Pathology Requests and Specimens€¦ · Web viewRequests for transfusion of blood or blood products must be made on a Transfusion Request form, or raised electronically via e-Orders.

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Canberra Hospital and Health ServicesClinical ProcedurePathology Requests and SpecimensContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 3

Section 1 – Requesting Pathology Tests/Examinations.............................................................3

Section 2 – Specimen Collection and Labelling.........................................................................5

Section 3 – Use of Pre-printed Self-adhesive Specimen Labels.................................................6

Section 4 – E-Orders..................................................................................................................6

Section 5 – Patient Self Collected Specimens............................................................................7

Section 6 – Tissue Specimens....................................................................................................9

Section 7 – Other Specific Specimens.....................................................................................11

Section 8 – Transporting Specimens to ACT Pathology...........................................................12

Section 9 – Inadequately Labelled and Mislabelled Specimens..............................................15

Section 10 – Wrong Blood in Tube (WBIT)/ Major Mislabelled Specimens.............................16

Implementation...................................................................................................................... 18

Related Policies, Procedures, Guidelines and Legislation.......................................................18

References.............................................................................................................................. 18

Definition of Terms................................................................................................................. 19

Search Terms.......................................................................................................................... 19

Doc Number Version Issued Review Date Area Responsible PageCHHS18/166 1.0 15/06/2018 01/07/2019 Pathology 1 of 20

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

This procedure describes how Pathology tests are correctly requested, how specimens are handled (including tissue specimens and patient collected specimens), and how specimens are transported to the laboratory.

The requirements that must be complied with when ACT Pathology receives specimens and/or Pathology request forms that are inappropriately labelled is also explained.

This document does not describe how patients are identified immediately prior to the collection of Pathology specimens, nor the technical procedure of how specimens are collected and then labelled immediately after collection. Refer to the ACT Health “Patient Identification – Pathology Specimen Labelling” procedure and the “Venepuncture Blood Specimen Collection” clinical procedure for this information. This procedure supports staff to comply with National Safety and Quality Health Service Standards, in particular, Standard 5 Patient Identification and Procedure Matching, and Standard 7 Blood and Blood Products.

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Alerts

Information on Pathology request forms must be completed in legible handwriting. Incorrectly completed request forms will cause delays in specimen processing. ACT

Pathology Laboratory departments may refuse to accept them. The use of large pre-printed self-adhesive specimen labels (larger than 65 mm x 25 mm

for normal blood specimen tubes, and 50 mm x 28 mm for paediatric blood specimen tubes) are unacceptable as specimens jam in analyser racks. This may cause analysis time to be considerably lengthened, which compromises test turnaround time and ultimately the quality of patient care.

For inpatients collecting a 24 hour urine specimen, clear emphasis must be given to the patient that they must keep the specimen under or beside their bed at all times (not in the amenities room), even after each time urine is added to the container. Otherwise their specimen may be mixed up with another patient’s specimen. Explain to the patient that after the last time they add urine into the container (i.e. at the conclusion of the 24 hours) they must place their identification label that they were initially provided with, on the specimen container.

A patient self-collected specimen delivered to an ACT Health facility by someone other than the patient must not be accepted if it is unlabelled, illegibly, or inadequately labelled. The specimen must be returned to the patient for them to personally label, as per step 2 of section 4 and initial the specimen label. The specimen must then be delivered to an ACT Pathology laboratory as soon as possible.



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NEVER use yellow infectious waste bags for sending amputated limbs to ACT Pathology for Pathological investigation. They may be discarded before the Pathology examination can be completed.

Zero tolerance for pathology specimen labelling requires a recollection for all misidentification issues with specimen or request forms, irrespective of how minor the incident is (including illegible patient identification details). ACT Pathology will enter a Kestrel Incident Report for the patient, which includes where the incident has occurred and outline that they have requested a recollection due to the misidentification error. The collector responsible for the initial error should be the person responsible for organising the recollection if available. Refer to Section 9 and 10 of this procedure for further information.

Where ACT Pathology deems a specimen unsatisfactory for any reason, it may not be possible to test or examine it. Should this occur, the requesting medical officer, nurse/midwife or allied health professional shall be informed of the reason for non-acceptance and requested to recollect. (Refer to the ACT Pathology Handbook for additional information.)


