DEFINITIONS
 
Clinical Laboratory - Chemistry, Blood Bank, Hematology, Urinalysis, Flow Cytometry, Microbiology, Molecular Microbiology, Immunology, Phlebotomy, Central Accessioning/Send-outs (All non-anatomic pathology laboratories)
 
Anatomic Pathology – Surgical Pathology, Cytopathology, and Autopsy sections of the Pathology & Laboratory Medicine Service
 
SPECIMEN LABELING (ANATOMIC PATHOLOGY) – Anatomic Pathology specimens must be labeled with the patient’s full name, full SSN, collection date and site identification that can be correlated to requisition (e.g., A, B, C, etc.). The requisition can contain the site identification in more detail (specimen type, location, laterality, parts, etc.) Note: Brain Neuropath samples do not need to be labeled with site identification. Additional Anatomic pathology specimen labeling requirements can be found online in the Lab Collection Manual Anatomic Pathology section. All specimen labels must be affixed to the specimen container. The label should be legible, and the appropriate information should be clearly indicated. If any information on the specimen label is unclear the lab staff should contact the collector or provider for clarification.
 
SPECIMEN LABELING (CLINICAL LABORATORY) - All specimen labels should be legible and the appropriate information should be clearly indicated. If any information on the specimen label is unclear the lab staff should contact the collector or provider for clarification. The specimen label must be affixed to the specimen container. All clinical laboratory specimens must include the following:
 

1. Patient's full name.

 

2. Patient's full Social Security Number

 

3. Patient's location (ward or clinic) –
   1. Requirement for Blood Bank specimens
   2. Required on all other clinical laboratory specimens only if information is not contained in the electronic order or on the requisition.

 

4. CPRS order number for the test(s) requested by provider. For additional information refer to the “Laboratory Electronic Orders and Requisitions” section of this procedure.

 

5. Collection date and time

1. Phlebotomist/staff member collector’s initials or signature on specimen container label will denote that date and time printed on label by computer system is correct and should be used as specimen collection date and time. Blood Bank specimens require the phlebotomist’s full signature.
2. If the date and time printed on the label by the computer system is incorrect, the collector must handwrite the collection date and time on the specimen container.

 

6. The initials of the phlebotomist/staff member collector. Blood Bank specimens require the phlebotomist’s full signature. Exceptions to this requirement are the following:

1. VISN 1 (non-BHS sites) - Except for Blood Bank, clinical lab samples sent to the VA BHS laboratory for reference lab testing (e.g., Maine, VA CT, Providence, etc.), may not have collector initials. Identity of the collector is maintained by the sending VA lab.
2. VA Contracted Laboratory Collection Centers and VA Contracted home infusion – Collector initials are either on the specimen container or the paper requisition (e.g., doctor’s order sheet) submitted with the specimen.  Alternatively, for Quest collection centers, the collector identity is available as needed from the Quest collection center. These areas are NOT allowed to collect Blood Bank samples.

 

7. The source or type of specimen if not venous blood. (e.g. CSF, pleural fluid, arterial blood etc.)

 

8. The site of the specimen (Microbiology). The site may be embedded in the electronic order specified in the site/specimen, entered as a comment in the electronic order, handwritten directly on the specimen or written on the requisition.

1. The specimen site for microbiology specimens is required for the following culture types.

• Abscess
• Aspirate
• Bone
• Drainage
• Medical Device
• Tissue
• Wound

2. The specimen site for microbiology specimens is recommended for the following culture types.

• Ear
• Eye
• Synovial fluid

 

9. All drug levels that are drawn Pre-dose or Post-dose must have "Pre" or "Post" written on the tube.

 

10. Exemption for specimens collected by patients in their home environment and mailed to the laboratory (e.g. FOB cards) – Patients who express concern over use of full social security number on a mailed specimen can either drop the specimen off at the laboratory or use alternative patient/specimen identifiers. Patients can use their DOB in lieu of full social security number when labeling the specimen that will be mailed to the laboratory. Full name and DOB can be used as the primary specimen identifiers for mailed specimens. To further assist the lab staff; patients are asked to provide their last four SSN but only if the patient has no objections. Use of the last four SSN is not for primary patient/specimen identification.

