
A lack of patient or sample information may result in the
laboratory not conducting the analysis/examination.
Examples could include:
- No swab site indicated
- No dates and times of sampling
- No clinical details given
- Location for report delivery not given
It may not be possible to issue a report or to interpret
Appropriate comments will be made on the report where this can
Anonymous/uniquely identified specimens and requests
In certain circumstances, patient identification details are
intentionally hidden or substituted with particular ID numbers (eg.
Sexual Health, clinical trials, donor specimens), in such
instances, a properly coded identifier must be used in place of the
patient last name and first name.
Clinical and epidemiological information
To ensure samples can be safely and appropriately tested in the
laboratory, information including details of foreign travel,
symptoms and known or suspected contact with other patients known
to have communicable disease is important.
For example, samples likely to contain high risk pathogens [as
described by the Advisory Committee for Dangerous Pathogens] are
handled at a higher containment level to safeguard both laboratory
staff and other downstream workers.
The information is also of benefit to the patient ensuring that
appropriate testing is performed to safeguard the patient and
benefit their patient journey.