Scope

This document pertains to all patients requiring Pathology testing at an ACT Pathology laboratory.

This document applies to staff, who are working within their scope of practice, including: Medical Officers Pathology Staff Allied Health Professionals Occupational Medicine Unit (OMU) After Hours Clinical Nurse Consultant (AHCNC) Nurses and Midwives Students under direct supervision.


Section 1 – Requesting Pathology Tests/Examinations

Procedure The specimen(s) collected from each single episode must be sent to the laboratory accompanied by either a hardcopy request form, or associated with an electronic order (e-order).

Only specimens accompanied by a request form, or associated with an electronic e-order will be processed by ACT Pathology.

Pathology Request Forms



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The following information is mandatory on Pathology request forms:1. The patient’s given name and family name2. The patient’s Date of Birth3. The patient’s Unique Record Number (URN) (only applicable for outpatients having a

procedure and inpatients)4. Patient Address (only mandatory for patients who are not required to wear an

identification (ID) band)5. Patient’s gender6. Ward or unit7. Requesting practitioner’s printed name (if the request is to be billed to Medicare, also

include the doctor’s provider number)8. Date request was written9. Address for report, and also where appropriate the name and address of any Health

Professional requiring a copy of the report10. Tests or examinations required11. Relevant clinical information (including pre and postoperative diagnosis where

appropriate) and current drug therapy12. Date and time of collection13. Collector’s printed name and signature14. Type and number of specimen(s) collected15. Site of specimen origin (essential for Anatomical Pathology specimens and any specimen

where this information is diagnostically important, e.g. swabs for culture and sensitivity).

Where available, pre-printed self-adhesive patient identification labels can be placed on the request form as an alternative to hand writing the patient identification details on the form.

Transfusion Request FormsRequests for transfusion of blood or blood products must be made on a Transfusion Request form, or raised electronically via e-Orders. This request form must include the information required as detailed above. E-Orders must not be used for requesting Group, Screen and Hold (GS) Transfusion tests.

In addition, hardcopy Transfusion request forms must be signed by: the requesting practitioner, the collector, and a witness.

Note: For procedural information regarding requests for blood and blood products for transfusion, refer to the “Fresh Blood Products Administration - Adults, Paediatrics (Including Mature Minors), Infants and Neonates)” Clinical Procedure.



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Urgent RequestsIf the test result is required urgently, the urgent box on the Pathology or Transfusion Request Form must be ticked.

Priority Discharge RequestsIf the patient is scheduled for discharge on the day of request mark the form with ‘Priority Discharge’ to facilitate prioritising of the sample once it has reached the laboratory.


Section 2 – Specimen Collection and Labelling

Procedure Specimen CollectionPrior to specimen collection, the identification of the patient must be established as per the ACT Health, “Patient Identification - Pathology Specimen Labelling” Procedure.

Refer to the ACT Pathology Handbook for detailed information regarding the specimen requirements for different types of requested tests. The ACT Pathology Handbook is reviewed and reissued periodically and is available via the ACT Health Intranet and Internet site. To obtain a hardcopy of the Handbook, contact Pathology Customer Services on 6244 2932.

Specimen LabellingSpecimens must be personally labelled by the collector before leaving the patient, as per the ACT Health “Patient Identification - Pathology Specimen Labelling” Procedure.

Witnessing Specimen CollectionsAll Transfusion specimens and all specimens collected from patients not wearing an identification band that are not lucid or are unable to respond intelligently must be witnessed.

For responsibilities and requirements of a witness, refer to the ACT Health “Patient Identification - Pathology Specimen Labelling” Procedure.

Note: The technical procedure for collecting blood specimens via venepuncture is described in the “Venepuncture Blood Specimen Collection” Clinical Procedure.




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Section 3 – Use of Pre-printed Self-adhesive Specimen Labels

Procedure It is preferable that patient identification information is neatly handwritten on specimen containers. The use of pre-printed self-adhesive labels is associated with a significantly higher incidence of incorrectly identified/labelled specimens, which can cause serious if not fatal errors.

