Manual / SPECIMEN COLLECTION / Page 1 of 3
Procedure / SC.01 / Patient Identification and Specimen Labeling

CRITTENTON HOSPITAL MEDICAL CENTER

PATHOLOGY DEPARTMENT POLICIES AND PROCEDURES

Manual / SPECIMEN COLLECTION
Procedure / SC.01 / Patient Identification and Specimen Labeling

Purpose

Establish the proper patient identification procedure for collection of specimens by Crittenton Hospital Medical Center associates. This policy also outlines information required on the specimen label.

Scope

CLAs (Phlebotomist), Techs (I, II, III, IV, V)

turnaround time standards

Turnaround time requirements for collecting blood samples from order to collect:

  • STAT...... 20 minutes
  • NOW...... 1 hour
  • ROUTINE...4 hours
  • TIMED...... may begin drawing up to 1 hour before timed draw is due and no longer than 15 minutes after the order time.

Procedure

1.Inpatient Identification

a.Ask the patient his/her name and date of birth (DOB)

  1. If the patient is unresponsive (not rational, comatose, confused, unable to speak), the patient must be positively identified by a Nurse.
  2. After receiving the correct name, verify the patient’s name and medical record number on the wristband match the test labels.
  1. Outpatient Identification
  2. Ask the patient his/her name and DOB.
  3. If the patient is unresponsive (not rational, comatose, confused, unable to speak), the patient must be positively identified by a relative or caregiver, if available.
  4. After receiving the name and DOB, check the name and DOB against the requisition sheet.
  5. Patient Identification:
  6. Compare the information given by the patient to ALL of the following forms/labels used at the specific collection site:
1)Patient-provided identification

1)Physician order (“script”)

2)Registration form (face sheet)

3)Requisition slip

4)Computer-generated labels

5)Addressograph labels

  1. The hospital number and/or the medical record number must also be compared on all of the above forms, if available.
  2. Inpatient armband must then be compared with all the above identifiers.

1)The armband must be attached to the patient, not separated or taped to the bed.

2)Laboratory associates will not draw an inpatientthat does not have an armband.

  1. Corrections must be resolved prior to specimen collection for:

1)Missing armband.

2)Incorrect armband.

3)Error(s) on verified form(s).

  1. In all cases, compare the information on the “Label” to the information used to identify the patient.The minimum information acceptable on a patient label:

1)Last name, first name.

2)DOB and/or medical record number.

  1. Correction of information on specimen labels.
  • Specimens received with insufficient, questionable or misleading labeling cannot be processed until the deficiency is corrected.The laboratory will make every effort to have the discrepancy corrected as quickly as possible but it may cause a delay in reporting.
  1. Blood Bank Identification

Refer to Blood Bank procedure Blood Bank Specimen Collection and Retention.

Specimen Labeling

Cerner Barcode Label, Addressograph Label, Other

  1. All specimens must be labeled immediately after the venipuncture or collection process in the presence of the patient at the bed/chair side.
  • Do not pre-label specimen tubes/containers prior to collection.
  1. The label/requisition should contain the following information:
  2. Patient's First and Last Name
  3. Date of Birth
  4. Patient's Medical Record/Hospital Number
  5. Document the following information on the label attached to the tube:

1)Date & time of collection

2)CLA/phlebotomist's Identification

  1. Specimen label information may NOT be altered or corrected after collection.
  • Any corrections that need to be made to the label/requisition must be made prior to labeling the specimen(s).
  1. Computer-generated barcode labels, if available, are placed on the specimen.
  2. Labels must be applied lengthwise over the commercial label of tubes for easy visualization of the blood.
  3. Addressograph labels may be used if computer labels are unavailable.
  4. All transfusion related specimens must be labeled following established Blood Bank requirements.
  5. If there are any issues with specimen labeling or quality, these deviations from Policy are recorded on the Quality Improvement Worksheet or may also be computer recorded and saved in the Event Reporting system.

Procedure Notes

  1. Specimens improperly labeled will be rejected.
  2. When recollection of the specimen is not possible, correction may be permitted in special circumstances.
  • Refer to Specimen Rejection Policies.
  1. Rejection of a mislabeled specimen must be entered ASAP into the event reporting system.

References

  1. CHMC Laboratory Policy Quality Management Program – Specimen Labeling
  2. CAP GEN.40490 Does the individual collecting the specimen positively identify the patient before collecting a specimen?
  3. CAP GEN.40491 Are primary specimen containers labeled by at least 2 identifiers?