 

11. VA Contracted Laboratory Collection Centers and VA Contracted home infusion therapy – These entities may not have access to the VA computerized labels (e.g., CPRS labels or VA Lab Package labels). These entities can use the patient’s full name and full SSN (or DOB alternative) when labeling specimen containers. A requisition (e.g., doctor’s order sheet) containing the patient’s name, patient’s SSN and order # accompanies the specimen when it is submitted to the VA Laboratory for testing. (Note: Blood Bank samples cannot be collected by individuals at non VA staffed drawing stations; e.g., Framingham, Quincy and Plymouth Quest Patient Service Centers.

 

12. Blood Bank specimen requirements are stricter than most clinical laboratory departments.

1. All specimen tubes drawn for Blood Bank must be labeled with the following legible information:

1. Patient’s full name
2. Patient's full Social Security Number.
3. Signature (not initials) of the phlebotomist who drew and verified patient’s identity.
4. Date and time collected as well as patient location.
5. Submit 1, 6mL plastic pink top (EDTA) tube.
6. Specimens not meeting these criteria are discarded; it cannot be retrospectively identified.

2. Individuals who can collect blood bank specimens:

1. Employed by the VA Boston Healthcare System
2. Participating in a VA Boston Healthcare System academic training program (e.g., medical, surgical, nursing and other allied health professionals)
3. VA Boston Healthcare System contracted employee working within a VA facility.
4. VA Pathology & Laboratory Medicine contracted employee.
5. Blood Bank specimens cannot be collected by individuals at non-VA staffed drawing stations (e.g., Quest Patient Service Centers)
6. Bedford employees – VA Bedford patients requiring transfusion are transferred to another VA facility. Blood Bank specimens should not be drawn at the Bedford VAMC. The Bedford lab discourages obtaining a blood bank specimen before the patient is transferred. (However, if the sample is properly labeled the WROX lab will accept the specimen.)

 
 
LABORATORY ELECTRONIC ORDERS and REQUISITIONS –
 
1. Clinical laboratory tests require entry of an electronic order before laboratory testing will be performed; with the exception of Anatomic Pathology requests and VA contracted home based healthcare.  Note: In addition to a CPRS order for Type and Screen or blood products, Blood Bank samples must be submitted with a properly completed blood bank specimen collection form.
 
2. Electronic orders and requisition slips should be legible, and the appropriate information should be clearly indicated. If any information on the requisition is unclear the lab staff should contact the ordering provider for clarification.
 
3. With the exception of anatomic pathology and VA contracted sites, all ordering should be done through the CPRS order menus. In the event of computer system failure, a requisition form should be utilized when ordering clinical laboratory testing. Note: Blood Bank samples must be submitted with a properly completed blood bank specimen collection form.
 
4. VA contracted laboratory collection sites and VA contracted home infusion therapy – a requisition form should be utilized when ordering clinical laboratory testing (e.g. VA doctor order sheet with CPRS Order Number contained on the order sheet, home infusion therapy physician’s order)
 
5. Blood Gas specimens submitted to the Brockton Lab must be accompanied by a properly completed requisition.
 
6. Specimens collected by patients in their home environment (e.g. FOB) should contain the CPRS/GUI order # on the specimen container. If the order# does not appear on the specimen container, the laboratory will review the patient’s record for a valid order number. If a valid order number is not available, the staff will contact the provider.
 
7. Anatomic Pathology Tissue Request form (Surgical SF515, Cytopathology VISN 1 requisition) – Anatomic Pathology requisitions must be labeled with the patient’s full name and full SSN. Additional Anatomic Pathology requisition requirements can be found online in the Lab Collection Manual Anatomic Pathology section. Requisition slips should be legible and the appropriate information should be clearly indicated. If any information on the requisition is unclear the lab staff should contact the ordering provider for clarification.
 