If pre-printed self-adhesive patient identification labels are used to label blood specimen tubes, they must be purpose designed, small, and no larger than 65mm x 25mm, and must be approved by the Pathology Department.

Paediatric blood specimen tubes must not be labelled with pre-printed self-adhesive patient identification labels that are larger than 50 mm x 28 mm, and must also be approved by the Pathology Department. Adhesive labels must be placed longitudinally on specimen tubes with a “window” allowing the specimen to be viewed (i.e. place pre-printed label over the specimen tube’s manufactured label).

Please contact the Pathology Department Customer Services Manager on 6244 2932 with questions regarding the acceptable use of pre-printed self-adhesive labels.


Section 4 – E-Orders

ProcedureInpatient requests can be made via E-Orders, with the exception of Group, Screen and Hold (GS) Transfusion requests for blood group and antibody screening; and Anatomical Pathology requests. GS requests must be made on a red Transfusion hardcopy request form. Anatomical Pathology requests – use the normal Pathology request form.

Requests using e-Orders are electronic, no hardcopy request form is used. The requesting practitioner enters the request into the e-Orders system. Mandatory fields must be completed with the required information before submission of the request. This ensures that the mandatory information listed in Section 1, under “Request Forms” is entered. The requester is automatically traceable.

Once an e-Order request has been submitted, it will be displayed on the pending requests lists, which are accessible by collection staff.

Prior to collecting the specimen, specimen collection staff will identify the patient using the same principles described in the ACT Health “Patient Identification – Pathology Specimen



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Labelling” Procedure, ensuring that the patient identification details on the patient’s identification label, in the e-Order’s request (as displayed by the Computer on Wheels (COW)) and what is stated by the patient are all consistent, with no discrepancies.

The collector scans the barcode on their staff identification card and on the patient’s identification band to record in the e-Order system that they are collecting the specimen(s) for the relevant request. After the specimens are collected the system will print the specimen labels, from a printer which is located on the COW trolley, which are utilised by the collector for the labelling of the specimen(s), as per the ACT Health “Patient Identification – Pathology Specimen Labelling” procedure.

Note: E-Order specimen labels must not be used to label specimens collected for Group, Screen and Hold (GS) Transfusion requests. These specimens must be either labelled with conventional pre-printed labels or hand written and must include the date and time of collection and the collector’s initials.

Each patient collection is sent to the Pathology Laboratory in a separate bag, but with no request form.

If the scanning of the barcodes on either the Collector’s staff identification card or the patient’s identification band do not function, the collection must be made using a hardcopy request.


Section 5 – Patient Self Collected Specimens

ProcedureEvery effort should be made to have specimen collection done in the presence of a health care worker, to ensure appropriate labelling procedures. Where this is not possible (for example midstream urine (MSU) and Faecal specimens) the following procedure must be followed:

1. The patient’s identification is established with the patient by asking them to state (strictly without prompting) their full name (given and family names), date of birth, and if they are not wearing an ID band (and are not required to), their address; as per the ACT Health “Patient Identification – Pathology Specimen Labelling Procedure.”

2. Write on a blank label the identification details confirmed in step 1, or print a label with these details, but do not place the label on the container. Leave the label on its backing paper. It is a National Association of Testing Authorities (NATA) requirement that specimen containers must not be labelled before collection.Note: For inpatients label the empty container with the patient’s URN, obtained from their ID band and compared with what is on the request form. For patients not wearing an ID band (and are not required to), label the empty container with the patient’s address postcode.



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3. Ask the patient to confirm that the identification details on the label are theirs and correct. Then place this identification label, together with a copy of the request form (if e-Orders has not been used) in the sleeve of a biohazard bag.

4. Provide the patient with an unlabelled empty specimen container and the biohazard bag with the copy of the request form (if e-Orders has not been used), and the specimen identification label still left on its backing paper.

5. Instruct the patient to self-collect the required specimen and place their identification label on the specimen container immediately after the specimen has been collected, then return the container with the collected specimen and request form immediately to a designated ACT Health location staffed with health care workers.

