Laboratory Request Form Completion and Specimen Labelling Reference Number:

Transcription

1 This is an official Northern Trust policy and should not be edited in any way Laboratory Request Form Completion and Specimen Labelling Reference Number: NHSCT/12/582 Target audience: This policy is directed to all phlebotomists, healthcare assistants, nurses and doctors who complete laboratory request forms or label sample containers. Sources of advice in relation to this document: Maureen Entwistle, Pathology Quality Manager David Wallace, Acting Assistant Director Clinical & Diagnostic Services Replaces (if appropriate): Northern Trust Laboratory Request Form Completion and Specimen Labelling (HSCT/10/333) Type of Document: Trust Wide Approved by: Policy, Standards and Guidelines Committee Date Approved: 28 June 2012 Date Issued by Policy Unit: 30 August 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves

2 Laboratory Request Form Completion and Specimen Labelling 24 April 2012 Version 1_1

3 Laboratory Request Form Completion & Specimen Labelling Introduction In accordance with best practice guidelines and Standard E5.2 (CPA UK) the Clinical Pathology Laboratory in the Northern Trust has a strict policy in regard to the acceptance or rejection of specimens. It is intended to ensure that the right investigation is performed on the right specimen. The Minimum Data Set is a nationally agreed set of standards for the appropriate labelling of samples and completion of request forms. It is the responsibility of the requestor to ensure that samples are labelled correctly and request forms are completed at least to these minimum standards. Unequivocal identification is essential to prevent attribution of results to the wrong patient and to avoid multiple computer entries for the same patient. Request forms and/or specimens with inadequate, inaccurate or illegible information inevitably disrupt laboratory processing causing unnecessary delay. Where there is a possibility of risk of potentially serious error, there is no alternative but to reject the specimen. In line with DHSSPSNI Safer Practice Circular 05/09 the Health and Care number (HCN) should be the unique identification number used for patients; the local hospital number may be used alongside the HCN but NOT instead of it. Recent audits of the completion of laboratory request forms revealed that 52% had no Consultant detail; 5% no time of sampling; 2% no ward and 25% of handwritten forms had no patient gender. Purpose This policy outlines the essential patient identifiers and information required on both laboratory request forms and specimen containers. Target Audience This policy is directed to all phlebotomists, healthcare assistants, nurses and doctors who complete laboratory request forms or label sample containers. 1

4 Responsibilities The responsibility for compliance with the standard requirements for requesting a laboratory service / test lies with the patient s clinician even when the requesting process is delegated to other staff acting on their behalf. It is therefore the responsibility of the requestor to ensure that specimen containers are correctly labelled and that request forms are completed to the required standard. It is recognised that there may be circumstances in which exceptional procedures need to be applied e.g. where the identity of the patient or other standard information is unknown, where the patient is not easily accessible for a repeat test or where the repeat sample would not have the same clinical significance. This policy sets out the procedures to be followed in such cases. Policy Statement Specimens will not be accepted for analysis where: 1. The essential criterion in the Minimum Data Set is not met on either the form or the specimen container. 2. The specimen has been collected inappropriately e.g. unsuitable anticoagulant or preservative. 3. The integrity of the specimen is in question e.g. leaked in transit, undue delay in transport. 4. The specimen is unlabelled. 5. The specimen is incorrectly labelled to such a degree as to compromise reliable identification of the patient The subsequent action will be determined by the Biomedical Scientists but may include:- Requesting a fresh specimen and form Processing the specimen but withholding results Storing the specimen in a manner appropriate for later analysis At the discretion of Senior Biomedical Scientists the requestor may be contacted for ward & consultant details required to complete the minimum data set; any modification to the request form is recorded. The requestor will be required to complete any missing data in the laboratory only in exceptional circumstances will samples be returned to sender. All blood bank samples / request forms that do not conform to the minimum data set will be rejected. Point of Care Samples All Point of Care record sheets and specimen containers (where appropriate) must also contain the ESSENTIAL information. 2