8. A properly completed clinical laboratory requisition form or CPRS order will contain the following information.
 

1. Patient's full name.

 

2. Patient's full Social Security Number

 

3. Patient's location (clinic or ward)

 

4. Requesting physician or provider

 

5. Test urgency (Stat, ASAP, Routine etc.)

 

6. The tests requested.

 

7. Source/Type of specimen (blood, CSF, sputum, etc.)

 

8. Site of specimen (right heel, chest, etc.)

 

1. The date and time of collection (if not included on the specimen label)

 

10. Dosage information regarding therapeutic drugs (i.e. "Pre" or "Post.” or “# minutes past stimulation” if applicable)

 

11. “Rule Out” information as applicable.

 
9. All blood bank specimens must be accompanied by a blood bank specimen collection form.  The blood bank specimen collection form must contain the following information:
 

1. Patient's Full Name.

 

2. Patient's Full Social Security Number.

 

3. Signature of the phlebotomist.  

 

4. Printed name of the phlebotomist

 

5. Date and Time of sample collection.

 

6. If the preceding requirements are not fulfilled, the requested work will not be processed until the deficiencies are corrected.

 

7. All specimens should be brought to the laboratory as soon as possible.  All specimens should be left with a laboratory technologist/technician only.  Specimens must not be left outside the Laboratory and/or with non-laboratory personnel since this may result in specimen loss and/or the delay of testing and reporting.  Specimens brought to the lab on the weekend, evening, or night shift must be handed to the technologist on duty.

 
10. Requests for additional clinical laboratory testing

1. Additional (add on) testing may be requested by telephone but requires a follow-up electronic order. The Lab will not perform additional testing until the provider places an order into VISTA.

 

2. The Technician/Technologist will look up the patient accession number using the option “order test status”, locate the specimen and determine if:

• the specimen has been collected appropriately for the additional testing
• the age of the specimen is acceptable for the additional testing

• the specimen has been stored properly for the additional testing
• the volume of specimen is adequate for the additional testing

 

3. If the specimen is acceptable, the Provider will be asked to place an order in GUI. Using the Laboratory Menu, choose “other labs” (under the “All Location” heading) and then choose “Send patient to lab” as the collection type (it is understood that the patient will not be sent to the lab, this collection type is used so that the patient lab order will not be built on a collection list).  If the provider does not place an order in VISTA, the additional testing will not be performed.
4. Once the order has been placed, Laboratory personnel will receipt the order into the laboratory using the VISTA option “Accessioning tests ordered by ward order entry”. The correct collection date and time must be entered when accepting the new order.
5. Laboratory personnel will attach the new label to the specimen making sure not to cover the original accession #.
6. Exception for Confirmatory Toxicology Testing (VA BHS): Electronic orders for confirmatory drug testing are accepted.  The provider must select DAU CONFIRMATION ADD-ON from VA BHS CPRS LAB ORDERS to order a confirmation. After the provider signs the order, a VISTA alert will be sent to laboratory for processing.
7. Exception for Confirmatory Toxicology Testing (VA Bedford): Electronic orders for confirmatory drug testing are accepted. The provider must select DAU ADD-ON LABS from Bedford CPRS LAB ORDERS to order a confirmation. After the provider signs the order, the order will print in the Bedford laboratory. The laboratory staff member will retrieve order from printer and process the sample. All printed orders will be saved as hardcopy test requisitions.
8. Summary of process:

• Provider Responsibilities:
  1. Contacting the laboratory to request additional testing.
  2. Placing an order for the additional testing into VISTA
• Laboratory Responsibilities:
  1. Ensuring that the specimen meets collection, volume, and storage requirements for the test(s) requested.
  2. Accepting the new order into the laboratory using the correct collection date and time
  3. Labeling the specimen correctly
  4. Performing the additional test(s)

 
11. Ordering in Emergent Situations (Clinical laboratory): The clinical laboratory will accept verbal orders in emergent situations.

1. Laboratory personnel will confirm all verbal orders by writing the order down and then reading back the order to the provider.
2. Remind the provider that he/she is required to electronically sign the order that the Lab enters. This order must be signed within 24 hours.
3. Laboratory personnel will enter the electronic order. The “nature of order” will be either verbal or telephone. The computer software automatically generates a VA alert to the provider requesting his/her electronic signature.
4.  Laboratory personnel will enter comment EMER (~Order placed during an emergent situation) into the patient report
5. Refer to the Blood Bank Verbal Order policy for further instructions applicable to Blood Bank orders.