Note:If a 24 hour urine specimen is being collected, provide the patient with a 24 hour Urine Collection Factsheet (there are two, one for where acid preservative is in the container, and one when there is no acid). These factsheets are available from the ACT Pathology Customer Services department or Specimen Reception. Explain the information on the Factsheet to the patient, and in particular that they must write the exact date and time on the container when the collection period commences and then ends.For 24 hour urine specimens collected by inpatients, refer to the alert on this topic in the Alert Section.

6.7. When the patient delivers the container with the self-collected specimen to a

designated ACT Health location, the receiving health care worker must ask the patient to confirm their identification details, as per step 1. The health care worker then checks the patient identification details on the specimen container label, and that they are identical with what is recorded on the request form.

8. If the request was placed via e-Orders, the health care worker must print a label from e-Orders and place it on the container. This must be undertaken after confirming the identity of the patient, as per step 1, and comparing these patient identification details with the request in e-Orders (including the URN, if the patient is required to wear an identification band) and the patient’s identification on the label already placed on the specimen container by the patient.

9. If the specimen is received unlabelled (e.g. if original label has come off the container), or is illegible; the health care worker must label the specimen container in the presence of the patient, as per steps 1 and 2 above, and then ask the patient to confirm the identification details on the specimen container label.

Note:“Dropped Off Specimen” stamps can be obtained from the ACT Pathology Customer Service department, phone 6244 3367, or 6244 2934.

10. After the health care worker has checked the patient identification labelling on the specimen with the patient, they must write their name in the place provided (if there is one) on the specimen label for the checking staff member. Where there is a



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hardcopy request form (i.e. when e-Orders has not been used), it should be stamped with the “Dropped Off Specimen” stamp and the required details such as staff name, time, date, and location filled in.

11. If the patient does not personally deliver the specimen, the person delivering it must be asked to confirm that it is from the patient identified on the label (i.e. they must be asked to state, who the specimen is from without prompting).

Note:If the specimen container is unlabelled, illegible, or inadequately labelled; refer to the alert on this issue.

12. Using gloves, the health care worker must place the specimen in a Biohazard bag (or other suitable bag if a Biohazard bag is too small), and ensure it is delivered to ACT Pathology.


Section 6 – Tissue Specimens

ProcedureAll body tissue removed during surgical or diagnostic procedures, including limb amputations and termination of pregnancy, must be sent to ACT Pathology or the mortuary for examination and/or disposal.

In addition to the procedural requirements detailed above, the following requirements must be adhered to:

1. Fresh Tissue SpecimensFresh tissue must NOT be placed in Formalin and should be transported to the laboratory as soon as possible after collection.

Fresh tissue specimens are required for:1. Frozen Sections2. Microbiological and/or Flow Cytometry examinations (e.g. Lung Biopsies and Lymph

Node Biopsies)3. Renal Biopsies4. Immunofluorescence examinations5. Products of Conception that are to be examined by both Cytogenetics and Histology.6. All placentas

Tissue must not be placed in Formalin whenever there is an examination request other than for Histology or whenever there is an examination request that is additional to a Histology request. If in doubt, contact the Anatomical Pathology department of ACT Pathology on 6244 2874 or 6244 2867.



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Refer to the ACT Pathology Handbook for additional information.

2. Routine Tissue SpecimensSpecimens must be suspended or totally immersed in ten times their volume of 10% Neutral Buffered Formalin to maintain the integrity of the specimen until Histological examination is made.

3. Large Cancer SpecimensThese specimens must be sent to Pathology within 2 hours in a large sealable container, totally immersed in 10% Neutral Buffered Formalin. Please contact the couriers for their immediate transfer to Pathology with the signed request form.

4. Limb Amputations for Pathological InvestigationThe following must be performed by theatre staff:(a) The specimen must be placed in a strong black plastic bag, clearly labelled with the

patient’s first name, last name, date of birth and URNo Stick a pre-printed self-adhesive patient identification label to the lower part of

the bag. A hand written label can also be used.o Apply sticky tape around the entire perimeter of the label to ensure that it does

not become detached.

(b) A Pathology request form with the patient identification details, a description of the underlying medical condition, and indicating the type of Pathological examination required (e.g. Histology, must be securely affixed to the bag containing the specimen with sticky tape

(c) Arrange for the labelled bag to be delivered to Pathology Specimen Reception, Level 2, Building 10 ASAP.

