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Acceptance Policy for Specimen Identification (1502.5.06)

Acceptance Policy for Specimen Identification (1502.5.06) - Policies, Clinical, UWHC Clinical, Department Specific, Clinical Laboratories

1502.5.06

UWHC Clinical Laboratories Original Date: November 7, 1997
Current Version: 2
Document Title: Acceptance Policy for Specimen Identification
Document ID: 1502.5.06 Page 1 of 5

Effective Date: April 12. 2016
Medical Director Date Medical Director Date Admin. Director Date
Teresa Darcy, MD 1/7/2014 Suzanne Selvaggi, MD 1/9/14 Marilee Welliver 1/7/14
Teresa Darcy, MD 1/8/2015 Kurt Reed, MD 1/15/14 Marilee Welliver 1/12/15
Teresa Darcy, MD 1/11/2016 Suzanne Selvaggi, MD 1/7/15 Michele A. Marggi 1/8/16
Teresa Darcy, MD 4/6/2016 Kurt Reed, MD 1/7/15 Michele A. Marggi 4/6/16
David T. Yang, MD 1/7/2017 Suzanne Selvaggi, MD 1/8/16 Michele A. Marggi 1/5/17
Suzanne Selvaggi, MD 4/12/16
Suzanne Selvaggi, MD 1/7/17


I. Purpose

To outline UW Health Clinical Laboratory requirements for labeling laboratory specimens and
request forms with respect to patient identification. The policy does not cover what constitutes
a properly completed test request form for purposes of test ordering, result reporting or billing.

II. Policy

Safe patient care and accurate test result reporting depend on correct patient identification
throughout the specimen collection and labeling process.

A. It is the responsibility of all persons who collect laboratory specimens:
1. to positively identity the patient prior to specimen collection using at least two forms of
patient specific identification
2. to confirm that each specimen label has at least two patient specific identifiers that
match the identified patient. The identifiers must be accurate, complete, and legible
and agree with the test order
3. to label patient specimens immediately after collection and in the presence of the
identified patient

B. A labeled specimen and its accompanying request should, whenever possible, be received
together, preferably in a single transport bag containing only one patient’s specimen and
form. A paper request is not always required for an electronically placed order.

C. These identification and labeling requirements apply to all specimens submitted from
internal and external sources.

D. Specimens (and paper request forms) that do not meet the identification criteria outlined in
this policy are considered improperly identified and will be handled as described in section
IV of this policy.

E. Improperly labeled specimens will not be returned to the ordering source.

F. Each specimen identification event will be reported in the Patient Safety Net (PSN) system.
Exceptions to the requirement for PSN are ID events from outside source clients.




III. Identification Requirements

A. Specimens


UWHC Clinical Laboratories Original Date: November 7, 1997
Current Version: 2
Document Title: Acceptance Policy for Specimen
Identification

Document ID: 1502.5.06 Page 2 of 5


Every specimen container must have a patient identification label permanently affixed to
the container, not to a specimen lid or to the plastic bag the specimen is submitted in.
Attaching the label by rubber band is not considered permanently affixed.

Note 1: For Point of Service: if testing is not performed at the patient's bedside or
treatment room where the specimen was collected, the specimen container
must be labeled with two patient identifiers.

Note 2: Capillary blood gas tubes: these tubes may be placed in a syringe barrel
and the barrel labeled with the patient information.

1. The specimen label must contain patient identification that is accurate, complete, and
legible and whenever possible, printed by a machine or device.
2. At a minimum, the patient information on the specimen must include at least two
patient-specific identifiers:

a. Inpatient setting: Patient’s full name (first and last) and UW medical record
number. A trauma identification name and trauma ID# may be used in lieu of name
until an actual patient identity is assigned.
b. Outpatient setting:

1. (Requirements are a patient’s full name and a unique identity
number. Medical record # is preferred; other numbers are
acceptable such as UNOS #, SS#, outside source medical record
number. Date of birth may also be used as an identifier.
2. When specimen labels are handwritten, the use of three patient-
specific identifiers is recommended.
3. Requirements for Transplant Donors/Recipients are as follows: .
AT LEAST ONE of the following;
 Patient’s full name (first and last),
 UNOS ID#(deceased or living donors),
 NMDP ID#(stem cell donors)

AND AT LEAST ONE of the following;
 UWHC medical record number (preferred),
 UNOS ID#(deceased or living donors),
 NMDP ID#(stem cell donors),
 Social Security#
 Another hospital’s medical record number
 Lab assigned Autogen “60..” prefix number)
 Accession number (if a computer generated label is attached
to tube)
 Date of birth
c. Long patient names: In the case of machine printed labels, there is a limit to the
number of characters that can be displayed. If a complete first and last name is
not displayed on the label but two other patient identifiers are present and match
the electronic order or paper request form, the specimen is acceptable and this
does not constitute an identification event.


UWHC Clinical Laboratories Original Date: November 7, 1997
Current Version: 2
Document Title: Acceptance Policy for Specimen
Identification

Document ID: 1502.5.06 Page 3 of 5


3. Labels on specimens used for compatibility testing, i.e. Type & Screen, Type &
Crossmatch, or Hold Tube for Possible Crossmatch, must follow specific procedures
(UWHC Policy 2.26 and Transfusion Services Policy 4.01) of the Transfusion Services.