5 Minimum Data Set for all pathology requests except Blood Transfusion On occasion some of the desirable data may be essential; it is preferable to supply all of the information detailed below to ensure that the patient is not inconvenienced or put at unnecessary risk due to delay in provision of results. For example serum Potassium rises significantly within 2 hours of sampling whilst other analytes are stable for a longer period; therefore the time of sampling may be essential. Essential Specimen Desirable Health and Care Number (HCN) Date & Time Destination for report Request Form HCN Gender (except Cellular & Molecular Pathology) Patient s location and destination for report Patient s Consultant, GP or name of requesting practitioner Investigations required Relevant Clinical information* Date & Time of sampling** Patient s address Contact number of requestor in the event of further communication being required Hazard Group 3 (Cat 3) Hazard Sticker if applicable *For Cellular and Molecular Pathology specimens relevant patient clinical history, source and type of specimen and the identity of the requesting practitioner are essential criteria on the request form. The DoB and / or HCN are acceptable on the sample in addition to the patient s full name. *For Microbiology specimens relevant clinical history, source of specimen and current antibiotics are essential criteria on the request form. **Date and time of sample is highly desirable for Biochemistry requests and some analytes, e.g. Potassium, will not be reported if date and time of sample is not provided Where addressograph labels are used for sample containers care must be taken to ensure that the sample in the tube is not totally obscured by the label; Biomedical Scientists in the laboratory often need to see the blood level and consistency in the container. Where addressograph labels are used for request forms the patient s location and Consultant must be added. Results cannot be reported if the source and location of the request is in doubt. Note that the GP cypher number alone is not sufficient. In the case of an unconscious patient or for reasons of confidentiality the coded PID s are acceptable. 3

6 Blood transfusion The requirements of the NPSA SPN 14 Right patient, right blood competency 1 Obtaining a venous sample for pre-transfusion testing must be adhered to. The details on the request form and specimen container must tally with the details on the patient s wristband. Specimen Request Form Essential Hospital number / unique identifier Date & Time Signature of person taking specimen details MUST be handwritten Hospital number / unique identifier Gender Patient s location and destination for report Patient s Consultant, GP or name of requesting practitioner Printed name, Signature, staff group & professional / Staff number of person taking sample Investigations required Date & Time of sampling Addressograph labels are acceptable on request forms ensure that all essential details are added Desirable Destination for report Transfusion history* Patient s postcode Hazard Group 3 (Cat 3) Hazard Sticker if applicable Additional information required if blood component / products are ordered Type & number of product required Special requirements if any Date / time / location of transfusion Reason for transfusion Recent Haemoglobin result with date Name, professional ID number / staff number and the signature of the person requesting the product *blood group / antibody history if known; previous / recent transfusions including date; previous transfusion reactions; obstetric history including recent anti-d administration (if applicable) 4

7 Equality, Human Rights and DDA This policy is purely clinical / technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Alternative Formats This document can be made available on request on disc, larger font, Braille, audio-cassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. References Patient Specimen and Request form Identification Criteria. The Institute of Biomedical Science (IBMS) BCSH Guidelines for compatibility procedures in blood transfusion laboratories Transfusion Medicine, 2004, 14, NPSA Safer Practice Notice (14) Right Patient, Right Blood DHSSPSNI Safer Practice Circular 05/09 use of the Health and Care Number _use_of_health_and_care_number_.pdf 5

8 Biochemistry, Haematology, Microbiology, Histopathology & Blood Transfusion Requests Cytopathology requests Essential Desirable Essential Desirable Specimen Request Form HCN Gender Patient s location and destination for report Patient s Consultant, GP or name of requesting practitioner Investigations required Health and Care Number (HCN) Date & Time Destination for report Relevant Clinical information* Date & Time of sampling** Patient s address Contact number of requestor in the event of further communication being required *For Cellular and Molecular Pathology specimens relevant patient clinical history, source and type of specimen and the identity of the requesting practitioner are essential criteria on the request form. The DoB and / or HCN are acceptable on the sample in addition to the patient s full name. *For Microbiology specimens relevant clinical history, source of specimen and current antibiotics are essential criteria on the request form. **Date and time of sample is highly desirable for Biochemistry requests and some analytes, e.g. Potassium, will not be reported if date and time of sample is not provided NB addressograph labels DO NOT contain the patient s location or Consultant Specimen Request Form Additional information required if blood component / products are ordered Hospital number / unique identifier Date & Time Signature of person taking specimen details MUST be handwritten Hospital number / unique identifier Gender Patient s location and destination for report Patient s Consultant, GP or name of requesting practitioner Printed name, Signature, staff group & professional / Staff number of person taking sample Investigations required Date & Time of sampling Addressograph labels are acceptable on request forms ensure that all essential details are added Type & number of product required Special requirements if any Date / time / location of transfusion Reason for transfusion Recent Haemoglobin result with date Name, professional ID number / staff number and the signature of the person requesting the product Destination for report Transfusion history* Patient s postcode *blood group/antibody history if known; previous/recent transfusions including date; previous transfusion reactions; obstetric history including recent anti-d administration (if applicable) 6

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