Note:Black plastic bags are available as a stock item from stores at Mitchell.

PICS Order Number: 84084PICS Product Name: “BAG BLACK”Bag Dimensions: 770 x 1390 mmSupplier Code: LMTOLVTHEBUI



http://www.health.act.gov.au/c/health?a=sendfile&ft=p&fid=-1774166952&sid=

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5. Disposal of Specimens(a) Tissue Specimens Tissue not requiring Pathology examination must be placed in an appropriate

specimen container completely immersed in Formalin and clearly labelled “FOR DISPOSAL.”

A Pathology Request form must accompany the specimen with the patient details recorded, and “FOR DISPOSAL” clearly written in the “Tests Requested” area.

Send the tissue specimen to the Anatomical Pathology Department of ACT Pathology for disposal.

(b) Limb AmputationsThe following must be performed by theatre staff:1. The specimen must be placed in a strong black plastic bag, clearly labelled with the

patient’s given name, family name, date of birth and URN.o Stick a pre-printed self-adhesive patient identification label to the lower part of

the bag. A hand written label can also be used.o Apply sticky tape around the entire perimeter of the label to ensure that it does

not become detached

2. A Pathology Request form with the patient details and identification of the underlying medical condition must be affixed to the bag containing the limb, with the words “FOR DISPOSAL” clearly written in the “Tests Requested” area.

The labelled bag is placed by hospital couriers on a tray in the body refrigerator in the Canberra Hospital Mortuary cold room.

Amputated limbs for disposal will be collected by the contract cleaners from the mortuary on Fridays and transferred to Totalcare at Mitchell for incineration.


Section 7 – Other Specific Specimens

ProcedureIn addition to the general procedural requirements detailed above, the following requirements must be adhered to:

Infectious SpecimensAll specimens are to be handled as potentially infectious, but there may be special precautions for patients with specific infections. Please refer to the ACT Health Infection Prevention and Control Policies and Procedures.



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Blood Specimens for Human Immunodeficiency Virus (HIV) TestingPrior to collection, the patient must be counselled by a medical officer, or a member of the Occupational Medicine Unit (OMU), or the after-hours clinical nurse consultant (AHCNC).

Research SpecimensFor information regarding ACT Pathology’s involvement in research, please direct enquiries to the [email protected] mail box.


Section 8 – Transporting Specimens to ACT Pathology

Equipment Specimen tube or container Specimen biohazard bags Large sealable plastic bags Absorbent Under Pads ‘Blueys’ Newspaper Ice brick Esky Pneumatic Tube canister

ProcedureSpecimens from the one patient collection episode must be placed in their own specimen bag for transfer to ACT Pathology. Tests from requests on other patients must not be placed in the same specimen bag.

Transporting Specimens within the Hospital to ACT PathologySpecimens may be delivered to ACT Pathology via the pneumatic tube system or hand delivered to the Specimen Reception front receipt counter. Specimens must be triple packed.

Collected specimens must be:1. Collected into a leak proof receptacle (the specimen tube or container)2. Placed into a clip locked specimen biohazard bag, ensuring that specimens from each

patient collection episode are placed into their own individual clip locked specimen biohazard bag. Any associated hardcopy request form is to be placed separately in the document sleeve section of the specimen biohazard bag

3. Transported to the laboratory:a) Via Pneumatic tube

The specimen bags must be placed inside a pneumatic tube canister prior to sending to ACT Pathology.



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b) Personally to an ACT Pathology Specimen Reception PointIf racks of specimens or multiple patient specimens are personally transported in public areas they should be placed in outer packaging, such as a cardboard, polystyrene or plastic box; or a dispatch satchel.(i) Canberra Hospital

Ward staff can deliver the specimens to ACT Pathology staff at the Specimen Reception front counter.

(ii) University of Canberra Hospital (UCH) Pathology specimens collected on the ward are to be delivered

to the ACT Pathology Collection Centre processing room. An ACT Pathology courier is scheduled to pick up samples for transport to Calvary Laboratory four times daily Monday to Friday, excluding public holidays. The last courier time for the day is at 4:15pm. All samples must be received by the collection centre by 4pm daily for packaging to transport to the laboratory.

