Northern Devon Healthcare NHS Trust Title: Specimen Collection, Handling &

Transportation
Pathology Department Page 1 of 12
Q-Pulse Document No. Q-SOP-10 Version 1.3

Specimen Collection, Handling and

Transport to the Laboratory

VERSION No 1.3
AUTHORISED BY B. Seymour
AUTHOR B. Seymour
COPY 3
1. Quality Manager’s Office
LOCATION OF COPIES 2. Q-Pulse
3. Pathology Handbook on Bob

Essential, Minor, Handwritten Amendments

Essential minor amendments (maximum 10) can be handwritten in this document if:-
 The amendments are made by the author and approved by the owner of the document
 The author initials/signs & dates each page which has been amended
 Associated documents e.g. wall laminates are also amended

LABORATORY PROCEDURAL INFORMATION

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Q-Pulse Document No. Q-SOP-10 Version 1.3

CONTENTS

0 INTRODUCTION............................................................................................................3
0.1 SCOPE AND PURPOSE...............................................................................................3
0.2 RESPONSIBILITY........................................................................................................3
0.3 REFERENCES............................................................................................................ 3
1 PATHOLOGY SAMPLES/SPECIMENS - COLLECTION & HANDLING.......................4
1.1 INTRODUCTION..........................................................................................................4
1.2 CONSENT.................................................................................................................4
1.3 INSTRUCTIONS FOR USERS BEFORE COLLECTING SPECIMENS.....................................4
1.3.1 Guidance on Completing (Paper) Pathology Request forms............................4
1.3.2 Guidance for GP Practices on Completing Order Coms Request forms..........5
1.3.3 Guidance on Preparing Patients for Specimen Collection................................5
1.3.4 Guidance on Specimen and Container Type & Amount of Sample to Collect...5
1.4 INSTRUCTIONS FOR USERS ON COLLECTING SPECIMENS.............................................6
1.4.1 Identifying the Patient......................................................................................6
1.4.2 Confirmation that the Patient is Appropriately Prepared...................................6
1.4.3 Instructions and Guidance for the Collection of Specimens.............................7
1.4.4 Guidance for Collecting Primary Specimens as Part of Clinical Practice..........7
1.4.5 Instructions for Labelling of Primary Specimens..............................................8
1.4.6 Instructions for Proper Storage Conditions Prior to Transport to the Laboratory
9
2 PACKING OF SAMPLES FOR TRANSPORTATION.....................................................9

3 SPECIMEN TRANSPORTATION.................................................................................10
3.1.1 Responsibility for Transportation....................................................................10
3.1.2 Ensuring the Safety of the General Public......................................................10
3.1.3 Monitoring of Transportation of Specimens....................................................11
3.1.4 Identification of Compromised Specimen Integrity or Unsafe Packaging.......12
3.2 Reporting of Incidents Relating to Specimen Packing & Transportation................12

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Q-Pulse Document No. Q-SOP-10 Version 1.3

0 INTRODUCTION

0.1 Scope and purpose

This document gives guidance to users on the collection, handling and transportation of
pathology specimens (biological material) to the Pathology Department. It also acts as an
index to other sources of information on specimen collection, handling and transport to the
laboratory.

0.2 Responsibility

Whilst the laboratory gives guidance and advice on the correct way to collect, handle and
transport pathological specimens, it remains the prime responsibility of the user/sender to
collect and package specimens according to the relevant legislation and local procedures
currently in force. The Pathology Dept. reserves the right to refuse acceptance of patients’
specimens which have not been packaged in accordance with current regulations which
pose a hazard to its staff, the general public, couriers or other Health Care Workers.

All those who collect, handle, send or transport specimens to pathology laboratories
must ensure that the container used is the appropriate one for the purpose, is
properly closed, and is not externally contaminated by the contents.

If a specimen is suspected or known to present an infectious hazard, the person taking the
specimen has the responsibility to ensure that the form and containers are labelled as such.

The Out Patient Department is responsible for the Phlebotomy department. Sodexo are
responsible for managing the NDHT portering and van delivery/collection service.

0.3 References

 CPA Standards C5, E1, E3 and E4

 ISO 15189:2012 Standard, clauses 5.4.4 and 5.4.5
 Pathology Department Health and Safety Code of Practice (PATH-1)

TO ACCESS THE LINKS IN THIS DOCUMENT – HOLD THE CONTROL KEY (Ctrl) AND
CLICK THE LINK. Please report broken links to the Pathology Quality Manager 0n 01271 335758

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Q-Pulse Document No. Q-SOP-10 Version 1.3

1 PATHOLOGY SAMPLES/SPECIMENS - COLLECTION &

HANDLING

Proper preparation of the patient, specimen collection and handling are essential for the
production of valid results by the laboratory.

