Irretrievable Specimen Re Label UNM Health Sciences Center Umbilical Cord

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Irretrievable Specimen Re Label UNM Health Sciences Center Umbilical Cord Powered By Docstoc
					                                                 Applies To: [All HSC Hospitals, CRTC, or UNMH]
                                                 Responsible Department:

 Title:   Misidentified Irretrievable Specimen Policy                       Procedure
                 (Request for Re-labeling)

 Patient Age Group:         ( ) N/A      (X ) All Ages   ( ) Newborns      ( ) Pediatric   ( ) Adult

   1.1 Irretrievable specimens are usually obtained via invasive procedures. Each
       collection of such a specimen can represent a hazard to the patient. In the pre-
       analytical phase of testing, these precious specimens must be handled
       appropriately from the moment they are obtained. A mislabeled specimen is a
       compromised specimen. In the event that an irretrievable specimen is
       mislabeled, this specimen may be relabeled only if certain criteria are met.

          The decision to re-label an irretrievable misidentified specimen can only be made
          by the patient’s attending or supervising physician, because patient care decisions
          will be made by that physician based on the diagnostic information obtained from
          this specimen.

  1. Licensed care providers (LCPs) responsible for obtaining patient specimens for
     laboratory testing.
  2. Laboratory staff who discover specimens that are mislabeled by non laboratory
  3. Attending physicians or supervisory physicians.

1. A misidentified irretrievable specimen is discovered by the University Hospital
   1.1 The laboratory will notify the LCP who collected the specimen that the specimen
       is not properly identified.
   1.2 If the LCP wishes to re-label the specimen, he/she must come to the lab to
       identify the specimen in the presence of a laboratory staff member.
   1.3 If after examining the specimen, the LCP is absolutely positive that the specimen
       can be identified, then he/she must notify the patient’s attending/supervising
       physician and obtain approval to re-label the specimen.
   1.4 In order to proceed further, the laboratory must receive phone or written
       documentation from the patient’s attending/supervising physician that approval
       was granted to re-label the specimen.
    1.5 If there is a delay in receiving the approval to re-label the specimen, of greater
        than one hour, lab staff will inform the on-call pathology resident of the problem.
        The pathology resident will assist in contacting the attending/supervising
    1.6 If the specimen is otherwise cleared for re-labeling, the LCP will fill out the
        Request to Re-label Form which is presented to the laboratory staff member.
    1.7 If the LCP is sure, BEYOND ANY DOUBT, that the specimen can be
        accurately matched to the correct patient, then he/she may re-label the specimen
        with the correct patient information.
    1.8 The laboratory reserves the right to reject a mis-labeled specimen if, after the
        completion of the above processes, there continues to be significant doubts about
        whether the sample is correctly linked to the patient.

    1. No label affixed to specimen container
    2. Labeled specimen does not match requisition
    3. Specimen label is missing these essential data elements:
               a. Patient name
               b. Patient MRN or date of birth
    4. Specimen and requisition match but do not match in the hospital information
       system and/or laboratory information system.
    5. Exceptions: if any of these data are missing:
               a. Date of collection
               b. Time of collection
               c. Collector’s initials
               d. TYPE of specimen and SITE (i.e. pleural fluid, right lung).
       The laboratory will call the LCP to come to the lab and add the missing
       information to the specimen container. These omissions will not require the
       initiation of the Request to Re-label protocol.
    6. Specimens submitted in the wrong media or collection device will be rejected if
       the ordered tests cannot be performed and the LCP will be notified.

  1. If permission to re-label is denied, the ordered lab tests will be cancelled and a
     comment will appear in the patient record indicating that the specimen was
     rejected due to improper labeling by non-laboratory staff.

    2.   If the request to re-label is granted, the results of the ordered tests on the
         specimen will be reported into the CERNER patient record together with the
         following comments:

               “INTERPRET RESULTS WITH CAUTION. Specimen improperly
               identified by non-laboratory staff. Specimen identification corrected
               by (LCP’s name).”
    3.   The incident will be reported in the Patient Safety Network.

This policy applies to all UNMH LCPs who are directly involved in obtaining patient
specimens and their supervising or attending physicians.

The UNMH Medical Executive Committee

HSC policy # 2209 “Specimen Labeling”

The JCAHO 2007 National Patient Safety Goal #1A
The JCAHO 2007 National Patient Safety Goal #2A

Makary, MA, Epstein, J et al. Surgical specimen identification errors: a new measure
of quality in surgical care. Surgery. 2007 Apr;141 (4):450-5.

Slavin, L. Gone but not forgotten: the search for the lost surgical specimens:
application of quality improvement techniques in reducing medical error. Qual
Manag Health Care. 2001 Fall;10(1):45-53.

Wagar, EA et al. Patient Safety in the Clinical Laboratory : A Longitudinal Analysis of
Specimen Identification Errors. Archives of Pathology and Laboratory Medicine. 2006;

Irretrievable Specimen (examples):
     Specimens collected via invasive procedures (other than routine phlebotomy)
     Blood cultures collected pre-antibiotic treatment
     PUBS (Percutaneous Umbilical Cord Sample)
     CODE samples

The process required to re-label a misidentified specimen will increase the accountability
of LCPs submitting specimens. This protocol gives the attending/supervising physicians
immediate notification of specimen misidentification, so that they may make decisions
regarding the rejection or submission of that specimen. The pathology resident on-call is
available 24/7 (968-1055) to assist with difficult specimen triaging and questions
regarding submission and testing of specimens.

Specimen, Misidentified
Patient Safety
Quality Assurance

The office and specific individual position title – with telephone number and email address, as appropriate
– that should be contacted for interpretations, resolution of problems, and special situations.

                    Resource/Dept                                              Internet/Link
 UNMH Department of Pathology                        Dr. Glynnis Ingall, MD, PhD, Kelly Devers, MD


             Item                                   Contact                                Date           Approval
 Owner                          [Name, Title, Department/Area]
 Consultant(s)                  [Name, Title]

 Committee(s)                   [Committee Name(s)]                                                      [Y or N/A]

 Nursing Officer                [Name], Chief Nursing Officer                                            [Y or N/A]
 Medical Director/Officer       [Name, Department (or Chief Medical Officer)]                            [Y or N/A]
 Human Resources                [Name], HR Administrator, [UNMH or UNM]                                  [Y or N/A]
 Finance Officer                [Name, Title], [UNMH or HSC]                                             [Y or N/A]
 Legal (Required)               [Name, Title], [UNMH or HSC]                                                 Y
 Official Approver              [Name, Title, Area]                                                          Y
 Official Signature                                                                  [Day/Mo/Year]
 2 Approver (Optional)
 Signature                                                                           [Day/Mo/Year]
 Effective Date                                                                      [Day/Mo/Year]
 Origination Date                                                                    [Month/Year]
 Issue Date                  Clinical Operations Policy Coordinator

(List and attach all forms needed to complete the procedure. A transaction flow chart might also be
included in this section. Attach document(s), beginning on the next page, or provide an electronic file and
list its filename here.)

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Description: Irretrievable Specimen Re Label UNM Health Sciences Center Umbilical Cord