Out of Hours and weekend specimens are required to be transported to ACT Pathology Calvary Laboratory utilising a taxi service. Specimens will be required to be packaged as per below section.

Transporting Specimens from Non-hospital/Other Sites to ACT PathologySpecimens collected by ACT Health staff in a community setting (e.g. a patient’s home or residential aged care facility) must be transported to an ACT Pathology courier pick up point securely triple packed.

Collected specimens must be:1. Collected into a leak proof receptacle (the specimen tube or container).2. Placed into a clip locked specimen biohazard bag, ensuring that specimens from each

patient collection episode are placed into their own individual clip locked specimen biohazard bag. The associated hardcopy request form is to be placed separately in the document sleeve section of the specimen biohazard bag. All these specimen biohazard



Note: Ice must not be sent in the pneumatic tube system. Coagulation specimens may be sent in the pneumatic tube system, with the

exception of factor assays. If the pneumatic tube system at Canberra Hospital is unavailable during normal

hours, wards need to contact the Central Equipment and Courier Services supervisor on phone number 0413 515 414 and arrange for a courier to pick up and transfer specimens to Pathology. Alternatively, wards can contact the Central Equipment and Courier Services Urgent Courier, by phoning 0413 515 365 and requesting an urgent specimen be picked up and transferred to Pathology. If the system is unavailable after the Central Equipment and Courier Service’s operating hours, wards need to page their relevant wards-person to transfer specimens to the lab.

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bags are then placed in a large clip lock bag containing absorbent under pads ‘Blueys’ as an absorbent material.

3. Place the large clip lock bag containing the individual Biohazard bags in an Esky, which has an ice brick wrapped in newspaper and covered by an absorbent under pad ‘Bluey’ in the bottom. The Esky must be labelled with:

(a) The sender’s name and address(b) The receiver’s name and address(c) An emergency contact name and phone number(d) “Dry Ice” if it contains dry ice.

Deliver Pathology specimens to one of the following ACT Pathology courier pick up points, leaving them such that they can be easily visible to the courier:o Phillip Health Centre: Administration desk, Ground Floor o City Health Centre: Breast Screen Section, Ground Floor o Belconnen Community Health Centre: ACT Pathology collection centre, Level 1o Tuggeranong Community Health Centre: ACT Pathology collection centre, Level 1o Gungahlin Community Health Centre: ACT Pathology collection centre, Ground floor.o University of Canberra Hospital (UCH): ACT Pathology collection centre, Ground floor

Specimens should arrive at an ACT Pathology laboratory within four (4) hours of collection. If there is a likelihood that specimens will not arrive at the laboratory within this timeframe, contact the ACT Pathology Customer Services department on 6244 2932.

If there is a delay in transporting blood and urine specimens to ACT Pathology, to ensure their viability is maintained, they must be kept at refrigeration temperature (2 – 6 OC).

Specimens for unusual tests may have special storage requirements. Consult the ACT Pathology Handbook to determine if these specimens have special storage requirements, or need to be transported immediately to an ACT Pathology laboratory (e.g. by taxi). Some specimens with special handling requirements may need to be collected at an ACT Pathology collection centre that is located near or at a laboratory.

Transport via road should be in a separate luggage compartment or boot of the vehicle.




Note:Dry Ice must be placed in special containers with a vent to prevent explosion and possible personal injury. These containers are available from the Customer Services department of ACT Pathology.

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Section 9 – Inadequately Labelled and Mislabelled Specimens

ProcedureWhere specimens and/or their request forms have been identified as being inadequately labelled i.e. they do not comply with the labelling requirements documented in the ACT Health “Patient Identification - Pathology Specimen Labelling Procedure,” ACT Pathology will reject the specimens and request they be recollected, as per the Zero Tolerance specimen labelling errors process. This includes specimens and/or request forms that have illegible patient identification details.

The Kestrel Incident Report will be entered by Specimen reception staff of Pathology into the laboratory interface system (LIS) detailing the misidentification issue and requesting a recollection.