1.1 Introduction

Note: In situations where specimens are collected by methods that deviate from the
information in this document, please inform the laboratory by telephone (Contact Us) or by
indicating on the pathology request form (hardcopy or electronic Order Coms form) that
accompany the specimens.

This is so that we can include the (alternative specimen collection) information as part of the
report, as the way specimens are collected could have a bearing on their integrity and
therefore the results that are reported.

1.2 Consent

All procedures carried out on a patient need the informed consent of the patient. For most
routine specimen collection procedures, consent can be inferred when the patient presents
themselves and willingly submits to the usual collecting procedure, for example,
phlebotomy.

Special specimen collection procedures, including more invasive procedures, or those with
an increased risk of complications to the patient, (e.g. surgical procedures), will need a
more detailed explanation and, in some cases, written consent – this is the responsibility of
the team collecting the specimens as it is outside of laboratory control.

Laboratory staff accept that In emergency situations, consent might not be possible; under
these circumstances it is acceptable to carry out necessary specimen collection procedures,
provided they are in the patient’s best interest.

1.3 Instructions for Users before Collecting Specimens

1.3.1 Guidance on Completing (Paper) Pathology Request forms

Guidance on how to complete hardcopy pathology request form is available in the
Pathology Handbook:
http://www.northdevonhealth.nhs.uk/pathology/completing-pathology-request-forms/

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1.3.2 Guidance for GP Practices on Completing Order Coms Request forms

Each GP practice has had training from the Pathology I.T. Department. Should further
advice/guidance or top-up training be required, please contact Pathology I.T. on 01271
322324 or by email ndht.pathit@nhs.net
1.3.3 Guidance on Preparing Patients for Specimen Collection

Patients – Some specimens are collected by patients themselves. There are information
sheets available for patients for the following specimens:-

 24 Hour Urine Collection

 Obtaining a Semen Sample

These information sheets are usually distributed to patients by users. These information
sheets are available from the Laboratory Supplies Dept: Fax 2328 or phone ext. 2342 from
within the N.D.D.H. or 01271 322342 from outside, (answer phone out of hours).

Sample Collectors -

Information is available for all sample collectors on any special requirements for patient
preparations in the Pathology Handbook as follows:

 PDF ‘Sample Collection Guide’ for blood tests

 Microbiology Specimen Collection Guide

1.3.4 Guidance on Specimen and Container Type & Amount of Sample to Collect

Along with the PDF ‘Sample Collection Guide’ for blood tests document the following
Pathology Hand Book pages may be of use for users. Information on special timing of
collection, required clinical information (e.g. history of drug administration) and urgent
transportation requirements can also be found.

 Biochemistry Tests

 Haematology Tests

 Blood Transfusion Tests

 Microbiology Specimen Collection Guide

 Histology Specimens & Cytology Specimens

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1.4 Instructions for Users on Collecting Specimens

1.4.1 Identifying the Patient

Patients wearing hospital I.D. wristbands. The identity of the patient must be confirmed
by checking the patient’s wrist band. Do not rely on the information on the headboard of the
bed.

ALL HOSPITAL INPATIENT SPECIMENS MUST BE LABELLED AFTER CHECKING THE

PATIENT’S WRISTBAND AND, WHERE POSSIBLE, AT THE PATIENT’S BEDSIDE.

Patients NOT wearing hospital I.D. wristbands. The identity of the patient must be
confirmed by asking them to confirm their full name and date of birth. If positive
identification of the patient cannot be confirmed by asking for these details, do not
collect the specimen. Refer to a member of staff who can confirm the patient’s
identity, e.g. nurse or doctor and allow them to collect the specimen.

Relevant Trust policies:-

 Patient identification Policy
 Specimen Acceptance Policy

1.4.2 Confirmation that the Patient is Appropriately Prepared

Specimen collectors should satisfy themselves of any special requirements for patient
preparation by referring to the guidance in section 1.3.3 above. If special requirements, e.g.
fasting are noted, this should be confirmed verbally with the patient prior to the specimen
collection process commencing.

For non-appointment specimen collection, e.g. phlebotomy, if the patient has not been
prepared appropriately they should be asked to return at a future time after preparing
correctly. Where timed appointments have been made for specimen collection, advice
should be sought either from the laboratory staff (Contact Us) or from the healthcare
professional who’s care the patient is under.

WARNING!
Specimen collection when the patient is not appropriately prepared could affect the
integrity of any test results.

