Document Number: QAQC.81.Proc Manual: Quality Assurance Quality Control Version: 002 Publish March 2013 Positive patient identification (ld) is the crucial first step to ensuring patient safety in the delivery of health care processes, regardless of the clinical setting. Failures in accurate patient ID can have serious and adverse consequences for patients, including incorrect treatment, lack of treatment, injury, disability, and death. A minimum of two unique identifiers are to be used when identifying a patient, labeling a laboratory specimen and / or providing results to a licensed practitioner. Positive patient/specimen identification is to be applied through all phases of specimen collection, laboratory processing, and testing. This includes specimen collection in a physician office, patient service center, clinics, medical office buildings, Point of Care testing and specimen aliquoting and derivative preparation in the laboratory. This procedure applies to all clinical and anatomic pathology specimens regardless of who collected the specimen or where the specimen was collected. 2.1 Patient's full name 2.2 Date of birth 2.3 Medical Record Number 2.4 Gender 2.5 Name, address and telephone number of physician or legally authorized person ordering the test. 2.6 Tests requested 2.7 Last menstrual period (for gynecologic specimens) 2.8 Date and time of specimen collection 2.9 Collector full name and/or initials 2.10 Source of specimen, if other than blood 2.11 Clinical information, when appropriate 2.12 Reason for test/ medical necessity for test. 2.13 Special handling requests when appropriate 2.14 Insurance information when appropriate
3.0 Patient Identification: Document Number: QAQC.81-002 The person collecting the specimen (blood or non-blood sample) must confirm that the identity of the patient matches the identity of the individual designated on the test requisition or order. Two unique identifiers must match. Unique identifiers include full patient name, date of birth, and Saint Francis/ CLS medical record number. 3.1.1 The health care provider (HCP) should use active voice question whenever possible, for example: 3.1.2 Ask the patient to state his or her full name. 3.2.2 Ask the patient his or her date of birth. 3.2.3 Do not provide the patient name or date and birth and ask the patient to confirm. They must provide this information as outlined above. NOTE: Ifpatient identification is not confirmed DO NOT proceed to venipuncture procedure The person collecting the specimen (blood or non-blood sample) must confirm that the identity of the patient matches the identity of the individual designated on the test requisition or order. Two unique identifiers must match. Unique identifiers include full patient name, date of birth, and Saint Francis/ CLS medical record number. 3.2.1 Call patient from the waiting room using first name and last initial for privacy purposes. 3.2.2 To ensure patient identification, ask the patient to present their Photo ID and insurance card. 3.2.3 Ensure patient confidentiality is maintained throughout the registration process and ask the patient to complete the Collaborative Laboratory Services (CLS) Patient Information Form (# 29100116). 3.2.4 After the registration and accessioning is complete, place the requisition in the queue for the pwebotomy procedure. 3.2.5 Return the photo ID and insurance card to the patient. 3.2.6 Escort the patient to the draw room. 3.2.7 The HCP should obtain the requisition from the queue. 3.2.8 The HCP should obtain the computer generated label from the label machine. 3.2.9 The HCP must verify patient name and MRN from the label to the requisition. 3.2.10 The HCP will then greet the patient.
3.2.11 The HCP will request the patient to state his or her full name and date of birth. 3.2.12 Do not provide the patient name or date of birth and ask the patient to confirm. They must provide the information as outlined above. 3.2.13 Verify information provided verbally from the patient to the patient information sheet and the LIS generated labels. 3.2.14 The HCP will request the patient to review the information provided on the LIS "Requisition label (RL)"generated label and initial to confirm acceptability. 3.2.15 Pretransfusion Specimens The HCP will prepare a Blood Recipient (i.e., Typenex ) identification bracelet to include: Patient's full name Saint Francis Hospital Medical Record Number Date of birth 3.2.16 The HCP will request the patient to review the information provided on the Typenex band and initial to confirm acceptability. 3.2.17 The HCP will attach the bracelet securely to patient's extremity. 3.2.18 The HCP will inform the patient that the band must remain secured on the patient through the surgical or transfusion procedure. 3.2.19 Remove extra numbers from bracelet and send with specimen to Blood bank to be used in the lab. 3.2.20 Affix an adhesive label from the Typenex number to the test requisition. 3.2.21 Affix an adhesive label from the Typenex to the specimen(s) in addition to the required labeling components above. NOTE: If patient identification is not confirmed DO NOT proceed to venipuncture procedure. The person collecting the specimen (blood or non-blood sample) must confirm that the identity of the patient matches the identity of the individual designated on the test requisition or order. Two unique identifiers must match. Unique identifiers include full patient name, date of birth, and Saint Francis/ CLS medical record number. 3.3.1 Obtain patient requisition from Nursing Home nursing unit. 3.3.2 Proceed to the residence room. 3.3.3 The HCP will knock and greet the patient the patient as they enter the room. 3.3.4 The HCP will explain the procedure to be performed. 3.3.5 The HCP should use active voice question whenever possible, for example: 3.3.5.1 Ask the patient to state his or her full name. 3.3.5.2 Ask the patient his or her date of birth.