The zero tolerance policy applies to all inadequately labelled Pathology Specimens and includes all forms of specimen labelling errors, no matter how minor. ‘Precious’ samples will be dealt with under the guidelines as set out below.

‘Precious’ specimens are handled as follows: The collector; or the staff member who personally labelled the specimen (in the case of

an inappropriately labelled precious specimen from theatres, or any other area where the collector is scrubbed) will be:o required to go to the Specimen Reception counter, of the Pathology Department

(Level 2, Building 10); or if the collection was made at UCH, the collection rooms on the ground floor; and sign the “Misidentified Specimen – Request Form Identification Declaration,” guaranteeing that the specimen belongs to the patient identified on the request form that accompanied the specimen. By signing this declaration, the collector takes full responsibility for any adverse consequence should the specimen labelling be incorrect. The collector’s signing of the declaration is also an acknowledgement that ACT Pathology takes no responsibility for the accurate identification of the specimen(s) and request form.

o Required to provide a reason for the specimen being classified as precious on the declaration form.

o Given a flowchart and factsheet summarising the correct procedure for correctly identifying a patient prior to specimen collection, and accurately labelling specimens immediately after collection and before leaving the patient.

The signed declaration will be scanned and filed against the patient record within the Laboratory Information System (LIS).

The declaration will be forwarded to the treating clinician as notification of the mislabelling incident.

The declaration will also be sent to clinical leads for monitoring of repeat occurrences or inappropriate declarations of ‘precious’ samples when the samples could have been recollected.



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Where specimen identification cannot be confirmed with absolute certainty, the manager of the area identifying this non-conformance with the ‘Patient Identification – Pathology Specimen Labelling’ procedure is to ensure the incident is recorded in a Riskman report, irrespective of whether the specimen was recollected or not.

For any minor mislabelling error, the individual clinician/collector management process described below is to be followed.

Management Process for Individual Clinicians/Collectors:1. The first incident of a specimen labelling error will require that the clinician/collector has

a conversation with their immediate line-manager regarding the circumstances of the error and the individual will be required to do the patient identification – pathology specimen labelling e-learning

2. In the event of a second specimen labelling error the individual will be required to meet with their unit director, director of nursing or director of allied health as relevant and undertake a reflection tool (in line with the current major mislabelling escalation pathway)

3. In the event of a third specimen labelling error the individual will be required to meet with their professional lead to discuss a performance plan with respect to adherence with the relevant policies and procedures.

NOTE: Pathology Reports issued on test results produced from inappropriately labelled specimens will include a disclaimer that ACT Pathology takes no responsibility for the accurate identification of the test report produced on these specimens.


Section 10 – Wrong Blood in Tube (WBIT)/ Major Mislabelled Specimens

ProcedureA WBIT incident refers to when any type of specimen (not just a blood specimen) and request form is received by ACT Pathology where both are labelled identically with the same unique patient identification details, but it is subsequently discovered that the specimen and request form belong to a different patient to that identified on the request form and specimen labels.

Major mislabelling incident refers to: where the specimen is unlabelled, specimens where the labelling on the sample is a different patient to the patient on the

request form (specimen/form mismatch), that is specimen is labelled Patient A and request form is labelled Patient B;

where there is less than 2 patient identifiers on the sample or request form.



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These incidents of misidentification where the identity of the patient is uncertain must be recollected for the safety of the patient. These incidents will be recorded within the Riskman incident management system for further investigation.

These types of errors should not occur if the ACT Health ‘Patient Identification - Pathology Specimen Labelling’ procedure is complied with. However, if this error occurs, the following corrective actions must be complied with:1. The correct patient must be collected (or recollected) and the specimens sent to

Pathology with a new request form. 2. Precious samples that cannot be recollected due to being unique (e.g. tissue biopsy,

devices/prosthetics, amputations) will be entered into the LIS by specimen reception and forwarded to the respective department where a decision to report will be at the discretion of the pathologist in consultation with the requesting clinician.

3. Where the specimen is precious, the Pathology report will not be issued under the claimed correct patient’s name until the requesting practitioner presents at the Specimen Reception counter of the Pathology Department (Level 2, Building 10) at Canberra Hospital; or if at the University of Canberra Hospital, the collection room and processing area; and completes and signs an “Incorrect Patient Declaration” authorising the results to be issued under the claimed correct patient’s name and taking responsibility for any adverse consequence due to misidentification of the specimen(s) and report issued on tests of this specimen(s).

