NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
SAMPLE ACCEPTANCE AND REJECTION FOR PATHOLOGY LABORATORIES
PROCEDURE
Documentation Control
Reference
Date approved
CL/CGP/049
22 SEPTEMBER 2009
Approving Body
DIRECTORS’ GROUP
Implementation Date
Version
Supersedes
Consultation undertaken
22 SEPTEMBER 2009
1
N/A
PATHOLOGY CLINICAL GOVERNANCE
GROUP
CLINICAL RISK COMMITTEE
HOSPITAL TRANSFUSION COMMITTEE
ALL REQUESTERS OF PATHOLOGY
SERVICES
REQUEST AND SPECIMEN LABELLING
POLICY
September 2011
MEDICAL DIRECTOR
TONY SCRIVEN, HEAD OF PATHOLOGY
SERVICES
ALL HEADS OF SERVICE, PATHOLOGY
SPECIALITIES
Target audience
Supporting procedure
Review Date
Lead Executive
Author/Lead Manager
Further
Guidance/Information
SAMPLE ACCEPTANCE AND REJECTION FOR PATHOLOGY LABORATORIES PROCEDURE
Version 1
September 2009
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CONTENTS
Paragraph
1
2
Title
Introduction
Page
3
Repeatable samples that do not meet the
required standard requirements (Not Blood
Transfusion)
3
2.1
Acceptance Criteria
4
2.2
Laboratory procedure
criteria are not met
when
acceptance
4
3
Unrepeatable samples that do not meet the
standard
requirements
(Not
Blood
Transfusion)
5
3.1
3.2
Examples of unrepeatable samples
Laboratory procedure when acceptance
criteria are not met in the case of
unrepeatable samples.
5
5
4
5
6
Appendix 1
Equality and Diversity
Implementation and Monitoring plan
References
Employee Record Of Having Read The Policy
5
6
6
7
SAMPLE ACCEPTANCE AND REJECTION FOR PATHOLOGY LABORATORIES PROCEDURE
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1.
Introduction
This document details the procedure for dealing with non-compliant requests
and samples throughout Nottingham University Hospitals NHS Trust. In the
interests of patient safety and diagnostic management it is essential that both
request forms and samples contain an adequate amount of information.
The standards required are detailed in the separate policy document entitled,
“Nottingham University Hospitals NHS Trust Request and Specimen Labelling
Policy” CL/CGP/018
It is essential that the person requesting and collecting the sample ensure that
they have correctly identified the patient, prior to collection, by asking the patient
for his/her name and date of birth and/or confirmation either by a separate form
of identification or via a wristband as appropriate. Samples must be labelled at
the time of collection not prior to, or remotely from the patient after collection.
This document has been compiled to meet the standard requirements of the
Clinical Pathology Accreditation (UK) Ltd (CPA) system and to the British
Committee for Standards in Haematology.
This document also takes into account other appropriate national guidelines
from organisations like the National Patient Safety Agency, the National
Programme for IT and Connecting for Health as well as publications from
professional bodies like the Royal College of Pathologists, the Association of
Clinical Biochemists and the Institute of Biomedical Science.
2.
Repeatable samples that do not meet the standard requirements (Not
Blood Transfusion*)
Laboratories will not process unlabelled or mislabelled samples. The requesting
clinician will be advised that repeat request form and sample collections are
necessary. Exceptions to this may apply in the case of unrepeatable samples
(see section 3 of this document)
* For regulations applying to Blood Transfusion samples please refer to the
Blood Transfusion Policy.
SAMPLE ACCEPTANCE AND REJECTION FOR PATHOLOGY LABORATORIES PROCEDURE
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2.1 Acceptance Criteria
Requests/Samples will not be accepted if any of these criteria are not met:
There is no unique identifier quoted on the request form*
If any of the following are missing or incorrect
Full name - Surname and Forename (in full and not initials)
Date of Birth
The sample or request form is illegible or unclear.