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1.4.3 Instructions and Guidance for the Collection of Specimens

The Pathology Department is not responsible for collection of specimens, although the
department’s staff are always able to offer advice on collection procedures (Contact Us).

Collection of Blood Specimens

A phlebotomy service is available for both in-patients and out-patients at North Devon
Hospital. Out-patient Clinic opening hours are Monday to Friday from 09:00am to 16:50pm
(last admission).

The phlebotomy service is managed by the Outpatient’s Department and can be found in
Outpatients C near to main reception on Level 2. Contact number for the phlebotomy room
is extension 2343.

Venepuncture courses are run by the Trust and are available to book on STAR.

Types of primary specimen container have already been covered in section 1.3.4 above.

When finished with, needles used for specimen collection should always be discarded
directly into an approved sharps container, without being re-sheathed. All other non-sharp
disposables should be placed in a clinical waste bag.

Related Trust Documents:

 Neonatal Venepuncture – Standard Operating Procedure Performance of

 Venepuncture – Standard Operating Procedure

Related Pathology Guidance

 Various Pathology Hand Book web pages as already described above.

Collection of Non-Blood Specimens

Various Pathology Hand Book web pages as already described, but particularly:-

 Microbiology Specimen Collection Guide

 Histology Specimens & Cytology Specimens

Types of primary specimen container have already been covered in section 1.3.4 above.

1.4.4 Guidance for Collecting Primary Specimens as Part of Clinical Practice

Information and guidance for these specimen collection procedures is the same as
described above.

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1.4.5 Instructions for Labelling of Primary Specimens

The Trust’s Specimen Acceptance Policy gives guidance on the labelling requirements for
primary specimens to ensure there is an unequivocal link with the patients from
whom they are collected. A summary of version 4 of the policy is shown below:-

Summary of the NDHT Specimen Acceptance Policy

Key Identifiers Include:

NHS or a NDDH hospital number

Date of birth
Name in full (not calling or preferred names)
Genito-urinary medicine number (GUM No.)
Unknown or Alias Male/Female – (see ‘Main Exceptions’ below).
Major incident patient number (e.g. MI001)

Labelling of Specimens

All specimens must be clearly and unequivocally identified with a minimum of two of the key
identifiers (one of which must be full name), and must match with the request form I.D.

Specimens not conforming to these criteria will be rejected by the Pathology Department.
Specimens may also be rejected if they have leaked.

Transfusion & Antenatal Serology Specimens Only – Additional Requirements:-

Must be identified with a minimum of three of the key identifiers. Must be labelled by
hand, not with sticky labels. Must be signed by the person collecting the specimen.

Completing Pathology Request Forms (Paper and Electronic) The request must contain a
minimum of three key identifiers and must match with the specimen I.D. Whenever possible,
the NHS or a NDDH hospital number should be used as one of the key identifiers.

The report destination, the name of the requesting practitioner and the analysis required
must also be included, along with relevant clinical information.

Pre-printed labels are accepted on request forms as a means of identification but they must
contain all relevant information. Poorly printed or misaligned labels (where ID cannot be
interpreted), will result in affected requests being rejected.

Labels must be attached to all copies of the request form. PAS labels are not acceptable on
blood tubes.

Without the presence of relevant clinical details, some specimens will not be processed*

Blood Transfusion Request Forms – Additional Requirement:- Request forms for blood
transfusion specimens must be signed by the person taking the specimen.

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GUM specimens Minimum required is GUM (Alias) number & DOB *

A/E unknown (unconscious) patient Minimum required is NDDH number & Gender*
Main
Exceptions
to the above In the event of a life-threatening or time critical situation, the consultant in charge of patient care will
criteria: discuss with the laboratory staff that they will accept the analysis of a specific, repeatable sample
and acknowledge in doing so acceptance of any governance issues involved. This exception will
not include samples for blood transfusion which are governed by national law.

* Refer to policy for full policy wording and all exceptions.

It is a requirement and important that the identity of the person who collects each primary
specimen and labels them is identified on the pathology request form along with the date of
specimen collection and, in some instances, time e.g. when monitoring therapeutic drug
levels.

1.4.6 Instructions for Proper Storage Conditions Prior to Transport to the Laboratory

Specimens should be transported to the laboratory as soon as possible after collection,

labelling and packing have occurred. Delay could result in deterioration in the specimen
which could invalidate the results of any investigations carried out or cause some or all tests
results to be unavailable.

If a delay in specimen transportation is likely, please refer to the ‘Pathology Specimen

Storage Guidance’ document found on this page in the Pathology Handbook.

