Patient ID & Labeling

Patient identification and specimen labeling is absolutely critical, as errors here can lead to misdiagnosis, incorrect treatment, and potentially harmful outcomes for the patient

Importance

• Patient Safety: The primary goal is to ensure the right test is performed on the right sample from the right patient. This is non-negotiable for patient safety
• Accurate Diagnosis: Correct identification and labeling are vital for accurate and reliable test results, which are the foundation of effective diagnosis and treatment
• Legal and Ethical Considerations: Mislabeled or misidentified specimens can have significant legal and ethical repercussions for the laboratory and healthcare providers
• Efficiency and Cost-Effectiveness: Errors in this phase can lead to repeat collections, delayed results, and increased costs for both the lab and the patient

Elements of Proper Patient Identification

• Active Patient Participation: Whenever possible, involve the patient in the identification process. Ask them to state their full name and date of birth
• Two-Factor Identification: Always use at least two unique patient identifiers. Common identifiers include:
  • Full Name: Including first, middle (if applicable), and last name
  • Date of Birth: Month, day, and year
  • Medical Record Number (MRN): A unique number assigned by the healthcare facility
  • Unique Identifier: Some facilities use unique patient identifiers specifically for specimen collection purposes
• Verification of Information: Compare the information provided by the patient with the information on the test request form or electronic order. Resolve any discrepancies before proceeding.
• Unconscious or Incapacitated Patients: Follow the healthcare facility’s policy for identifying patients who are unable to provide identification. This typically involves using a designated identification system (e.g., temporary ID band) and verifying the information with a nurse or other authorized healthcare professional

Essential Elements of Specimen Labeling

• Labeling at the Bedside/Point of Collection: Label the specimen immediately after collection and in the presence of the patient. This prevents mix-ups and ensures accurate association of the specimen with the patient
• Required Information on the Label: The label must include the following information, at a minimum:
  • Patient’s Full Name: Exactly as it appears on the test request form
  • Patient’s Unique Identifier: Usually the Medical Record Number (MRN) or other assigned number
  • Date of Collection: The date the specimen was collected (MM/DD/YYYY)
  • Time of Collection: The time the specimen was collected (HH:MM AM/PM)
  • Collector’s Initials: Identification of the person who collected the specimen
  • Specimen Source: (e.g., wound site, urine - clean catch). Very important!
• Label Format and Placement
  • Use pre-printed labels or write clearly and legibly with a permanent, waterproof marker
  • Affix the label directly to the specimen container, avoiding the lid (which may be removed and replaced)
  • Ensure the label is securely attached and won’t easily peel off during transport and handling
• Electronic Labeling Systems (if applicable)
  • Follow the manufacturer’s instructions and the facility’s policies for using barcode scanners and electronic labeling systems
  • Verify that the printed information on the label matches the information on the test request form

Procedure

1. Obtain the test request: Review the test request form or electronic order to understand the required tests and any specific collection instructions
2. Gather supplies: Assemble all necessary supplies, including specimen containers, labels, collection devices, and personal protective equipment (PPE)
3. Identify the patient: Ask the patient to state their full name and date of birth
4. Verify information: Compare the patient’s information with the information on the test request form. Resolve any discrepancies
5. Explain the procedure: Clearly explain the collection procedure to the patient
6. Collect the specimen: Collect the specimen according to established protocols
7. Label the specimen: Immediately after collection, label the specimen container with all required information
8. Final verification: Before leaving the patient’s side, double-check that the information on the label matches the information on the test request form
9. Transport the specimen: Transport the specimen to the laboratory according to established protocols

Common Errors and How to Avoid Them

• Misidentification: Asking “Are you Mr. Smith?” instead of asking the patient to state their name
  • Solution: Always ask the patient to state their full name and date of birth
• Pre-labeling: Labeling tubes before collecting the specimen
  • Solution: Never pre-label tubes. Label immediately after collection, in the patient’s presence
• Illegible handwriting: Writing information that is difficult to read
  • Solution: Use pre-printed labels or write clearly and legibly with a permanent marker
• Incomplete labeling: Leaving out essential information, such as the date or time of collection
  • Solution: Use a checklist to ensure all required information is included on the label
• Lid Labeling: Placing the label on the lid rather than the container itself
  • Solution: Place the label directly on the container, not the lid

Documentation

• Maintain accurate records of specimen collection and labeling, including any discrepancies or issues that arise
• Follow the healthcare facility’s policies for documenting patient identification and specimen labeling procedures

Training and Competency

• All personnel involved in specimen collection and labeling must receive thorough training on proper procedures
• Regular competency assessments should be performed to ensure that personnel are following established protocols

Quality Control

• Implement a quality control program to monitor patient identification and specimen labeling practices
• Regularly review error logs and incident reports to identify areas for improvement
• Participate in proficiency testing programs to assess the accuracy of patient identification and specimen labeling procedures

Key Terms

• Patient Identification: The process of accurately and reliably verifying the identity of the individual from whom a specimen is being collected. This typically involves using two or more unique identifiers
• Specimen Labeling: The act of attaching a label with specific information to a specimen container to ensure accurate association of the specimen with the correct patient and test
• Unique Identifier: A piece of information that definitively distinguishes one patient from another. Examples include Medical Record Number (MRN), date of birth, or a unique patient identifier assigned by the healthcare facility
• Point of Collection: The location where the specimen is obtained from the patient. Ideally, specimen labeling should occur at the point of collection immediately after the specimen is collected
• Two-Factor Identification: The practice of using at least two distinct patient identifiers (e.g., name and date of birth) to confirm a patient’s identity, enhancing accuracy and reducing the risk of errors
• Discrepancy: Any inconsistency or disagreement between the information provided by the patient, the information on the test request form, or the information on the specimen label. Discrepancies must be resolved before proceeding
• Pre-Labeling: The practice of preparing specimen labels in advance, before the specimen has been collected. This is generally discouraged as it increases the risk of errors
• Chain of Custody: A process that tracks the handling and storage of a specimen from the point of collection to its final disposition. It is essential in forensic testing and other situations where the integrity of the specimen must be documented
• Requisition Form: Also known as a test request form, this document contains the patient’s information, the tests to be performed, and any relevant clinical information. It is used to order and track laboratory tests
• Specimen Integrity: The quality or condition of a specimen. Proper patient identification and specimen labeling are crucial for maintaining specimen integrity and ensuring accurate test results