 
12. Clinical laboratory orders on discharged inpatients (or inpatients that have died after specimen collection but prior to specimen receipt in laboratory): Occasionally specimens such as 24-hour urine specimens, urine DAU specimens, fluids, and other non-blood specimens will be sent to the laboratory after an inpatient has been discharged from the Medical Center. During the discharge process, the computer system will automatically cancel the lab orders (auto discontinue). Occasionally specimens will be submitted to the lab after the system has cancelled the order due to a patient’s death. In these specific incidents, the following procedure will be used.

1. Laboratory tech will use the multipurpose accessioning option to place an order into the computer using the exact information provided in the original order (patient location, ordering provider, test requested). Reference the original order number in the patient report.

 

2. The "service correction" nature of order comment will be used.

 
IDENTIFICATION OF ALIQUOT AND DILUTION TUBES

1. Aliquot and dilution tubes are labeled with the same accession label as the primary tube. Prior to pouring sample into the secondary tube (aliquot or dilution tube), verify that patient identification information on secondary tube is identical to the information on the primary tube.
2. Exceptions to this policy will appear in the Section Specific procedure manuals (ie. Flow Cytometry)

 
 
UNACCEPTABLE ANATOMIC PATHOLOGY AND CLINICAL LABORATORY SPECIMEN CRITERIA –
 
The following criteria have been established for unacceptable specimen conditions, specimen labels and requisition slips. If any of these deficiencies exist, the specimen and/or requisition slip is to be rejected. (Unless otherwise indicated per policy below)
 
It is the responsibility of the laboratory staff member who identifies an unacceptable specimen to inform the requesting provider/clinical surrogate and/or ward/clinical service so that a new specimen may be obtained, or appropriate action taken. For rejected specimens; the laboratory staff member will enter the cause of rejection, person notified, date of notification, time of notification and lab staff member’s initials into the electronic patient report.
 
Specimen Conditions: There may be circumstances when specimen recollection is not possible or practical (e.g. specimens that are impossible or difficult to recollect, such as cerebrospinal fluid, bone marrow, biopsies, etc.). These irreplaceable specimens should not be rejected, even though the acceptance criteria have not been met.  The laboratory staff member should notify the provider of the unacceptable specimen. If another specimen would be difficult or impossible to obtain (irreplaceable), the laboratory will process the original specimen, with a comment in the computer as to the nature of the deficiency of the sample and that provider notification occurred.  Further details about this process are discussed in the General (Specimen Conditions) section of this procedure.
 
Specimen Label: Irreplaceable (difficult or impossible to obtain) specimens (biopsy, CSF, bone marrow, etc.) that contain wrong, partial or no patient identifiers will be processed only if the collector/healthcare provider label the specimen container with all information required by this policy. Detailed information about this process is discussed in the General (Specimen Label) section of this procedure. Exception: Blood Bank samples that are improperly labeled (or unlabeled) are discarded
 
UNACCEPTABLE SPECIMEN CRITERIA:
 
General (Specimen Label)
 

1. All routine specimens (urine, blood, sputum, etc.) that have wrong, partial or no patient identifiers will be discarded. Re-labeling of routine specimens due to patient identification errors is not allowed.
2. Irreplaceable (difficult or impossible to obtain) specimens (biopsy, CSF, bone marrow, etc.) that have wrong, partial or no patient identifiers will be processed only if the collector/healthcare provider labels the specimen container with all information required by this policy. Exception: Blood Bank samples that are improperly labeled are discarded.