3.3.6 Do not provide the patient name or date and birth and ask the patient to confirm. They must provide this information as outlined above. 3.3.7 If the patient is not able to verbally provide the information outlined above, verify using: 3.3.7.1 Patient ID Band 3.3.7.2 Ask patient's nurse to identify the patient using two unique identifiers. 3.3.7.3 Record the name of the person who has identified the resident and request them to date and initial the requisition. 3.3.8 Pretransfusion Specimens The HCP will prepare a Prepare Blood Recipient (i.e., Typenex ) identification bracelet to include: Patient's full name Saint Francis Hospital Medical Record Number Date of birth 3.3.9 The HCP will attach the bracelet securely to patient's extremity. 3.3.10 Remove extra numbers from bracelet and send with specimen to Blood bank to be used in the lab. 3.3.11 Affix an adhesive label from the Typenex number to the test requisition. 3.3.12 Affix an adhesive label from the Typenex to the specimen( s) in addition to the required labeling components above. NOTE: If patient identification is not confirmed DO NOT proceed to venipuncture procedure NOTE: Patient's room number and bed number or physical location may not be used as an identifier. 4.1.1 A minimum of two unique identifiers: 4.1.1.1 Patient's full name (or a unique code number in lieu ofa patient name). 4.1.1.2 Medical Record Number (In-patients) 4.1.1.3 Date of Birth (Out-patients) 4.1.2 Date of Collection 4.1.3 Time of Collection 4.1.4 Initials and/or ID number of the person who collected the sample. 4.2 Source of the sample is also required if other than blood. 4.3 All specimens, including Point of Care, are to be properly labeled at the time of collection at the bedside or in the presence of the patient by the person collecting the sample. Point of Care specimens that will be tested in the presence of the patient do not require labeling.
If a sample is divided into one or more parts and placed into a separate tube or container, the label on the new tube needs to be checked to confirm that it contains two identifiers that uniquely link the aliquot to the primary sample. 5.1 Aliquot labels require the same 5 labeling elements as the primary specimen. Initials and/or ID number of person preparing the aliquot replace initials and/or ID number of person who collected the sample. Laboratory accession number is also required. 5.2 The aliquot specimen tube is labeled prior to manually transferring the specimen. 5.3 Verify the two unique identifiers on the aliquot label match the two unique identifiers on the primary specimen container label. 5.4 Only one patient is to be aliquoted at a time. 5.5 All aliquoting for a given specimen must be completed before aliquoting another specimen. 5.6 Samples are aliquoted individually with a fresh disposable pipette to prevent cross contamination. 5.7 Derivative specimens such as blood smear and pathology slides, pathology blocks, microbiology plates and tubes with limited space may have limited labeling capacity. 5.7.1 Pathology slides require name, medical number and surgical number 5.7.2 Pathology blocks require surgical number, letter and part number 5.7.3 Blood smear slides require name, accession number and date 5.7.4 Microbiology plates and tubes require name, accession number, and medical record number 5.7.5 Cytology non-gynecological ThinPrep slides prepared on the ThinPrep Processor 2000 require cytology accession number and specimen source 5.7.6 Cytology gynecological specimens prepared on the ThinPrep Processor 3000 require accession number only. 6.1 Specimens that do not meet minimum labeling requirements will be rejected for analysis with the exception of non-retrievable pathology specimens, operating room specimens and specimens obtained through invasive procedures. 6.2 Refer to the Specimen Acceptance / Rejection Policy (QAQC.1.Proc) in the Quality Control/Quality Assurance Manual.
7.0 References: Document Number: QAQC.81-002 7.1 CLSI. H3-A6. Procedures for the Collection of Diagnostic Blood Specimens by Venipunture; Approved Standared - Sixth Edition. CLSI document H3-A6 [ISBN 1-56238-650-6]. CLSI, 940 West Valley Road, Suite 1400, Wayne PN 19087, 2007. 7.2 CLSI. GP33-A. Laboratory Accuracy in Patient and Smaple Identification; Approved Guideline. CLSI document GP33-A [ISBN 1-56238-721-9]. CLSI, 940 West Valley Road, Suite 1400, Wayne PN 19087,2010 7.3 CLSI. AUT012-A. Specimen Labels: Content and Location, Fonts, and Label Orientation: Approved Standard. CLSI document AUT012-A [ISBN 1-56238- 748-0]. CLSI, 940 West Valley Road, Suite 1400, Wayne PN 19087, 2011. 7.4 Ward-Cook, Kory M., Lehmann, Craig A., Schoeff, Larry E., Williams, Robert H., Clinical Diagnostic Technology The Total Testing Process, Volume 1: The Preanalytical Phase. AACC Press 2101 L Street, NW, Suite 202, Washington, CD 20037-1558. 2003.
Date New Procedure # Comment Name of person Revisinl! May 2013 QAQC.81.Proc-002 Revised Patient Mary Zaleski, PhD Identification Section
Approval Page Approved: ~/gu4" J ~I'.g--",~ Director Approved: C3j;K/;5 ~7 Approved: 3"~3'200 Approved: Y\t..a ~ Oju) Vb' 1-= c3//3//3 Site Man er Approved: s~t L~ ~a 6 \3 2C (:3> Author: Mary Zaleski, PhD, MT (ASCP) ~~4 Q30jl1-'