The Department of Pathology would like to inform staff physicians as well as all support staff of a new procedure that will affect the way the clinical labs (excluding Blood Bank) will address the handling of results arising from a sample that has been misidentified (i.e., the sample has the wrong patient name on the tube). The purpose of this procedure is to ensure patient safety by requiring that all patient specimens be correctly identified.

When a misidentified sample is discovered either by the laboratory or patient care area, the policy of the laboratory will be to discontinue testing on that sample until complete resolution of the problem has been achieved.  Result(s) will not be transferred to another patient’s record unless the staff physician responsible for that patient determines that the sample is irreplaceable (i.e., difficult to repeat the collection-bone marrow samples, CSF samples, etc.) and that the sample in question does indeed belong to the patient whose record will receive the transferred results.

Laboratory personnel will initiate the “Misidentified Sample Form” when a misidentified sample is discovered.  The laboratory will inform the ordering physician or patient care area personnel that the ordering physician needs to stop by the laboratory that made the call within two hours and sign a form indicating that the specimen is irreplaceable. The signing physician is therefore assuming responsibility for the identity of the specimen.  The Diagnostic Service Subcommittee has reviewed and approved this policy.  The go-live date for this policy is Thursday, July 28, 2005.  If there are any questions, please contact Dr. John Kemp, Director of Clinical Laboratories at 384-9611, or Chris James, Quality Assurance Coordinator for Clinical Pathology at 353-8503.