1. Clinical Laboratory Medicine Specimens: Documentation about the condition of the specimen when initially received by the lab (wrong, partial or no patient identifiers), name of individual positively identifying specimen, date and time must be entered into the patient record.
2. Anatomic Pathology Specimens: Specimens must be labeled with all information required by this policy AND signs a release form (Attachment A). By signing the release form, the collector/healthcare provider is accepting responsibility for the specimen and assuring the lab that the specimen was indeed from the patient indicated on the form. The signed release form will be kept with the individual anatomic pathology case paperwork.
   3. Code Blue (or emergency specimens) – Code Blue (or emergency specimens) are considered irreplaceable. The collector/healthcare provider will label the specimen container with all information required by this policy. A statement should be entered into the patient report that the specimen was obtained under emergency conditions. In addition, the documentation should include the condition of the specimen when it was received by the laboratory, the name of individual positively identifying specimen, date and time. Exception: Blood Bank samples that are improperly labeled (or unlabeled) are discarded

 

4. Specimens not completely labeled with non-patient identifiers on specimen label (collection date/time, collector initials, collection signature, order #, non-blood source, etc.) –
   1. CPRS order number (clinical laboratory) –
      1. If requisition submitted with specimen that contains CPRS order number; use order number on requisition.
      2. If CPRS order number is unknown, contact collector/healthcare provider to request order be placed for clinical laboratory testing.
      3. When computer is down; refer to Computer Downtime procedure.
      4. Transfusion Medicine specimens are submitted to lab with a blood bank specimen collection form. Blood Bank samples that are incompletely/partially/incorrectly labeled are discarded.
   2. CPRS order number (Anatomic Pathology) – Anatomic pathology specimens are submitted to lab with a tissue examination form (no CPRS order number required).
   3. Collection date/time (Clinical Laboratory) – Exception: Blood bank samples that are incompletely labeled are discarded.

1. If requisition submitted with specimen that contains collection date/time; use this information when processing specimen.
2. If collection date/time is unknown, contact collector/clinical surrogate to determine the collection date/time (refer to “correction of incorrect non-patient identifiers” for guidance on how to input missing data into computer)
   4. Collector Initials (Clinical Laboratory) – No specimen will be rejected or held for testing due to lack of collector initials unless specimen integrity is questionable (e.g. order date/time on CPRS label indicates specimen may be too old for testing and there are no collector initials on container to validate collection date/time). Exception: Blood bank samples require the collector’s signature on the sample. If this information is missing, then sample is discarded.
   5. Specimen Site/Type (Anatomic Pathology) – If specimen site/type is not evident by visual inspection contact the submitting provider for clarification. Use this information when processing the specimen.
   6. Specimen Site (Microbiology) – If the site that the specimen was taken does not appear on the specimen label, review the order in CPRS or VISTA Lab Package or the paper requisition. Use this information when processing the specimen.
5. Correction of incorrect non-patient identifiers on clinical specimen label (collection date/time, collector initials, order #) – The laboratory will contact the collector/clinical surrogate whenever there is a question concerning the validity of specimen label information.

1. Collection date/time - If the discrepancy is identified prior to accepting the order into the computer (lab software), the correct information will be used when accepting the order into the lab software. The laboratory accession label, which will contain the correct information, will be placed on the specimen. Exception: Blood Bank samples that are improperly labeled are discarded
2. Collection date/time - If the order has already been accepted into the lab software, then the correct information will either be entered into the comment section of the patient report, or a new accession will be generated (and the accession with the incorrect information will be marked as not performed). Consult supervisor.  Exception: Blood Bank samples that are improperly labeled are discarded
3. Collector initials – The collector will be allowed to correct his/her initials on the specimen. (non-blood bank specimens)
4. Phlebotomist signature – Blood Bank specimens require the phlebotomist signature on the tube. Correction of this information is NOT allowed. Specimen will be discarded.
5. Order # on specimen container is not associated with type of specimen/source collected (e.g. Order # test is urine culture, but specimen collected is sputum) – contact collector/healthcare provider to determine if order is incorrect or if specimen/source collected is incorrect. If wrong specimen/source collected follow guidance from the “general specimen condition” section of procedure. If incorrect order # then request that a new order be placed if testing is still required. Exception: Blood Bank samples that are improperly labeled are discarded

 
 
 
 
 
 
General (Anatomic Pathology requisition) –

1. If specimen site/type on specimen container does not match specimen site/type on requisition, contact submitting provider for clarification.
2. If patient clinical history is not on the requisition access patient’s medical record for clinical history
3. Requisitions that contain wrong, partial or no patient identifiers must be corrected.

