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.
|Mandatory Labelling Requirement
||Action by Laboratory if requirement not
Specimens MUST be labelled with a minimum of 3
unique identifiers from:
unique identification number (eg hospital number)
- Last name
- First name
- Date of birth
The request form data MUST
match the above information on the specimen or be
labelled with another suitable unique identifier.
Drug administered, dose, time of last dose, time of specimen in
relation to dose for therapeutic drug monitoring
Multiple specimens taken at different times on a
patient MUST be labelled on the specimen container
with the time (24 hr clock) when the specimen is taken. The
request form should be labelled accordingly.
No analysis will be performed. The event may be reported as an
incident on the Trust incident report system
Where the specimen is repeatable/reproducible, no analysis will
be performed and the specimen will be discarded.
Where the specimen is unrepeatable/unreproducible, the risk to
the patient of rejection of the specimen must be weighed against
the risk of acceptance of a wrongly labelled specimen, local
procedures will be followed.
Laboratory Medicine will accept no responsibility for specimens
analysed which initially failed to meet the acceptance criteria and
will issue a disclaimer on such reports.
|The request form data MUST match the above specimen
- Last name
- First name
- Date of birth/unique identification number
Request forms SHALL 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 specimen collection
- Anatomical site and type of specimen
- (where relevant)
- All relevant clinical information
- Patient address for GP requests
A lack of patient or specimen 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
Good practice demands the provision of more than the
minimum of information.
The use of NHS number is becoming more prevalent and will be
considered as an essential identifying criterion in future policy.
The DLM is currently reviewing ways in which this can be
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.