4. Occult Blood Collection Cards/Vials

Occult blood collection cards/vials given out by UWHC should have a UWHC label on
them with two identifiers. On occasion we receive cards/vials where the patient has
completed the requested information on the card/vial. This information includes; Name,
Age, Street, City, State, Zip, Sample collection date, Phone number and physician
name. As long as the name, address and age as compared to birth year match the LIS
records, these specimens are acceptable.

B. Laboratory Test Orders: electronic orders and paper request forms
1. All orders for laboratory testing must be submitted either by electronic means, (i.e.
HealthLink order entry) or by use of a paper request form.
2. When an electronic order is submitted, at least two patient specific identifiers on the
specimen must be positively matched to the electronic order.
3. If a paper request form is used:
a. The form must have patient identification that is accurate, complete, and legible
and whenever possible, printed by a machine or device.
b. At a minimum, the patient identification must include two patient specific identifiers:
i. Inpatient setting: patient’s full name and medical record number. A trauma
identification name and trauma ID# may be used in lieu of name until an actual
patient identity is assigned.
ii. Outpatient setting: patient’s full name and a unique identity number. Medical
record # is preferred; other numbers are acceptable such as UNOS#, SS#,
outside source medical record number. Date of birth may also be used as an
identifier. When specimen labels are handwritten, the use of three patient-
specific identifiers is recommended. Donor requirements for paperwork are the
same as listed above for sample identification in section III.A.2.b.3.
iii. Long patient names: In the case of computer program printed labels, there is a
limit to the number of characters that can be displayed. If complete name are
not displayed on the label but two other patient identifiers are present and
match the electronic order or paper request, this does not constitute a
specimen identification event
c. Information on patient location, ordering physician, and collector ID and collect
time/date are considered important for optimal patient care. However, omissions
and inaccuracies in these do not constitute misidentification as defined in this
policy (except as noted for Transfusion Service).
d. For purposes of acceptable specimen identification, at least two of the patient
identifiers on the request form must match two of the patient identifiers on the
specimen label, one of which should be a unique identity number.



IV. Management of Specimen Identification Events

A. Specimen identification events are defined as follows:
1. Unlabeled specimen or request form – no patient identifiers

UWHC Clinical Laboratories Original Date: November 7, 1997
Current Version: 2
Document Title: Acceptance Policy for Specimen
Identification

Document ID: 1502.5.06 Page 4 of 5


2. Incomplete or partial patient identification - lacks two acceptable patient identifiers
3. Illegible patient identification - lacks two acceptable patient identifiers
4. Mismatch – two identifiers on specimen and accompanying order (electronic,
workstation order or paper request) form are not the same.
Note: all specimens submitted must match for any specimen to be considered
acceptable.
5. Mislabeled (wrong patient) – specimen submitted using another patient’s identification

B. Whenever a specimen identification event occurs, laboratory testing will not be performed.
The ordering source (unit, clinic, outside facility) will be notified that testing will not proceed
due to a specimen identification problem and that a new specimen needs to be collected.
The test order will be canceled and the reason for specimen unacceptability documented
and reported in the electronic health record. Identification events on inpatient specimens
collected by laboratory staff will be immediately re-ordered and re-collected by the
laboratory.

C. When an identification event is discovered after test results have been reported, the
laboratory will immediately notify the ordering source and follow laboratory policy and
procedure to correct test results and document the event.

D. In very limited circumstances, the attending physician may request that the laboratory
proceed with testing.

NOTE: The attending physician must make the request directly to laboratory staff.
Requests will not be granted for blood, urine, sputum, throat swabs or feces/stool
specimens unless they meet the criteria outlined below.

1. Consideration to test will be given for specimens that meet the following criteria:
a. Life-threatening emergencies, including but not limited to blue carts. Results will be
verbally communicated per policy with the understanding that the results are
unofficial and will not appear in the medical record until the person who collected
and labeled the specimen/request form and medical director (or designee)
complete step IV.D.3 of this policy.
b. Specimens collected via invasive procedures, e.g. tissue, body fluids, BAL
collections, bladder washings, etc.
c. For patients <15 years old, blood collected by venipuncture or capillary draws.
d. Specimens received from outside clients (e.g., specimens from St. Mary’s).
e. Donor specimens collected outside UWHC.
f. Research Specimens – results not in patient’s medical record

2. For specimens that meet the above criteria, the person(s) who collected and labeled
the specimen must physically appear in the laboratory to identify the specimen,
discuss the event and complete the required documentation. A final decision whether
to allow testing to proceed will be made and documented by the laboratory’s medical
director or designee.

3. If specimen identification cannot be verified, testing will not be performed.
Documentation of the specimen identification event will be maintained in the
laboratory.


UWHC Clinical Laboratories Original Date: November 7, 1997
Current Version: 2
Document Title: Acceptance Policy for Specimen
Identification

Document ID: 1502.5.06 Page 5 of 5


4. If specimen identification is verified, testing will be performed and results reported.
The patient results in the laboratory computer system and in the electronic health
record will contain a trackable comment indicating there was a specimen identification
problem.

V. References – Not applicable

VI. Related Documents

A. UWHC Administrative Policy #2.26
B. Clinical Laboratory Transfusion Services Policy #4.01 Patient Orders, Specimen
Collection, & Specimen Handling
C. 1502.5.07 Specimen Rejection
D. 1502.6.03 Specimen ID Event Procedure

VII. Appendices and Forms – Not applicable

VIII. Coordination and Review

See Overview tab