 
General (Clinical Laboratory requisition) - Contact submitting provider or specimen collector if information on the paper requisition (computer downtime form, VA contracted lab collection site doctor order forms) is incomplete or does not match information on the specimen container. Requisitions that contain wrong, partial or no patient identifiers must be corrected.
 
General (Specimen Conditions) –
 

General (Specimen Conditions) Specimens with suboptimal specimen conditions, such as grossly hemolyzed, may be tested only at the provider’s request and a disclaimer comment will be entered in the patient report that the provider was notified and still requested the testing be performed. If a provider requests that a suboptimal specimen be tested, consult laboratory supervisor or pathologist if further guidance is needed to determine if testing can be performed.   1. Insufficient quantity, insufficient ratio of blood to additive, or improper tube. 2. Incorrect preservation or handling. 3. Incorrect tube used for specimen collection (i.e. a red top tube when a lavender tube is the correct specimen). 4. Grossly hemolyzed specimens. 5. Broken or leaking containers or tubes, broken smears. 6. Expired specimen collection containers, fecal occult blood cards/vials, and swabs.
Chemistry/Special Chemistry	Clotted body fluids.   Specimens that have been left on ward for >2 hours (one hour if enzymes are requested.)   Specimens containing radiology dyes.   Grossly lipemic specimens.   Grossly hemolyzed specimens.   Clotted blood gas specimens.   Blood gas syringes containing air bubble for the analysis of pH, pCO2 and pO2 will be rejected because of interference from ambient air.
Hematology/ Coagulation	Insufficient quantity of blood for correct ratio of anticoagulant to blood (<2.0 mL blood in lavender tube, < 2.43 mL blood in a blue-top tube).   Increased quantity of blood for correct ratio of anticoagulant to blood (>2.97 mL blood in a blue-top tube).   Clotted CBC or Coagulation specimens or specimens containing small clots   Clotted body fluids (full clots) – Cell count not performed (attempt to perform differential will be made).   Clotted body fluids (partial clots) – extent of the analysis will be determined on a case-by-case basis.   Specimens not kept at required temperatures or past required stability times.   Gross hemolysis in EDTA or Sodium Citrate tubes.
Urinalysis	Specimens contaminated with fecal material.   Clear and colorless specimens with a SG of 1.000   Specimens left unrefrigerated over two hours.   Specimens more than 48 hours old, even if refrigerated.   Specimens heavily colored by various drugs/radiology dyes which make interpretation difficult.
Fecal Occult Blood Specimens	Hemoccult Sensa: Improper placement of fecal material on test slide, expired card   FIT: No specimen in test vial, expired test vials
Blood Bank	Specimen hemolyzed
Flow Cytometry	1.   Specimens >72 hours old   Specimens determined to be non-viable   Clotted specimen (blood only).   Incorrect tube used for specimen collection.   STRECK preserved specimens >7days old.
Immunology	Specimens that are Grossly Hemolyzed, Lipemic or Icteric.   Specimens with Microbial growth   MRSA Surveillance PCR or MRSA Surveillance/Discharge AGAR Wrong swab Specimen > 24 hours at room temperature (15-30°C) Specimen > 7 days refrigerated (2-8°C)
Histology/ Cytology	Contaminated specimens.   Lack of appropriate preservative. (surgical specimens/cytology specimens)
Microbiology	General Nonsterile or leaking container Dried or expired swabs or lack of appropriate transport media Signs of gross external contamination Quantity not sufficient Incorrect specimen source for test requested. Incorrect collection container Received in cytology fixative or formalin. Specimen not kept at proper temperature. Urines Specimens greater than 24 hours old even if refrigerated. If from an outpatient, the specimen will be processed but a disclaimer will be entered into the patient report. Exception: Urine submitted in a BD Urine Vacutainer Tube may be processed for up to 48 hours. Foley catheter tips Stool Specimen sent on swab/Rectal Swab Stool. Exception: CP-CRE Rectal screen by PCR. Specimen in Cary Blair transport media. Exception: Gastrointestinal PCR Panel Cultures/Ova & Parasite Not performed if patient is an inpatient >3 days without GI or ID approval C. difficile Toxin B Gene PCR Formed Stool One specimen per patient per week. Norovirus PCR Formed Stool   G.C/Genital Cultures If refrigerated Specimens not delivered immediately to laboratory Anaerobe Cultures Swab specimens for anaerobic culture unless collected in anaerobic transport swab media obtained from microbiology Sputum Specimen greater than 24 hours old even if refrigerated Respiratory PCR Swab not broken off into VTM MTB PCR Specimens other than sputum
Toxicology (Chemistry)	Urine Samples for Drugs-of –Abuse (DAU) Testing   The Toxicology Laboratory does not have jurisdiction or control over the collection or transportation of urine specimens to be analyzed for drugs of abuse.    The laboratory does not supervise the collection of urine specimens.  Should a supervised specimen be desired, the collection is the responsibility of the practitioner or program submitting the specimen. (Exception is the Federal Employee Drug Program)   The following is intended as a guideline for those clinics utilizing the Toxicology section of the chemistry laboratory for urine drug screening. Urine samples should be collected under the direct supervision of authorized personnel if a supervised collection is desired. Samples should be collected directly into the container that will be transported to the testing laboratory. Sample containers should be clearly labeled. Samples should be stored in a secure area under refrigeration until such time as they can be transported to the laboratory. All requests for DAU testing are via CPRS LAB ADD ON ORDERS.   Understanding that the Chemistry Laboratory is not able to determine definitively whether a sample submitted to the laboratory has been subject to tampering, the laboratory will make every effort to analyze, in the normal manner, all samples submitted.  Should a sample exhibit signs of obvious tampering (i.e. smells like orange juice, apple juice, bleach, etc.), the practitioner (or clinic or laboratory providing the sample) will be notified regardless of the assay results. The Laboratory also performs sample adulteration testing that can be used by the provider when reviewing results.

