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Properly Labeling Specimen

I. Purpose To protect patients from adverse errors as a result of improperly labeled specimens. The correct identification of patients and specimens are two of the most critical steps in the specimen collection procedure. Proper identification helps to insure that each patient receives the correct laboratory results and diagnosis. The College of American Pathology (CAP) and The Joint Commission (TJC) specify the need for proper identification. II. Evaluation/Scope This protocol will provide a uniform policy for specimen acceptance/rejection that: A. Eliminates potential errors made due to improper labeling of specimens B. Protects specimen quality C. Has a positive impact on patient care III. Personnel A. Phlebotomy staff B. Covid swabbers C. Nurses IV. Labeling Requirements All specimens must contain labels with the following legible information: • Patient full name o Example: Last Name, First name • Patient date of birth o Example: 01/01/1925 • Medical professional’s initials o Example: J.D. o Date and time of collection  V. Materials needed 1. Proper PPE a. Face mask b. Eye protection c. Gloves d. Gown 2. Appropriate equipment for test ordered (i.e., tourniquet, needles, swabs, vacutainers, alcohol prep pads, gauze, etc.) 3. Indelible ink pen 4. Labels 5. Biohazard bag VI. Procedure 1. Before entering a patient’s room, assess that all needed equipment are in your possession. 2. Knock lightly, open the door slowly, and introduce yourself to the patient before proceeding to enter their room 3. Inform the patient about the procedure and obtain their consent to proceed 4. Identify the patient using two identifiers: patient’s FULL name and date of birth 5. Explain the procedure to the patient 6. Sanitize hands with either alcohol-based gel or soap and water 7. Put on vinyl or nitrile gloves 8. Position the patient for the procedure 9. Follow guidelines to perform the ordered procedure 10. Label sample tubes at the patient’s bedside immediately after the procedure with an indelible ink pen. 11. Each tube must be labeled with the patient’s two identifiers: full name and their date of birth. Write as clear as possible to avoid errors. Leave a visible window on the side of the tube so the contents can be seen. 12. The two identifiers on the label must match the corresponding identifiers on the order/requisition. 13. Specimens should be placed in a biohazard bag along with the requisition. One bag should be used for each patient. 14. Before leaving the room, thank the patient for their cooperation 15. Remove all PPE and dispose of them in the proper receptacle 16. Sanitize or wash hands following proper guidelines   VII. Summary Statement The outlined process is the procedure for correctly acquiring and labeling specimens. Identifying patient information can be provided by writing directly onto the vials in indelible ink. All patient specimens MUST be placed in biohazard bags for transport to the Laboratory. One bag should be used for each patient. Place all small bags in a larger biohazard specimen container. Every specimen brought to the Laboratory must have a label on it. It is not acceptable to label the lid of a specimen, the transport bag, or other containers used to transport the specimen. Specimens received unlabeled, double-labeled, or with a requisition bearing a name and/or date of birth different than what is affixed to the specimen will not be tested and must be rejected.