4. Declarations will be scanned and filed against the patient record in the laboratory interface system (LIS). Declarations will also be forwarded to Clinical Leads, Chief Medical Officer/Chief Nursing and Midwifery Officer/ Chief Allied Health Officer.

5. Where there is a requirement for the transfer of results from one patient to another, this must be approved by the relevant laboratory Chief Scientist and/or Department Director.

6. A retracted report will be issued on any previously issued report that allegedly had incorrect patient identification with all results replaced with stars, and a comment requesting that any previous hardcopy report issued with the same request number be discarded and destroyed.

7. For WBIT incidents, if a report must be reissued under the claimed correct patient’s name, it will include a disclaimer comment that the request form and specimen used to produce the result were both received by ACT Pathology labelled identically with a different patient’s identification details. The disclaimer will state that ACT Pathology takes no responsibility for the accurate identification of the report nor for any adverse consequence resulting from action taken on the report should it be misidentified. A warning is included that a clinical judgement will need to be made by the referring practitioner as to whether action should be taken, or not, on the basis of the report.

8. The manager of the area identifying the non-conformance with the ACT Health ‘Patient Identification – Pathology Specimen Labelling’ procedure is to ensure it is recorded in a Riskman report.

9. The clinician/collector of the sample which is subject to a major mislabelling event or WBIT will be required to complete the reflection tool as part of the Riskman investigation and procedure.



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Implementation

This procedure will be advertised to all ACT Health staff via an all staff e-mail issued by the Policy Committee when new policies and procedures are published in the Policy and Clinical Guidance Register, accessible via the ACT Health Intranet.


Related Policies, Procedures, Guidelines and Legislation

Policies Patient Identification and Procedure Matching Clinical Policy ACT Health Incident Management Policy ACT Health Nursing and Midwifery Continuing Competence Policy Consent and Treatment Policy

Procedures Patient Identification – Pathology Specimen Labelling Procedure Patient Identification and Procedure Matching Procedure Fresh Blood Products Administration – Adults, Paediatrics (Including Mature Minors),

Infants and Neonates Clinical Procedure Venepuncture Blood Specimen Collection Clinical Procedure ACT Health Incident Management Procedure Healthcare Associated Infections Clinical Procedure Nursing and Midwifery Continuing Competence

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011


References

1. International Standard ISO 15189 “Medical Laboratories - Particular requirements for quality and competence”

2. National Pathology Accreditation Advisory Council (NPAAC) “Requirements for the Packaging and Transport of Pathology Specimens and Associated Materials,” Fourth Edition, 2013

3. ACT Pathology Handbook



CHHS18/166


Definition of Terms

WBIT Wrong Blood in Tube. This refers to any type of specimen (not just blood specimens) where the patient identification on the specimen(s) is exactly the same as that on the accompanying request form. However, the specimen and request form belong to a different patient to what they are labelled with.

COW Computer on Wheels

Unlabelled Specimen Any specimen received by ACT Pathology with no patient identification at all.

Mislabelled Specimen Any specimen received by ACT Pathology with patient identification that does not match what is on the accompanying request form.

Inadequately Labelled Any specimen received by ACT Pathology with less than three (3) unique patient identifiers.

NATA National Association of Testing Authorities


Search Terms

Pathology, Request, Test, Specimen, Sample, Limb, Unlabelled, Mislabelled, WBIT, Label, Tissue, Disposal, Amputation, Blood, Transport




CHHS18/166

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 16 Jun 18 Complete Review Peter Collignon, ED

PathologyCHHS Policy Committee

3 Jul 18 Update to include e-Order requirements for Group and Screen tests

Peter Collignon, ED Pathology

CHHS Policy Committee Chair

This document supersedes the following: Document Number Document NameTCH11:012 Pathology Requests And Specimens



Pathology Requests and Specimens€¦ · Web viewRequests for transfusion of blood or blood products must be made on a Transfusion Request form, or raised electronically via e-Orders.

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