ph-015.05 patient idenification & specimen labeling · of identification. 2.2.3.1 if the...

LABORATORY POLICY AND PROCEDURE

TITLE/SUBJECT: Patient Identification and Specimen Labeling

FILE NUMBER: PH-015.05

ASSIGNED MANUAL: Phlebotomy Policies and Procedures

ORIGINATION DATE: 6-6-07

EFFECTIVE DATE: 03-18-2014

DISTRIBUTION: All SMH Laboratories

PRINCIPLE/PURPOSE:

JCAHO, CAP and CLIA mandate that all patients/patient samples must be clearly

identified with two positive identifiers throughout the testing process. The patient must

be consistently and accurately identified before any phlebotomy or specimen collection.

Once collected, all specimens must be labeled with two positive identifiers in the

presence of the patient.

PATIENT PREPARATION:

N/A

SPECIMEN/HANDLING:

N/A

MATERIALS:

Equipment Reagents Supplies

• • •

STANDARDS:

N/A

CALIBRATION:

N/A

QUALITY CONTROL:

N/A

PH-015.05 Patient Idenification & Specimen Labeling

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PROCEDURE:

Patient Identification:

1. Greet the patient and identify yourself.

1.1. Inpatients: Indicate you are from lab and will be collecting blood samples.

2. Identify the patient using TWO types of positive identification:

2.1 Ask the patient to spell their last name and compare that information to the

label or order that you have.

2.2 Ask the patient to state their date of birth and compare that information to the

label or order that you have.

2.2.1 If the information given by the patient does not match the order or

label, rectify the discrepancy prior to collecting the sample in order

to ensure that you are collecting the appropriate samples.

2.2.2 If the patient is wearing a hospital armband, also compare the

patient name and DOB (the information on the armband) with the

label or requisition to ensure that they are correct.

2.2.3 If the patient is unable to identify themselves (child, non-English

speaking, mentally disabled), it is acceptable to have the patient

identified by a family member or caregiver, again, using two types

of identification.

2.2.3.1 If the patient is a resident of a nursing facility, a staff

member can provide two types of identification.

2.2.4 Do NOT ask yes/no questions such as, “Are you John Smith?” or

“Is your date of birth 1/16/83?” This is NOT positive

identification.

2.2.5 Do NOT rely on the patient’s room number as a means of

identification.

2.2.6 All patients at risk for identifying themselves in a procedure or

adverse situation must have a hospital-approved armband.

2.2.6.1 If the armband is missing or incorrect, notify nursing.

2.2.7 If you are asked to help with the collection of a specimen and

subsequently collect the sample but were not the primary person to

identify the patient, you must also perform a positive patient

identification prior to labeling those specimens.

2.2.8 If the identity of the patient is unknown, place a blood bank

wristband on the patient and label all specimens with that number.

Do NOT use John or Jane Doe UNLESS Admitting has given them

an armband with John or Jane Doe on it.


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2.2.9 If going to PCH (Portage County Home) a daily print out from the

PCH Medicine chart will be available for lab staff. Every attempt

must be made to have the patient state both their full name and

DOB. If a patient can not ID themselves a PCH staff member must

be found to visually ID the patient. The patient’s DOB can then be

confirmed/verified against the daily Med Chart form.

2.2.10 PCH phlebotomist will document on the header label and on the

daily Med. Chart the name of the PCH staff that visually identified

the patient. When specimen(s) is/are brought back to the lab, this

information will be documented in Meditech.

2.2.11 PCH phlebotomist will highlight the patients they drew on the

daily Med chart form and bring back to the main lab. This

document will then be placed in the PCH 3-ring binder that is

located on the shelf in the back of phlebotomy where the PCH

supplies are kept.

2.2.12 Coverage: PCH phlebotomist - Monday, Wednesday & Friday they

will draw at PCH, SPCC, Wellington, River View Lodge, Care

Partners. Tuesday and Thursday will draw at PCH only.

3.0 Once a positive patient identification has occurred, collect the specimen from the

patient.

Specimen Labeling:

1.0 All specimens must be completely labeled in the presence of the patient.

2.0 Specimen containers must NOT be labeled prior to collection, except in the case

of urine containers and 24 hour urine jugs.

3.0 If labeling the specimens with pre-printed labels:

2.1 SEE ATTACHMENT: LABELING GUIDELINES for how to label different

types of specimens.

2.2 On the barcoded label that was used in comparison for the positive patient

identification, write your initials under the date to make sure it is correct and

write the time of collection. (The label already contains the full patient name,

date of birth, and the patient’s account number.)

2.3 Affix the label to the appropriate specimens as dictated by the label. (i.e.

“Protime” label to be affixed to blue top tube, “CBC” label to be affixed to

lavender top tube, etc)

2.4 Take care to align the labels correctly on the tubes by using the cap as a guide

and allow for specimen level to be visible.


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Label Alignment and Number Format for Labeling

• BD Vacutainers: Align label with bottom of stopper.

• Greiner Vacuettes: Align label so the top half of “Vacuette” is visible.

• Number format: 3 initials 0000 (24-hour/military time)

3.0 If labeling the specimens without pre-printed labels:

3.1 Label each specimen clearly written in black ink with the following

information:

3.1.1 Full patient name – avoid using nicknames or partial names.

3.1.2 Patient’s date of birth or account number (as the second patient

identifier)

3.1.3 Date of collection

3.1.4 Time of collection

3.1.5 Initials (three initials)

3.2 Even if planning to later affix computer generated labels to the specimen, at

time of draw, in the presence of the patient, all above listed information must

be placed on the specimen.

