A JOINT BULLETIN FROM CHESHIRE PATHOLOGY SERVICES
DECEMBER 2014
SPECIMEN ACCEPTANCE POLICY
Cheshire Pathology Services operates a Specimen Acceptance
Policy. This follows national directives from laboratory associated
professional bodies. It is the responsibility of the requestor to
ensure that samples are correctly labelled and request forms
completed to the required standard.
Due to a number of recent incidents regarding insufficient
labelling of specimens and request forms, action has been agreed
to remind users of the laboratory’s criteria for accepting and
rejecting specimens.
International Standard ISO 15189:2012 specifies requirements for quality and competence for medical
laboratories. Fulfilment of the requirements means the laboratory meets both the technical competence and
management system requirements that are necessary for it to consistently deliver technically valid results.
In order for our laboratories to comply with this standard and maintain accreditation we must ensure that the
specimen acceptance requirements are consistently applied and the quality of examination results assured. To do
this specimens have to be unequivocally traceable, by request and labelling, to an identified patient.
All specimens must be clearly and unequivocally identified with a minimum of three of the key identifiers. Key
identifiers must be correct and match the information given on the request form.
ISO 15189:2012 also states that the request form must include the name or other unique identifier of clinician,
healthcare provider, or other person legally authorised to request examinations or use medical information,
together with the destination for the report.
A summary of the Specimen Acceptance Policy is provided below.
Implementation of this policy ensures that:


Pathology specimens are unequivocally identified to a patient
Results are reported to the requester at the correct location
For Blood Transfusion sample labelling requirements please refer to the Trust’s Blood Transfusion Policy.
Samples labelled with pre-printed addressograph labels and incompletely labelled samples will not be accepted.
NEWS FROM BOTH TRUSTS TO THE WARDS
SPECIMEN ACCEPTANCE POLICY
The Pathology Department implements a Specimen Acceptance Policy to ensure the safety of the patient.
The policy describes the procedures required to ensure that all specimens are correctly identified and
that appropriate reports can be sent to the correct destination.
The key points are summarised below:
Action by laboratory if requirement not met
Requirement
Samples MUST be labelled with 3 unique No analysis will be performed.
identifiers from
 Surname
Where the sample is easily repeatable the
 Forename
laboratory will recommend the sample is
 Date of birth
discarded.
 NHS / Hospital Number
Where the risk to the patient of rejection outweighs
The request form data MUST match the the risk of acceptance, the sender will be contacted
by a senior pathology staff member.
above information on the sample.
Multiple samples taken at different times
on a patient MUST be labelled on the Pathology will accept no responsibility for samples
sample container with the time (24 hr clock) tested which initially failed to meet the acceptance
when the specimen is taken. The request criteria and will issue a disclaimer on such reports.
form should be labelled accordingly.
Request forms SHALL also contain:
 A unique patient identifier (i.e. hospital
number / NHS number)
 Sending location
 Name of Consultant or GP
 Tests required
 Date and time of sample
 Time of last dose and dosage
information for drug assays
 Anatomical site and type of specimen
(where relevant)
 Sex
 Relevant clinical information
Lack of information may result in laboratory not
conducting the analysis.
It may not be possible to issue a report or to
interpret results.
Appropriate comments will be made on the report
where this can be issued.
NEWS FROM BOTH TRUSTS TO THE WARDS
HISTOLOGY
DELAYS IN HISTOLOGY
Histology service users may be aware of current delays in turnaround times of histology reports. I would like to
apologise on behalf of the department for these delays, which are due to system pressures within the service.
The department has recently had high levels of staff turnover leading to an increased training burden and has
experienced an increasing level of demand on the service.
Every effort is being made to address the issues; locum staff have been recruited and laboratory staff continue to
work additional hours to help to reduce the turnaround times.
Please can you assist us by ensuring that you provide relevant clinical information and clearly indicate the following
detail on request cards:
 Cancer suspect
 Patient on cancer pathway
 Result required for MDT meeting
 Any other urgent request
This will enable us to process urgent cases as a priority: please ensure only genuinely urgent cases are marked as
urgent.
HISTOLOGY AND DIAGNOSTIC CYTOLOGY REQUEST CARDS
Please ensure that you use the correct (yellow) request card for Histology
and Diagnostic Cytology Specimens (see right) and that these are completed
fully, including the name and location of the sender.