 
 
 
 
REPORTING OF UNACCEPTABLE SPECIMENS or REQUISITIONS     
 

1. Anatomic laboratory specimens: It is the responsibility of the laboratory staff member who identifies an unacceptable specimen to inform the requesting provider/clinical surrogate and/or ward/clinical service so that a new specimen may be obtained, or appropriate action taken.
1. Document provider notification on the Problem Identification Log (PIDL).
2. Unsatisfactory anatomic laboratory specimen conditions (e.g. lack of appropriate fixative, leaking, etc.) will be reported on the Anatomic Pathology Problem Identification Log. These problems are reported to the Operative & Invasive procedure committee. The pathologist/cytotechnologist will comment about the lack of appropriate fixative in the patient report.
3. Specimen Label or Requisition Events are reported through the Joint Patient Safety Reporting System (JPSR). Refer to the Laboratory Nonconforming Event Management/Occurrence Management procedure.

 

2. Clinical laboratory specimens: It is the responsibility of the laboratory staff member who identifies an unacceptable specimen to inform the requesting provider/clinical surrogate and/or ward/clinical service so that a new specimen may be obtained, or appropriate action taken.
1. The laboratory staff member will enter the cause of the specimen rejection, person notified, lab staff member’s initials, date of notification, and time of notification into the electronic patient report.
2. Unsatisfactory clinical laboratory specimen conditions (e.g. clotted, QNS, grossly hemolyzed, too old) should be reported on the clinical laboratory section’s QA logs. Supervisor or lead technologist will review this data monthly to identify trends or areas for improvement.
3. Specimen Label or Requisition Events are reported through the Joint Patient Safety Reporting System (JPSR). Refer to the Laboratory Nonconforming Event Management/Occurrence Management procedure.

