Gloucestershire Hospitals NHSFT Pathology Policy for Specimen and Request form Labelling for Pathology Users

Transcription

1 Gloucestershire Hospitals NHSFT Pathology Policy for Specimen and Request form Labelling for Pathology Users This policy sets out the principles for the adequate identification of Pathology specimens and request forms in order for them to be accepted for analysis. Specimens or forms that do not conform to this policy will not be accepted. The requestor will be informed if a specimen or form is rejected. When specimens which do not conform to this policy are considered unrepeatable (all histology specimens, most non-gynae cytology specimens and others where a repeat specimen is not practical), there will be discussion with the clinician on an individual basis. LOCATION OF COPIES 1. Electronic copy on QWB 2. Electronic Pathology Website Page 1 of 6 Issue Date:

2 AMENDMENT HISTORY Amendment Issue Date No. Amendment detail (Include page numbers and/or section headings where the changes have occurred) For versions previous to version 5.3, see retained copies on QWB Inclusion of instruction for recording the identity of the sample collector. Removal of mammography number. Inclusion of statement regarding the importance of Location. Page 2 of 6 Issue Date:

3 TRANSFUSION AND BLOOD GROUPING REQUESTS The MINIMUM DATA SET for all Transfusion samples (including Group and Save / Crossmatch) to be accepted is: Surname Forename (NO shortened names or nicknames) Unique identity number (e.g. MRN, NHS or Major Incident number) Date of Birth (not age) Date of sample Signature of person taking the blood Name and bleep of clinician requesting the test. No Clinical Details No Any Special Requirements - where relevant e.g. irradiated blood No NOTE: 1. These minimum data must be accurate. 2. Printed (addressograph) labels are NOT acceptable on specimens, but are desirable on request forms. 3. Specimens where patient data has been crossed out or altered will not be accepted. 4. Unlabelled, wrongly labelled or inadequately labelled specimens will not be accepted. No specimen is considered unrepeatable ADDITIONAL INFORMATION required by the laboratory for the test to be processed effectively is: Time of sample taken Tests Required Source / Location of Request No Location for Report to be sent (if different from above) Residential Address Page 3 of 6 Issue Date:

4 ALL OTHER DEPARTMENTS: Chemical Pathology, Haematology, Microbiology, Cytology and Histology The MINIMUM DATA SET required for a sample to be accepted in to the Pathology departments named above is: Surname Forename (avoid the use of shortened names or nicknames) Unique identity number (e.g. MRN, NHS or Major Incident number) OR Date of Birth (not age) and current residential (D.O.B) (D.O.B) address No (address) (address) NOTE: Any alterations on the above data must be signed, and name printed. Where there is more than one alteration, a reason must be given. Correction fluid is not acceptable. ADDITIONAL INFORMATION required by the laboratory, where the design of the form allows, for the test to be processed effectively is shown below. If missing, the laboratory may need to make contact to establish these details that they require. Information such as date /time of sample taken and patient location have a potential impact on patient care. Date sample taken Time sample taken Source / Location of request (e.g. Ward) Specimen and/or Form Tests Required Address for report to be sent Signature or Identity of person collecting the sample Residential address No Requesting clinician Relevant clinical/treatment details Where GP OOH service is to be contacted with the results, a current patient telephone number is required. Pre-printed labels should be the correct size/font. Pre-printed labels should be placed lengthways directly over the sample tube label. n/a Pre-printed labels should be signed/initialled to confirm identification details. No Histology and non-gynae Cytology samples: Site identification. (Histo & Non- Gynae) (Histo & Non- Gynae) Page 4 of 6 Issue Date: OR OR

5 Microbiology non-blood samples: Site identification. No All Other Departments (Chemical Pathology, Haematology, Microbiology, Cytology and Histology) Continued... Further Information 1. Correction of Errors Specimens or forms where correction fluid has been used to alter patient identification details will not be accepted. If patient identification data have been crossed out or altered on the specimens or request form, the request will be accepted only if the reason for the alteration is documented on the request form, and signed & name printed by the person making the alteration. 2. Use of Pre-Printed Labels Printed labels are acceptable on all samples (with the exception of transfusion and blood grouping requests), provided they meet the following guidelines: Type and position of labels: Minimum label size Avery label L7654 (4.75 x 2.54 cm) - using a font of Bookman Old Style with a size of 7. Maximum label size of 5.0 x 3.0 cm - using a font of Bookman Old Style with a size of 7. An example is shown below. NHS No: XXX XXX XXXX Robinson Elizabeth 12/09/1902 Female 12 Fictional Road, Gloucester GL1 3NN Dr M Who JNSI01 L84099 The printed label must be placed lengthways directly over the sample tube label. Pre-printed labels on the sample should be signed/initialled to confirm identification details. 3. Printing of Reports Reports are available electronically. Reports are also printed except where locations have requested to be paperless. The laboratory will not print reports if a location has not been provided. Page 5 of 6 Issue Date:

6 ADDITIONAL DEPARTMENT OR TEST SPECIFIC INFORMATION As stated in the table on page 4: HISTOLOGY & NON-GYNAE - CYTOLOGY MICROBIOLOGY - specimens also require type / site identification on the specimen container and request form. specimens (other than blood) also require type / site identification on the specimen container. MYCOBACTERIUM OR HIV TESTING PLEASE NOTE - Unlabelled, wrongly labelled or inadequately labelled specimens for Mycobacterium or HIV testing will never be accepted. NEONATAL BLOOD SPECIMENS FOR THESE SPECIMENS ONLY - Where a Forename has not been given, and dates of birth may be very similar, only specimens labelled with correct MRN and Surname will be accepted. Wherever possible an additional identifier should be given (e.g. twin 1, twin 2, or address) DOWNS SCREENING SAMPLES FOR BOTH SAMPLE AND FORM: Surname, Forename, Unique Identification number AND Date of Birth are all required on these samples which are sent away to another laboratory. SPECIMENS FROM UNIDENTIFIED PATIENTS FOR THESE SPECIMENS ONLY - specimens must be identified with at least the MRN or MI (major incident) number, gender and approximate age of the patient. (MI number is still used for neonates and if there is a major IT system failure.) Anything less than this will not be accepted. Pre-printed labels should be signed. Note that in TRANSFUSION, printed labels are NOT acceptable on Transfusion samples at all. ANONYMISED PATIENT SPECIMENS e.g. GUM, HIV, etc. FOR THESE PATIENTS ONLY - specimens identified by a unique number and DOB alone will be accepted. Page 6 of 6 Issue Date: