Beth Israel Deaconess Medical Center
Laboratory Manual



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SPECIMEN LABELING POLICY

All patients must be positively identified before their blood and other samples are obtained.  Positive identification is the responsibility of the person collecting the sample.

The following information must be legibly recorded in an indelible fashion on a label affixed to the specimen tube or container, AND the accompanying laboratory test requisition.  A fully completed requisition must accompany the specimen.

PATIENT'S NAME (LAST, FIRST, MIDDLE)
Exactly as it appears in hospital record (on wristband or blue card).

UNIQUE IDENTIFYING NUMBER
A BIDMC medical record number is optimal.  Specimens sent to the laboratory from outside the hospital on patients who do not have a BIDMC medical record number should be identified by the patient’s date of birth.


DATE AND TIME
The specimen collection date must be written on the specimen label.  Time of specimen collection is optimal, but not mandatory.

COLLECTOR’S IDENTIFICATION
The person who identified the patient and collected and labeled the specimen must legibly sign the specimen label and/or the requisition.  Choice of acceptable collector ID includes full name; last name and first initial; pager ID (5 digits); or phlebotomy code.  Initials are not acceptable.

This signature attests to the fact that, after specimen collection, this person confirmed, verbally with the patient, or through comparison with the patient’s wristband, the patient’s identity by name and unique identifying number.

The specimen label with the patient’s name and unique identifying number may be generated prior to the time that the specimen is drawn or collected.  However, the date and time and the signature should only be recorded after the specimen has been drawn and only after verifying that the patient name and unique identifying number on the label agrees with verbal confirmation or the patient’s wristband.    This is the single most important factor in preventing errors in patient specimen identification.

PROPERLY LABELED SPECIMENS

A properly labeled specimen contains the following elements accompanied by a lab requisition at the time of specimen delivery to the lab:


Element
Specimen label AND Requisition*
Specimen label OR Requisition
Specimen label
Patient Name
X


Unique ID
X


Date


X
Collector's ID

X

*The patient name and unique ID on the specimen label and requisition must match.  If there is a mismatch, the specimen is considered mislabeled.
**For tissue specimens, the provider MD is recognized as the collector .
Routine blood and urine specimens that are not properly labeled will be voided and the ordering physician/unit will be notified; the ordering physician is required to request/submit a new, properly labeled specimen for laboratory testing.

The laboratory recognizes that there are specimens which, due to either the site they are obtained from, or timing of collection, are unrecollectable. In these cases, labeling errors will be handled differently. The following specimen types are automatically considered unrecollectable by the laboratory and will be processed following authorization by the provider MD.
  
Micro swabs
24 hours urines
Micro cultures*
Blood cultures
Blood Gases
Tissue specimens
Timed specimens such as GTT
* If a urine specimen is received and is incompletely labeled; we will consider both the culture and UA   recollectable.

The following report comment will be appended: "Specimen identified and testing authorized by {Provider} MD or RN, {date and time}."

As stated in section I, routine blood and urine specimens (submitted for urinalysis) are considered recollectable and, therefore, no testing will be performed in cases where specimen is incompletely labeled. In the rare event that testing is still requested, a laboratory medicine medical director will review the request with the ordering physician. In certain situations, specimens may be considered unrecollectable and the medical director may approve testing.

If approved by the Lab Medicine Director, the following report comment will be appended to the specimen: Specimen identified and testing authorized by {Provider} MD or RN, and approved by {Laboratory Medicine Physician}, {date and time}.

Revised/Reviewed 05/07/2008

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