Sample labelling

Stringent procedures, informed by guidance from professional bodies, for patient identification criteria on samples and request forms exist to ensure the safety of the patient (to ensure that the right investigation(s) is performed on the right sample(s) and the results assigned to the correct patient).

Sample and request form information must be compatible.

Additional identification is required for blood transfusion (see below)

Patient and sample information required on sample and request form:

1. Patient’s full name or unique coded identifier*
2. Date of birth
3. NHS number (preferable) or hospital number or unique coded identifier*.
4. Date and time collected
5. Nature of sample, including qualifying details, e.g. left, distal, etc. especially if more than one sample per request submitted (essential for Cellular Pathology samples).

* Note: For patients who have been allocated a unique coded identifier for confidentially purposes (e.g. Sexual Health Clinic patients), the NHS number should not be quoted

The request form must also state:

• Patient’s location or destination for report
• Consultant, GP or name of requesting Practitioner
• Investigation(s) required
• Clinical information including relevant medication

It is desirable to also include:

• Record of specimen taker
• Clinician’s contact number (Bleep/extension)
• Patient’s address including postcode
• Patient’s contact phone number

For antenatal screening for sickle cell and thalassaemia, the FOQ must have a tick for each parent in the family origin section

Patient Identification Criteria Required for Blood Transfusion

Sample (if not taken via Blood Track PDA):

1. Legibly handwritten by the specimen taker
2. Surname and forename correctly spelled
3. NHS number. Hospital numbers are acceptable in the following circumstances: where patient does not have an NHS number i.e. visitor to the country, a private patient or A&E major haemorrhage samples
4. Date of birth (not age)
5. Signed by specimen taker
6. Dated and timed (It is acceptable to just have the date, provided time is written on the request card).

Request form:

1. Agree in every detail with the sample and have all information detailed above. Patient “addressograph” or similar labels are acceptable on request forms so long as the details of the form and sample match
2. Must be signed by the specimen taker
3. Must have License number in box provided

The only exceptions to these rules are: Samples taken from patients for emergency transfusion testing, who are unconscious in the A&E department. In these cases the sample MUST have a handwritten hospital number or A&E emergency number as a minimum. The specimen should also have:

• Patient gender
• Source of the sample
• Date and time of collection
• Signature of specimen taker

Microscope slides (e.g. FNAS) must have the patient’s forename, surname and date of birth written in pencil. Bone marrow slides MUST be labelled with 3 points of identification for the patient and it is desirable to have the date taken

Major Incidents – In the event of a major incident the 10 digit Majax number MUST be used in place of an NHS number (see Trust Incident policy).

Samples or request forms received without the minimum identification criteria stated above will not be processed. Samples received without a request form will also be rejected.

In cases where an inadequately labelled request form/sample is received from a patient who is not easily accessible for a repeat, then, at the discretion of senior laboratory staff, the sample may be processed and the report will show a clear disclaimer detailing the shortcomings of the sample and/or request. The disclaimer will alert the requesting practitioner to take responsibility for the results and for any action taken as a result of the report.