CLINICAL LABORATORY SERVICES

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1 10. SPECIMEN ACCEPTANCE/ REJECTION General guidelines Complete the request form legibly, using a ball point pen, and completely; include a contact number. Samples which are inadequately identified may not be analysed. Please indicate clinical diagnosis and any drug therapy. Of absolute importance is the requirement to indicate the correct location, ensure this information appears on each individual form. Without a location, results cannot be transmitted for the appropriate requestor. Providing the CHI number will minimize delays. It is the responsibility of the doctor requesting the test to ensure that all request forms and specimens carry the minimum data-set. Only correctly and clearly labelled samples with matching request forms will be accepted. All samples, regardless of origin, must comply with the labelling requirements stated below. Failure to follow this procedure may result in your request being refused. The separate Policy for Transfusion Sampling must be followed without exception. Refer to NHS Shetland Policy and Procedure Handbook Sect 29 Blood Transfusion Policy for Blood Transfusion related requests. For certain tests, the date and time of collection MUST be shown. Samples that do not show these may be rejected, at the discretion of the laboratory. If more than one sample is included as part of a series, (e.g. GTT), or

2 multiple request (e.g. left and right drain) then those samples labels MUST contain such information. If the sample label is hand written then the above data must be legible and correct Rejection criteria Most rejected samples are placed to one side and dealt with at the end of the day, however urgent samples must be dealt with immediately and the requesting physician informed in order that a repeat sample can be collected. For outpatient samples the consultants secretary can be telephoned, or if a bleep number is given, the relevant junior doctor. For GP samples the surgery must be contacted. The samples are numbered according to the policy on specimen reception. A unique barcode is attached to the sample and form. Once the user has been informed the samples is then discarded. The request form is used to enter details on to MasterLab. a. Accident service specimens: in emergency situations the three points of identification needed on the specimen for it to be acceptable can include any one or more of the following: Unknown in place of the surname. Male/Female instead of a first name An accident service AE Number instead of a hospital number. b. Glass slides: where glass slides are prepared at the bedside, e.g. bone marrow biopsy, there may be insufficient space on the glass slide to include three points of ID and any other data required. Under these circumstances

3 two points of clear ID would be the minimum criteria acceptable. Sample acceptance will be at the discretion of the receiving laboratory. Labelling of glass slides SHOULD only be in pencil. c. Not matching the laboratory computer system database: samples that have matched with forms and have been accepted for processing but on subsequent entry in the laboratory computer a discrepancy is found. The requester will be contacted to resolve and correct the discrepancy. An appropriate comment will be annotated on the report if sample is analysed. NB: Laboratory staff must NOT amend details on form or sample Samples sent to other hospitals (Sendaway) Three points of identification will be required including the Surname. The CHI number or the local hospital number can be used in this situation as a point of identification together with first name or date of birth. Slides or other small samples may have insufficient room for three points of identification. Under these circumstances, sample acceptance will be at the discretion of the receiving laboratory. The identification number must be clearly referenced on the attached request form / referral letter. Samples which do not comply will be returned for appropriate references. Sample acceptance will be at the discretion of the receiving laboratory Recording rejected specimens or tests For samples rejected for testing, record on the laboratory internal Form 0140 ( Sample reception incident log ) and if appropriate complete a NC Form 0001/DATIX Record the issue and your actions including who you spoke to about the problem and the decision reached Problems with BT samples are recorded on Form 0001 and if appropriate complete a DATIX If there are reasons why some tests from a request cannot be performed, or the results may be affected, use the appropriate comment code on the request form and during order entry.

4 If necessary inform the Head of Department of the problem, this may be required if for example there are multiple problem samples from one location User notification of rejected specimens If samples are to be rejected from testing the originating location or clinician needs to be informed If the sample is from a Health Centre contact the location and speak to the requesting clinician, inform of the problem and the requirement to repeat the sample(s), record these details on the Form Refer to a senior member of staff if the clinician does not accept your actions as being appropriate For requests from within the hospital contact with the clinician can be made using the pager number (usually recorded on the request) If the identity of the patient has been established, an order entry for the request should be completed as usual but with an appropriate comment. In all cases a senior member of staff should be informed and any subsequent report annotated accordingly.