These are available from Central Specimen Reception via email
[email protected]
Endoscopy clinics use their own forms, which should be printed onto green
paper.
HISTOLOGY OFFICE DIRECT DIAL
The direct dial number to the histology office is 01270 273286. This number is printed at the bottom of histology
reports.
FROZEN SECTION SERVICE
The cut off time for receipt of frozen sections into histology is 4pm.
HISTOLOGY REPORTS ON WEB BROWSER
Please ensure that histology reports obtained via the web browser are read in full and note that SNOMED codes at
the bottom of the report are for laboratory use ONLY and should be ignored for diagnostic purposes.
Paul Simcock, Consultant Histopathologist & Clinical Lead for Histology
NEWS FROM BOTH TRUSTS TO THE WARDS
PRODUCTS OF CONCEPTION SPECIMENS OF 12 WEEKS AND BELOW GESTATION
All specimens that could potentially contain tissue from a miscarried pregnancy of a gestation of 12 weeks or under
must be accompanied by a consent form when sent for Histological examination. As the number of incidences
where this has not happened has increased recently this is a reminder of the protocol to assist colleagues in
handling such cases correctly.
The form must include the patient’s details, give the
patient’s consent (or otherwise) to the examination of the
tissue and her wishes for the method of disposal. The
form must be signed by the patient and by the doctor or
designated nurse/midwife involved with the case.
The form must also be the correct version – see right. The
current version of the form is available under Frequently
Used Forms on the Mid Cheshire NHSF Trust intranet site
and has been widely distributed at East Cheshire NHS
Trust. Please destroy any older versions as these are no
longer acceptable.
Without this information on the correct version of the
form the laboratory cannot process the specimen. To do
so would contravene the Human Tissue Act.
Failure to provide the appropriately filled in form will
delay the Histology report being issued and may result in
clinical/ward staff having to contact the patient at a later
date for this information, possibly causing her further
distress.
Where a form is missing or incomplete, the laboratory will
endeavour to contact the sender to alert them to the
need for a fully filled in form. If, after a week the
laboratory has not received the form then the specimen
will be returned to the sending location.
While the laboratory understands that staff caring for
such patients are often working in distressing situations we do ask that every effort is made to ensure the
completion of the consent form in order that the patient’s wishes are adhered to.
If you wish to discuss this further, please contact:
Julie Crawford
Service Lead for Cellular Pathology
: 01270 273730
: [email protected]
NEWS FROM BOTH TRUSTS TO THE WARDS
RENIN & ALDOSTERONE - CHANGE OF SAMPLE TYPE FOR ALDOSTERONE
We have just been notified by the referral laboratory to which we send samples for aldosterone analysis that they
now require EDTA rather than lithium heparin plasma for this test. The quoted reference range for the test has
also changed and will be included with future reports.
Therefore, with immediate effect please send 2 EDTA samples (lilac top Vacutainer) when requesting renin and
aldosterone measurements. The samples should be dispatched immediately NOT ON ICE to reach the laboratory
within 15 minutes of collection. Requests should be discussed with a clinical scientist or chemical pathologist
before taking blood, as several antihypertensive drugs interfere with the tests and need to be withdrawn for
periods of between 2 to 6 weeks before sample collection.
David Oleesky, Consultant Chemical Pathologist & Clinical Lead for Biochemistry
: [email protected] : 01625 66-1826
Ian Johnson, Technical Lead for Biochemistry
: [email protected] : 01270 27-3454
MICROBIOLOGY FORMS – BOTH COPIES NEED LABELLING
Microbiology forms come with two leaves. This means that we can deal with the specimen more
efficiently as one copy is taken to a separate area to be booked in to the computer while the other copy
stays with the specimen. The forms are designed to transfer writing on the first copy to the second copy.
If you are using pre-printed labels with patient details please label both leaves of the Microbiology
form.
If not, we cannot check that the correct details have been put onto the computer and you are more likely
to receive incorrectly ascribed results.
Labelling must include the source of the specimen (Consultant and ward or clinic). Specimens will be
rejected if the request forms are not fully labelled. Please see the specimen acceptance policy, part of the
Pathology User Manual on the Intranet.
:[email protected]
NEWS FROM BOTH TRUSTS TO THE WARDS