4.0 Re-labeling hand-written labels with a barcode label

4.1 Compare the patient identifiers on the specimen with the patient identifiers on

the barcode label.

4.2 Place the barcode label on the tube such that initials and time of draw can be

seen.

DERIVATION OF RESULTS:

NA


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REPORTING:

NA

NORMAL VALUES:

NA

CRITERIA FOR IMMEDIATE NOTIFICATION:

1.0 If it has been determined that there may have been an error in patient

identification:

1.1 Cease testing immediately.

1.2 Contact SMH lab immediately if specimens have been sent there for testing.

1.3 If reports have been printed to the provider office, place a phone call

immediately to that office and alert them to the situation.

2.0 If it has been determined that there may have been an error in specimen labeling:

2.1 Cease testing immediately.

2.2 Contact SMH lab immediately if specimens have been sent there for testing.

2.3 If reports have been printed to the provider office, place a phone call

immediately to that office and alert them to the situation.

3.0 If the misidentification or mislabeling is not able to be rectified, call all patients

involved back for recollection of all specimens.

INTERPRETATION:

NA

CRITERIA FOR UNACCEPTABLE RESULTS AND CORRECTIVE ACTION:

Specimens which are unlabeled, labeled incorrectly, labeled unclearly or collected into

the wrong or an expired container may be rejected and require recollection.

LIMITATIONS:

NA

PROCEDURE NOTES:

The person collecting the sample must wear their name badge at all times. It is important

that you explain the procedure you are about to perform and explain that their provider

has ordered these tests. Try to answer any questions or concerns they may have or seek

additional help when necessary.

SAFETY PRECAUTIONS:


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Follow procedures and precautions described in the Saint Michael's Hospital Infection

Control and Hazard Communication manuals, as well as the Saint Michael's Hospital

Chemical Hygiene Plan. Refer to the MSDS for reagent-specific handling guidelines.

ATTACHMENTS:

Labeling Guidelines

Blood tubes (Inpatient and Outpatient)

Write your three initials under the date and also, write the time of draw, and affix to tube.

Barcode label should cover tube label, and should sit right beneath the cap (see picture).

Write time of draw and your initials on the header label for Specimen Receiving.

Position barcode label over tube label and

align with cap.


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Outpatient: Urine Cups

Write your three initials on the aliquot sticker under the date and affix sticker to urine

cup. No other labeling is needed. Specimen is timed after collection. After collection,

write current time on aliquot label and header label (see pictures).

Write your three initials on aliquot sticker under the date and place

on cup before handing to patient.

After collection, write the current time on the top of the cap.


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Capiject tubes

Initial under the date, write the time of draw, and affix to tube lengthwise (see picture).

Write time of draw and your initials on the header label for Specimen Receiving.

Position aliquot label lengthwise so contents of capiject are still visible.


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Blood Cultures

Initial under the date on the barcode label, write the time of draw, and affix to bottle.

LABEL MUST BE PLACED SO THE MEDITECH BARCODE LINES RUN IN THE

SAME DIRECTION AS THE BOTTLE BARCODE. DO NOT COVER UP THE

BOTTLE BARCODES. THEY MUST BE SCANNED BEFORE LOADING. Write

source of blood on bottle (line, venous, arterial, dialysis). Write time of draw and your

initials on the header label for Specimen Receiving.


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Blood Bank Tubes

All tubes must be labeled at the patient’s bedside: There are no exceptions. The patient’s

name must be legibly written on the Blood Bank tube exactly as it appears on the

patient’s hospital wristband. Use an indelible ball point pen. Write the Blood Bank

wristband number on the Blood Bank tube. Write the patient’s date of birth on the tube.

Write the date, time, and your initials on the Blood Bank tube. Ask the patient if they

have been pregnant or transfused in the last three months, and write their answer on the

header label.

All Blood Bank tubes must be hand-labeled at the patient’s side.

Indicate on the label whether the patient has been

pregnant or transfused in the last three months.


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REFERENCES:

Patient Identification policy SPM #1 (retired)

Specimen Procurement – Venipuncture Policy and Procedure PH-001

Saint Michael’s Hospital “Specimen Handling” Policy

ORIGINATING DEPARTMENT/SECTION:

St. Michael’s Hospital Laboratory

AUTHOR AND DATE:

Dawn Finch, MT (ASCP), Laboratory Supervisor

REVISED BY AND DATE:

Chad Moertl, Phlebotomy Coordinator, 1/16/09

Mary West, MT (ASCP) – December 2013 (added PCH and CBRF ID process)

Judith Snow MT(ASCP) 12-23-2013

Joseph Teddy, MT(ASCP) 2/11/14

Joseph Teddy, MT(ASCP) 3/18/14

Changed write date on label to write intials under the date.

Removed:

Transfer all written information from the hand-labeled specimen onto the

barcode label.

Place the barcode label properly on the specimen.

Updated pictures

Changed urine cup labeling from “write the time of collection on header label,

aliquot label and top of cup” to “write the time of collection on the cap”.

APPROVAL:

___________________________________________________________

Dawn Finch, MT (ASCP), Laboratory Director

___________________________________________________________

Jason Heese, MD – Medical Director of Laboratory Services

ph-015.05 patient idenification & specimen labeling · of identification. 2.2.3.1 if the...

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