Welcome to the Training Program for Minimum Pathology Labelling Requirements

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Pathology Specimen Labelling Requirements

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Whenever you collect a sample for Pathology testing, it is imperative that you label it with the information needed to clearly identify which patient the sample has come from.

We receive hundreds of samples every day, and partial or incorrect labelling of samples and/or request forms remains one of the most common reasons for being unable to process samples. Worse still, as many as 1 in 2000 samples do not even belong to the patient whose name appears on the tube (and that is only the ones that are detected!)(1)

In order to maximise patient safety, National Safety and Quality Health Service Standards (NSQHS) have been expanded regarding the labelling of Pathology samples and the collection of Blood Products. These standards will be adopted across Eastern Health in October, 2012.

(1) Gonzalez-Porras, J. R., I. F. Graciani, et al. (2008). “Tubes for pretransfusion testing should be collected by blood bank staff and hand labelled until the implementation of new technology for improved sample labelling. Results of a prospective study.” Vox Sanguinis 95(1): 52-56.

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What are the new requirements?Every sample and request form must be labelled with three unique identifiers in legible form and the details on form and sample must match

(1) FULL name (surname and given name)

(2) Date of Birth

(3) UR Number OR Medicare Number OR Full AddressAlso, under the new Laboratory Accreditation requirements, re-labelling of specimens is NOT PERMITTED. Any specimens that are inadequately or incorrectly labelled will need to be re-collected

NO LABELS = NO TESTSClick here to continue

You must have.....1 : FULL NAME OF PATIENT

2 : DATE OF BIRTH

3 : UR or ADDRESS or MEDICARE NUMBER

A UR label contains all the information we

need, so this is acceptable on forms and

tubes (make sure the sticker is for the right

patient, though!)

B654321 CITIZEN, JOHN15 SMITH ST HMUYARRA JUNCTION 3456 39yPHONE: 035977777 05/08/73Medicare No: 333333333/3

B123433

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If you write the name of the test(s) you want CLEARLY AND LEGIBLY, there will be no confusion about

what is required

Always include a contact number for critical alerts

B654321

The specimen collector must complete this section

PR Bleed – PHx Ca Colon

FBEU+EClotting Profile

B654321 CITIZEN, JOHN15 SMITH ST HMUYARRA JUNCTION 3456 39yPHONE: 035977777 05/08/73Medicare No: 333333333/3

B123433

John Smith SMITH 3789 15 8 12

Mary Nurse MARY NURSE 15 8 12 1550

While we’re talking about Request Forms…..……you can help us to help you

Clinical notes help us prioritise urgent samples and interpret results

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Clinical Management Systems such as Symphony, and ehcare@eastern produce request forms (and in some cases, tube labels) which comply with the new requirements. The request forms generated by the software systems commonly used in General Practice also comply.

What about computer-generated request forms?

REMEMBER, THE LABELLING ON THE TUBE AND THE REQUEST FORM MUST MATCH OR A RE-COLLECTION WILL BE REQUIRED

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Is this for ALL samples?

YES!!Please note that the Zero Tolerance Criteria for Blood Bank testing still applies. Also, ‘precious’ samples such as biopsies and CSF will be processed but ONLY AFTER THE ATTENDING PHYSICIAN HAS COMPLETED A WRITTEN STATEMENT REGARDING THE IDENTIFICATION OF THE SAMPLE.

ALL OTHER SAMPLES WILL NEED TO BE RE-COLLECTED

NO LABELS = NO TESTS

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Example 1

ANN CITIZEN B12345615/6/75GN 19/9/12 1015

CITIZENANN B123456

15 6 75

G.NURSEGrey Nurse19 9 12 1015

TUBE

REQUEST FORM

Acceptable?Click to find out

Example 2

ANN CITIZEN15/6/75GN 19/9/12 1015

CITIZENANN

15 6 75

G.NURSEGrey Nurse19 9 12 1015

TUBE

REQUEST FORM

Acceptable?Click to find out

10 High St, Highton

10 HIGH ST HIGHTON

Example 3

Acceptable?Click to find out

ANN CITIZEN15/6/75GN 19/9/12 1015

CITIZEN

ANN

15 6 75

G.NURSEGrey Nurse19 9 12 1015

TUBE

REQUEST FORM

Medicare 3454346782

3454 34678 2

Example 4

ANN CITIZEN15/6/75GN 19/9/12 1015

CITIZENANN

15 6 75

G.NURSEGrey Nurse19 9 12 1015

TUBE

REQUEST FORM

No third identifier

RECOLLECTAcceptable?Click to find out

Example 5

CITIZENANN

15 6 75

G.NURSEGrey Nurse19 9 12 1015

TUBE

REQUEST FORM

GN 19/9/08 1015B123456

Illegible writing on tube

RECOLLECT

B123456

Acceptable?Click to find out

Example 6

ANN CIZITEN15/6/75GN 19/9/12 1015

CITIZEN

ANN

15 6 75

G.NURSEGrey Nurse19 9 12 1015

TUBE

REQUEST FORM

MC 3454346782

3454 34678 2

Name on tube and form do not match

RECOLLECTAcceptable?Click to find out

In summary...

NO LABELS = NO TESTS

Specimen labelling standards have been strengthened to promote patient safety and ensure that the right patient is getting the right result.

If you follow these requirements, the samples you have collected will be processed. However, if these requirements are not met, the staff in Pathology have no alternative but to ask for a re-collection of the sample. Please remember that when Pathology staff ask for a re-collection, they are only doing their job. They want to make sure that the results they put out are being used to treat the right patient.

Get it right the first time, and we will all be happy!

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