Specimen Acceptance Policy

(Medical Center Policy No. 0083)

The University of Virginia Medical Center laboratories shall follow a standardized specimen acceptance/rejection procedure in order to protect specimen quality, prevent patient identification errors, minimize risk of healthcare worker exposure, and comply with applicable regulatory and accreditation standards.

PROCEDURE:

  • 1. Specimen Requirements:
  • a. Every specimen submitted to the laboratory for analysis shall have the following information on the container (Information shall not appear on the lid since the lid can be removed during processing or on the specimen bag):
    • Patient's full first and last name. (Trauma ID numbers can be used until another permanent number is assigned when the patient name is not available.)
    • Medical record number. (Alternate secondary identifier accepted only for patients outside of the UVA Medical Center.)
    • Typenex identification label with collection date and collector's last name and 1st initial for all Blood Bank specimens collected for transfusion purposes. (see Appendix X for detailed procedure)
  • b. An identity code is acceptable only in the case where anonymity is required for pre-established reasons. Specimens submitted shall be appropriate for the analysis requested as specified in the Medical Center Medical Laboratories Handbook.
  • c. Specimens shall be submitted without attached needles or sharps devices and without any visible evidence of contamination by blood or body fluid on the outside of the specimen container.
  • 2. Transmittal/Requisition Requirements:

All specimens from Inpatient locations and Outpatient locations shall be accompanied by a MIS transmittal, laboratory requisition form or consult form that matches the labeled specimens, unless ordered through CARECAST.  All handwritten requisitions accompanying specimens shall be legibly written and provide the following information:

  • a. First and last name of patient and medical record number, or other secondary identifier for patients outside of the UVA Medical Center or trauma ID or special approved codes in case of anonymity.
  • b. Patient's date of birth.
  • c. Complete name of ordering clinician with UVA PIC number where applicable.
  • d. Ordering location.
  • e. Tests or procedures requested using only a test request code, approved abbreviation or full test or procedure name.
  • f. Date and time of collection.
  • g. Specimen source and body site for all non-blood or urine specimens.
  • h. Patient history for all biopsy specimens and for other specimens when necessary for interpretation of results.
  • i. Diagnosis code (ICD-9) for outpatients
  • j. Advanced Beneficiary Notice (ABN) if the test qualifies under Medicare Medical Necessity Guidelines.

In instances where the requisition requirements listed in a-h above are not met, testing will be performed but results will be held until the laboratory can contact the health care provider and obtain the necessary information.

  • 3. Specimen Rejection:

For specimens that do not meet the acceptable labeling criteria listed in Section 1a above, or shipping instructions listed in Section 1c above, the Laboratory staff will promptly contact the patient location.  RECOLLECTION WILL BE REQUIRED.

  • 4. Irreplaceable or Precious Specimen Criteria:

For those occasions where re-collection of a mis- or un-labeled sample is not possible and the attending physician determines that analysis of the specific specimen submitted is critical to the care of the patient, laboratory staff will consider exceptions to the above policy for the following irreplaceable or precious specimen:

  • a. Normally Sterile Body Fluids (i.e.: pericardial, peritoneal, CSF)
  • b. Bone Marrow
  • c. Fine Needle Aspirates (FNA)
  • d. Tissue Biopsies/Surgical Specimens
  • e. Bronchoscopy/Endoscopy Specimens (i.e., BAL's)
  • f. Drug levels timed for treatment (peak and trough)
  • g. Blood Cultures
  • h. PAP smears/Thin Preps
  • i. 24 hours urines

If the attending Physician concludes that the specimen was difficult to collect (arterial, central vein, femoral, subclavian) or the patient is no longer accessible, the physician must contact the laboratory supervisor who will consult with the Clinical Pathology Resident on call, as needed.

NOTE: No exceptions can be made for specimens collected for HIV testing, HLA testing or for Blood Bank.

If a specimen meets the criteria for being considered as irreplaceable or precious, subsequent results will be released into the patient's medical record only when the collector, patient's primary nurse or ordering physician agrees to accept responsibility for the specimen's identity, signs the Medical Laboratory Specimen Attestation Form and returns the form to Specimen Management. Once the signed attestation form has been received, the laboratory will label the precious specimen with a bar-coded accession label.

The final patient report will include a note that the specimen has been labeled with the laboratory test barcode.