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Specimen Acceptability Criteria Allina Health

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					Allina Hospitals and Clinics                                          Specimen Acceptability Criteria
Laboratory Services                                                 Hospital Inpatient and Outpatients
Policy

                        SPECIMEN ACCEPTABILITY CRITERIA
                      HOSPITAL INPATIENTS AND OUTPATIENTS

POLICY STATEMENT
This policy provides guidance for eliminating patient risk and assuring the clinical integrity of
laboratory specimens during collection, storage, and analysis. Specimens that do not meet the
acceptability criteria are subject to rejection and may only be accepted with pathologist or PhD
designee approval in extenuating circumstances.

PURPOSE
Specimen integrity is a critical step in the quality path of laboratory analysis. Specimens must be
labeled at the bedside by either the individual collecting the specimen, or by an individual who
assists with the collection. Each specimen submitted to the clinical laboratory must conform to
procedural requirements, and must have proper identification and handling throughout the
process. All specimens received by the laboratory are assessed for complete and correct
labeling, proper container, adequate amount, appropriate timing, proper transport and storage,
and methodology interference.
RESPONSIBILITY
1   Laboratory Staff:
    a. Understand specimen labeling and rejection criteria.
    b. Ensure this policy is available to caregivers with specimen collection responsibilities.

2   Laboratory Leaders:
    a. Provide guidance for laboratory staff regarding specimen labeling and rejection.
    b. Ensure this policy is available to caregivers with specimen collection responsibilities.

MAJOR REQUIREMENTS
1   ACCEPTABLE LABELING CRITERIA:
    a. DEFINITIONS
       a) Optimal Labeling. Information to be included on each label:
          (1) Patient first and last name- must agree exactly with wristband.
          (2) Medical record number (preferred), or date of birth
          (3) Date and time collected
          (4) Initials of person collecting specimen or tech number if assigned
          (5) Tests requested
          (6) Patient location
          (7) Source, if applicable
          (8) Other relevant information (i.e. arterial line, collected near IV, etc.)
          (9) Labels must be firmly attached to the primary collection container to insure that
              optimal labeling will be maintained throughout the processing and testing
              procedure. Labeling of lids is not acceptable.
       b) Minimal Labeling. Information to be included on each label:
          (1) Patient first and last name - must agree exactly with wristband.
          (2) Unique identifier
          (3) Other information may be requested to clarify the order.
          (4) All Histology and Cytology specimens must have labels attached to the primary
              container. Labeling of lids is not acceptable.
       c) Unlabeled Specimen. A specimen with no unique patient identifying information.


Date Printed: 11/4/2012 7:43 PM                                                           Page 1 of 4
Allina Hospitals and Clinics                                            Specimen Acceptability Criteria
Laboratory Services                                                   Hospital Inpatient and Outpatients
Policy
         d) Mislabeled Specimen. A specimen with ambiguous, conflicting, or incorrect patient
            identifying information, or where label is not attached to the primary collection
            container.
         e) Unique Identifier. Social security number, medical record number, date of birth,
            pseudo number, study number, or temporary confidentiality identifier.
         f) Specimen that CAN be easily recollected. Examples include blood, urine, throat
            swabs.
         g) Specimens that CANNOT be easily recollected. Examples include CSF, bone
            marrow, tissue, biopsies, body fluids, amniotic fluids, and some swabs for culture.
            Also, irretrievable specimens related to patient crisis, arrest, procedure timing issues,
            etc.

2    DEPARTMENT SPECIFIC LABELING REQUIREMENTS:
    a. Blood Bank Specimens
       a) Transfusion Services does not allow corrections to information on blood bank
          specimen labels. Exceptions to this policy are limited to pathologist approval.
          (1) Routine Blood Bank specimens must be correctly labeled with:
              (a) Patient First and Last name- must agree exactly with wristband.
              (b) Patient Identifying Number - must agree exactly with wristband.
              (c) ANW, Mercy and Unity – Medical record number and Blood Bank SafeMatch
                  label number.
              (d) United - Medical record number (plus Typenex label and wristband for
                  outpatient)
              (e) Date of Collection
              (f) Identity of Phlebotomist
          (1) Emergency Blood Bank specimens must be labeled with the red or yellow,
              numbered, Typenex System Armband (United) or the Blood Bank SafeMatch
              Label (ANW, Mercy and Unity) and the wristband and label must contain:
              (a) A patient identifier (as determined by site emergency identification policy)
              (b) Typenex Armband Number (United) or Blood Bank SafeMatch Label
                  (ANW,Mercy and Unity)
              (c) Date of Collection
              (d) Identity of Phlebotomist
          (2) Cord Blood Specimens must be labeled to include the following:
              (a) Baby’s first and last name
              (b) Baby’s medical record number
              (c) Date of collection
              (d) Initials of person collecting specimen
              (e) The specimen must be identified as cord blood.

2   NON-LABELING SPECIMEN ACCEPTABILITY CRITERIA:
    a. Specimens are rejected when the results are compromised due to submission in an
       improper container, improper anticoagulant ratio, inadequate volume, improper timing,
       transport or storage, or the presence of interfering substances. The following is a
       PARTIAL guideline to assess the appropriateness of laboratory specimens. Complete
       specimen requirement criteria include but are not limited to this list, and are included
       within the procedures of the laboratory section.
       a) Patient must be wearing an armband
       b) Correct container, anticoagulant, or solution
       c) Correct blood/anticoagulant ratio
       d) Adequate quantity for testing


Date Printed: 11/4/2012 7:43 PM                                                             Page 2 of 4
Allina Hospitals and Clinics                                        Specimen Acceptability Criteria
Laboratory Services                                               Hospital Inpatient and Outpatients
Policy
         e) Must meet testing procedure integrity requirements (i.e. clotting, hemolysis,
            contamination)
         f) Timely transport and proper storage of specimen
         g) Container sealed to prevent leakage and specimen contamination when applicable
         h) Accurate timing of collection
         i) Adequate preparation of the patient to avoid interfering substances
         j) Dietary limitations
         k) Appropriate fixative when applicable (i.e. formalin)

REFERENCES
1   College of American Pathology, Laboratory Accreditation Program, Laboratory General
    Checklist
2   Individual Laboratory Section Policies and Procedures
3   Reference Laboratory Policies and Procedures
4   Metro Hospital Patient Care Policies

DOCUMENT HISTORY
Table of Document History

APPROVAL
Author:   Heather Dawson
Approver: Lauren Anthony, M.D., Medical Director

KEY WORDS
Title: Specimen Acceptability Criteria, Hospital Inpatients and Outpatients
Department: General
Document Type: Policy
Applicable Sites: All
Alternate Terms: Labeling, Rejection, Specimen, Mislabeled, Unlabeled, Acceptability, Criteria,
Integrity
Date of Last Major Revision: 01/14/08
Document Owner: Heather A Dawson




Date Printed: 11/4/2012 7:43 PM                                                         Page 3 of 4
Allina Hospitals and Clinics                                               Specimen Acceptability Criteria
Laboratory Services                                                      Hospital Inpatient and Outpatients
Policy


DOCUMENT HISTORY return
        OnBase
  Date                                                 Summary of Change
        Version
01/14/2008     1               Converted to new template, removed procedural elements.
8/14/2009      2               Policy reviewed no changes to content.
8/14/2009      3               Document owner changed.
1/14/2010      4               Added Regional Sites
11/8/10        5               Updated Medical Director and applicable sites
3/1/11         6               SafeMatch labeling implemented at ANW




Date Printed: 11/4/2012 7:43 PM                                                                Page 4 of 4

				
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