Specimen Labeling & Adequacy

Specimen collection and labeling are essential steps to assuring reliable results.   The Joint Commission for Accreditation of Hospitals, CLIA, and other inspecting agencies require all specimen to have two patient identifiers.  The following guidelines apply to all specimen, routine laboratory, microbiology, cytology, and anatomic pathology.

DO NOT label the specimen tubes prior to collection.   24-hour urine containers, however, should be labeled prior to giving the container to the patient for collection.

1. Write the patient’s full first and last name on the specimen.
2. Write the patient’s date of birth on the specimen.
3. Write the date and time of collection and your initials on either the specimen or the accompanying requisition.

Unlabeled or mislabeled specimen will not be accepted if  labeling is not accurate and complete, as in the following scenarios:

• First or last name or both on the specimen do not match those on the requisition.
• The specimen is unlabeled, even though it arrives at the laboratory in a plastic specimen bag with the requisition.
• The patient’s complete name is not on the specimen.  Initials are not acceptable.

Irretrievable specimens may be an exception.  These include spinal fluids and biopsy materials.  In these cases, the physician or staff involved must sign the lab mislabeled/unlabeled documentation form before results can be reported.