 
RETENTION REQUIREMENTS: 
 

RETENTION REQUIREMENTS: CLINICAL LABORATORY
ITEM	RETENTION TIMEFRAME
Paper Test Requisitions	E.g. computer downtime form, requisition from VA contracted collection site   Most requests for testing are electronic.   If a paper requisition is received without an electronic order the paper requisition is retained for 2 years (Exception: Blood Bank computer downtime form Blood Product/Test Order Form is retained for 5 years)
Blood Bank Specimen Collection Form	5 years
Blood Transfusion Record Form (BTRF)	75 years
Slides	Bone Marrow smears – 10 years Flow Cytometry, Blood – 10 years Flow Cytometry, Body fluid, permanently stained (except for bone marrow) – 10 years Flow Cytometry, CSF, permanently stained – 10 years Hematology, Blood – 30 days Hematology, Body fluid, permanently stained (except for bone marrow) – 30 days Hematology, CSF, permanently stained –30 days Microbiology, permanently stained (including blood culture bottles) – 7 days Tissue and Fine Needle Aspiration (FNA) – 10 years
Specimen	Specimens must be kept under appropriate storage conditions. Unless noted, timeframe begins after results are reported. Blood Bank – 11 days Blood Culture Bottles – Negative bottles are discarded at 5 days. Isolates from positive bottles are frozen. Flow Cytometry– 3 days (minimum) Microbiology specimen containers (Original Container) – 7 days Microbiology Culture Plates representative of the culture – 7 days from the date of collection. MRSA Surveillance swabs – 5 days (the remaining swab from the set of two) Serum, plasma, CSF, and body fluids (except Blood Bank, Flow Cytometry, & urine specimens) – 7 days Urine (DAU and Immunology) – 7 days Urine (except DAU & Immunology) – 48 hours (Lab sites with sufficient storage space may elect to retain urines for 7 days) Whole Blood (except blood gas testing & Blood Bank) – 7 days
RETENTION REQUIREMENTS: ANATOMIC PATHOLOGY (Surgical, Cytology, Autopsy)
ITEM	RETENTION TIMEFRAME
Autopsy Consent	Scanned by Patient Services into the patient’s permanent medical record
Autopsy Paraffin blocks	10 years
Autopsy Representative Fixed Tissue	2 years
Autopsy Slides	10 years
Autopsy Wet Tissue	3 months from final report
Bone Marrow Smears	10 years
Cytology Fine needle aspiration (FNA) glass slides	10 years
Cytology GYN specimens	6 weeks (for reflex HPV testing)
Cytology NGYN and GYN Slides (atypical, LGSIL, HGSIL, suspicious, positive)	10 years
Cytology NGYN and GYN Slides (negative, unsatisfactory)	10 years
Cytology Non GYN specimens	2 weeks
Cytology Paraffin blocks	10 years
Frozen Section Log-in Sheets	5 years
Surgical Fixed Tissue	2 weeks after final report
Surgical Paraffin blocks	10 years
Surgical Slides	10 years
Tissue Request Form (Cytology)	5 years (to aid with 5 year HGSIL look back)
Tissue Request Form (Surgical)	25 years
RETENTION REQUIREMENTS: QUALITY MANAGEMENT REPORTS
ITEM	RETENTION TIMEFRAME
Anatomic Pathology Problem Identification Log (PIDL)	2 years
Clinical Laboratory QA Logs (non Blood Bank)	2 years
Clinical Laboratory QA Logs (Blood Bank)	10 years

 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ATTACHMENT A – RELEASE FORM
 
 
BOSTON HEALTHCARE SYSTEM (BHS) and BEDFORD VAMC
 

BOSTON AREA CONSOLIDATED LABORATORY

 
Release form for identification of Anatomic Pathology Specimens that are received by Pathology & Laboratory Medicine Service with inadequate patient identifiers. This form is used for specimens that are either unlabeled, contain partial patient identifiers or contain mislabeled patient identifiers.
 
(Please print clearly)
 
 
 
I, ______________________________, certify that the ___________________ specimen for
    Print Your Name                                                          Type of Specimen
 
 
 
__________________________________________ was collected from ______________________
Laboratory Test Requested & (optional) Accession #                              Patient’s Name and SSN
 
 
 
on _______________. 
       (Date collected)
 
 
 
I accept complete responsibility for the proper identification of this specimen.
 
 
I have signed this release form of my own free will.
 
 
 
 
_________________________
SIGNATURE
 
 
 
 
 
 
 

Specimen Labeling/Rejection