Identification, Collection, and Transport of Specimens

Every specimen container label MUST include:

• Patient's first and last name
• Patient's Medical Record number
• Date and time of collection
• Initials of collector

Do NOT label lid

Every specimen slide for Cytopathology MUST be labeled on the frosted end with a lead pencil and include:

• Patient's first and last name
• Patient's Medical Record number
• Source of specimen
• Do NOT label slide folder
• Every ThinPrep vial submitted to Cytopathology for gyn testing (Pap smear) must be labeled with patient's first and last name and patient's medical record number. It should be accompanied by a requisition with the matching patient identifiers. Unlabeled ThinPrep specimens will be rejected and a new specimen collection required. Mismatched requisitions and specimen containers will also be rejected and a new specimen collection required.

Every requisition MUST include:

• Patient's first and last name
• Patient's Medical Record number
• Patient's date of birth
• Patient's location Date and time of collection
• Initials of collector
• Requesting physician and UNC Hospitals physician code number
• Tests ordered, on the appropriate requisition
• Anatomic location of specimen site, where required
• All relevant patient clinical data for Anatomic Pathology and Cytopathology specimens (NOTE: menstrual history is of paramount importance on Gynecological Cytopathology specimens)

Priority requests:

• STATS: Emergency procedures should be indicated by attaching a completed red STAT slip to the regular requisition, or by inputting the order in EPIC with a STAT priority.

Inpatient specimen labeling:

• All specimens (except slides) must be labeled with a barcode ID label.
• All specimens must be labeled at bedside immediately upon collection and before leaving the patient's room.
• If a label is completed by hand at the patient's bedside (e.g., filling in unreadable or missing letters or numbers), the specimen is acceptable as long as the information is correct and consistent with the requisition.

Outpatient specimen labeling:

• All specimens must be labeled with a barcode ID label or with a computer-generated Lab Information System label.
• All specimens must be labeled immediately upon collection.

Specimen acceptance:

• Under universal sample precautions, only specimens collected in appropriate containers (e.g., screw top tubes for CSF) will be accepted. Needle-capped syringes will not be accepted, except for Cytopathology aspirates.
• Contaminated specimen containers and/or requisitions are not acceptable and will not be processed by the laboratories.
• Unlabeled, illegible or improperly labeled specimens and/or requisitions will not be processed.
• Specimen and/or requisition rejections will be handled according to a uniform acceptance procedure within the Department of Hospital Laboratories. Written notification/documentation of the rejection will be included in the patient's permanent chart.
• Questions regarding specific specimens should be directed to the individual laboratory supervisor.

Specimen Transportation:

• Specimens of blood or other potentially infectious materials shall be placed in a well constructed container with a secure lid (e.g., evacuated blood collection tube) which prevents leakage during collection, handling, processing, storage, transport, or shipping. If outside contamination of the primary container occurs, then a second leak proof container shall be placed over the outside of the first and closed to prevent leakage during handling, storage, or transport. Specimens which leave the hospital must be labeled with a BIOHAZARD label.
• When transporting multiple specimens of blood or other potentially infectious materials within the facility, a BIOHAZARD labeled transport container (i.e., BIOHAZARD labeled pail or cooler) shall be used.
• For further information on transportation on Infectious Substances or Diagnostic Specimens, see McLendon Clinical Laboratories Packaging and Shipment of Biological Specimens External to Medical Center. and UNC Hospitals Infection Control Manual, Exposure Control Plan for Bloodborne Pathogens.
• For transport of specimens via the Computerized Tube System (CTS) see the CTS Policy.