There is discrepancy between the details provided on the request card and
sample
* Except in the case where the unique identifier is not known, for example
Transients or asylum seekers
Requests/Samples will not be accepted if:
No Clinician or location is given to send a report.
For certain requests the site of specimen is not given
In exceptional circumstances and with the authorisation of Consultant or Senior
Laboratory Management staff the laboratory may call upon the person that
collected the specimen to attend the laboratory in order that the missing
information can be added. If this is not possible then a repeat sample will be
requested.
2.2 Laboratory procedure when acceptance criteria are not met
The laboratory will,
 Inform a senior member of laboratory staff.
 Notify the requesting Clinician or deputy and/or,
 Issue a report to the requesting Clinician
3. Unrepeatable samples that do not meet the standard requirements (Not
Blood Transfusion*)
In a number of circumstances, it would not be possible to repeat the collection of
the sample. The laboratory would classify these as ‘Unrepeatable samples’ or
unique specimens. Please note in general that specimens of Blood would not
normally be classified as ‘Unrepeatable’.
* For regulations applying to Blood Transfusion samples please refer to the
Trust Blood Transfusion Policy.
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3.1 Examples of unrepeatable samples would include:
All histology and non-gynae cytology samples.
Bone marrow, CSF samples, tissues and other fluids obtained by
invasive procedures (NOT blood samples).
Samples where recollection presents a risk to the patient.
Dynamic function test samples.
Post mortem samples where recollection is not possible
Samples collected in an acute situation where the clinical status of the
patient may have changed e.g. drug overdose, hypoglycaemic episode.
Samples for culture from normally sterile sites where antibiotic therapy
has been subsequently started e.g. blood cultures
This list is not intended to be exhaustive.
3.2
Laboratory procedure when acceptance criteria are not met in the case of
unrepeatable samples.
A senior member of the laboratory staff will,
 Contact the Clinician (or responsible deputy) in charge of the patient.
 Discuss the circumstances of sample collection and labelling with the
Clinician (or responsible deputy)
 Decide whether or not to process the sample(s) based on all the
information available and bearing in mind the potential risk to the patient
 Complete a log of the event and where appropriate complete an incident
report
 Reflect the decisions made within the incident report
 Issue a copy of the incident report to the requesting Clinician
 Patient reports will be identified clearly with the non-compliance and that
correct patient identification cannot be guaranteed.
4.
Equality and Diversity
This policy does not in any way discriminate against any group or individual.
5.
Implementation and Monitoring Plan
Non compliance with this policy will result in requests being delayed or rejected.
SAMPLE ACCEPTANCE AND REJECTION FOR PATHOLOGY LABORATORIES PROCEDURE
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The immediate implementation of this policy will be the responsibility of the
Clinical Directors and Clinical Leads.
The policy will be distributed via the Trust and Pathology websites.
Training for this procedure will be provided as part of the general Pathology
training
The policy will be monitored by the incident reporting process by the Pathology
Health Governance Group and the Hospital Transfusion Committee on a
quarterly basis.
6.
References
Standards for the Medical Laboratory – Clinical Pathology Accreditation (UK) Ltd September 2007
Safety in Health Service Laboratories: The labelling, transport and reception of
samples 1986; Health Services Advisory Committee. HSE Books, Sudbury, UK
Medical Laboratories - Particular requirements for quality and competence. BS EN
ISO 15189:2003 pp17
Patient Sample and Request Form Identification Criteria - The Institute of
Biomedical Science British Committee for Standards in Haematology
National Patient Safety Agency – personal correspondence
SAMPLE ACCEPTANCE AND REJECTION FOR PATHOLOGY LABORATORIES PROCEDURE
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Appendix 1
EMPLOYEE RECORD OF HAVING READ THE POLICY
SAMPLE ACCEPTANCE AND REJECTION FOR PATHOLOGY LABORATORIES
PROCEDURE
I have read and understand the principles contained in the named policy.
PRINT FULL NAME
SIGNATURE
DATE
SAMPLE ACCEPTANCE AND REJECTION FOR PATHOLOGY LABORATORIES PROCEDURE
Version 1
September 2009
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