5 10.6. Rejection reporting comments LABORATORY COMMENTS AND REJECTED SAMPLES PROBLEM CODE COMMENT / ACTION No/ no valid signature on request form/specimen Formed stool for C. Diff testing Insufficient sample for microscopy Small sample (micro only) Urine received in white top universal container Required sample NOT received Sample spun and leak through gel barrier Old sample More than 48 hours SIG CDNT IFM LV NBA NS S&L OLD A VALID SIGNATURE IS REQUIRED ON ALL REQUESTS FORMS Formed stool not indicated for C difficile testing Insufficient sample for microscopy Low sample volume received in specimen container SAMPLE NOT IN BORIC ACID NO SAMPLE RECEIVED SAMPLE SPUN BUT LEAKED THROUGH GEL BARRIER. Action: Use yellow tube for glucose. Use S&L and OLD if electrolytes required Chemistry comment code: OLD SAMPLE ELECTROLYTES MAY BE INVALID. For Haematology comment code: MCV AND RELATED INDICES INVALID ON OLD SAMPLES. For Micro: SAMPLE TRANSIT EXCEEDED TOO OLD TO PROCESS More than 24 hours F SPECIMEN TOO OLD FOR FILM REPORT More than 48 hours DIFF FBC SPECIMEN TOO OLD FOR WBC DIFFERENTIAL Sample haemolysed SH SAMPLE HAEMOLYSED Sample Lipaemic SL SPECIMEN LIPAEMIC Not enough sample to test INS INSUFFICIENT SAMPLE, PLEASE REPEAT Under / over filled UNDE R SPECIMEN UNDERFILLED UNSUITABLE FOR TESTING. Note: Affects FBC, ESR,

6 PROBLEM CODE COMMENT / ACTION CLOT, APTT, INR, and DD Clotted sample Rejected sample because it is unsuitable for testing CLOT RPT SAMPLE CLOTTED UNSUITABLE FOR TESTING. Action: Affects FBC, ESR, CLOT, APTT, INR, DD, and RCF PLEASE SEND REPEAT SAMPLE Sample not labelled L SAMPLE UNLABELLED Leaking sample LEAK Chemistry & Haematology: SAMPLE LEAKED IN TRANSIT for Microbiology: SAMPLE LEAKED IN TRANSIT - DISCARDED Leaking sample SRL Microbiology: Specimen received leaking Wrong container WC UNAPROVED LABORATORY CONTAINER. PLEASE USE LABORATORY APPROVED CONTAINERS

7 TEST APTT BNP CLOT D-DIMER ESR FBC GLUCOSE TIME RESTRICTIONS TIME LIMIT LESS THAN 4 LESS THAN 72 LESS THAN 4 LESS THAN 4 LESS THAN 24 IF MORE THAN 24 OLD IF MORE THAN 48 OLD IF MORE THAN 4 DAYS NO LIMIT (Fluoride tube) 8 (GEL tube) COMMENT CODE APTT - COLD DD ESR F F and DIFF FOLD PARACETAMOL MIN 4 * - COMMENT APTT NOT TESTED, SPECIMEN TOO OLD Action: also part of CLOT profile COAGULATION STUDIES SPECIMEN TOO OLD FOR TESTING Note: If INR only requested see section below D-DIMER NOT TESTED, SPECIMEN TOO OLD Note: Requests usually urgent ESR NOT TESTED SPECIMEN TOO OLD Note: Health Centres now perform their own ESRs (code EGP) SPECIMEN TOO OLD FOR BLOOD FILM REPORT As above and FBC SPECIMEN TOO OLD FOR WBC DIFFERENTIAL. FULL BLOOD COUNT SPECIMEN TOO OLD FOR TESTING - 8 hours yellow unspun gel tube Must be taken at least 4 hours post Overdose TROPONIN INR ELECTROLYTES (SODIUM POTASSIUM CHLORIDE) LESS THAN 24 LESS THAN 48 IF LEFT OVERNIGHT - Applies to Troponin I and T IOLD ON INR SPECIMENT TOO OLD FOR TESTING Note: PT part of CLOT profile SPECIMEN UNSEPARATED OVERNIGHT Specimen taken during night but not centrifuged.