2 PACKING OF SAMPLES FOR TRANSPORTATION

The packaging of specimens must consist of three components to comply with UN 3373
regulations:

(a) A primary receptacle – e.g. the container or blood tube a specimen is collected into;

(b) Secondary packaging – e.g. the purpose designed plastic specimen bag

(c) An outer packaging – e.g. the Versapak bag used to transport specimens to the
laboratory.

There should be absorbent material present in the outer packaging to absorb potential spills
and leakages.

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Specimen containers must be tightly sealed to render them leak proof. Specimens and
request forms must be placed in purpose designed plastic specimen bags. The specimens
must be placed in the specimen chamber which must be sealed, the request form placed in
the side pocket.

Specimens and request forms must not be put in the same compartment in case of leaking
sample containers.

(a) Biochemistry and Haematology samples can be sent together, in the same
specimen bag. There is a single, combined request form for these tests.

(b) Although all samples should be treated as HIGH-RISK, (standard precautions),

known high risk specimens should be labelled as ‘High Risk’. See ‘High Risk
Specimens and Safety’ in the Pathology Hand Book for further information.

(c) Specimens should be transported to the laboratory using the supplied UN3373
compliant carriers, e.g. Versapak transport bags. These are secure; contain an
inner, replaceable lining for maximum sample & staff protection and safety and
absorbent material to soak up any potential leakages. Various sizes are available
for individual or multiple specimens, including satchels for night porters who
have to multi task.

(d) When using these carriers there is no need for the person transporting the
container to wear gloves or face protection. For advice on UN3373 carriers
contact Mr Lee Luscombe on 01271 311754, internal ext. 3754.

It is the prime responsibility of the user/sender to collect and package specimens

according to the relevant legislation in force and these guidelines. The Pathology
Dept. reserves the right to refuse acceptance of patients’ specimens, not packaged in
accordance with current regulations which pose a hazard to its staff, couriers or
other Health Care Workers.

3 SPECIMEN TRANSPORTATION

3.1.1 Responsibility for Transportation

Sodexo are responsible for providing transportation services in the Primary and Secondary
care environments. The Pathology Management Team have good links with Sodexo which
enable cooperation between the two services for timeliness and safety considerations.

Sodexo portering managers are responsible for training of porters and drivers in the nature
of pathology specimens and health & safety requirements, including dealing with spillages.

3.1.2 Ensuring the Safety of the General Public

Should there be a breakage or spillage of one or more specimens which are in an area
which the general public have access to, e.g. ward and clinic areas or public corridors, the
following guidance should be followed:-

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The person who has dropped the specimen or noticed that the specimen was leaking
should contact the Pathology Department requesting assistance. They should try to ensure
that the area is kept clear from all staff, members of the general public, relatives and
patients, by enlisting help if possible and available.

A Biomedical Scientist (BMS) from the department should go to the site where the
leakage/breakage occurred. Either Biochemistry staff or Haematology staff should be
contacted if one of their blood tubes is involved.

The BMS should assess the situation and the relevant risks if any associated with the
specimen.

The BMS will clean up the spillage/leakage according to the procedure in section 29.3 in the
Pathology Health & Safety Code of Practice (Q-Pulse ref. PATH-1).

A Datix incident record should be completed.

3.1.3 Monitoring of Transportation of Specimens

Regular audits are carried out of the transport arrangements of pathology specimens to the
laboratory from NDHT and community locations according to documented laboratory
procedure.

Time & Temperature

These audits are undertaken to ensure that specimens are (i) transported within a time
frame appropriate to the nature of the requested tests (i.e. making sure there is no undue
delay in getting samples to the laboratory. This is accepted to be between 4 and 5 hours)
and (ii) transported within a temperature range between 10 and 28oC to ensure sample
integrity.

Warning!
Where specimens need to be collected and kept at a temperature outside of the above
range or, where transport to the laboratory is time critical, e.g. lactate, patients should be
advised to attend the NDDH phlebotomy clinics.

Where specimens have been collected in a primary care setting and centrifuged, these
samples will be stabilised for longer periods and can be transported to the lab the next day.
(Refer to the ‘Quick Guide for Spinning Blood Tubes - distributed to GP practices as part of
the centrifuge implementation.

Specimen Container Preservatives

Continuous, real time monitoring of specimens occurs when they are received in the
laboratory. This monitoring checks for the correct specimen container and volume of
specimen for the requested tests as well as completeness of patient ID.

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3.1.4 Identification of Compromised Specimen Integrity or Unsafe Packaging

In all instances where, upon receipt of a sample whose integrity was compromised or it has
come to the attention of laboratory staff that specimen packing or transportation practices
could have or did jeopardise the safety of the courier or the general public, the laboratory
will investigate the issue and contact the sender of the specimen to inform them about
measures to be taken to minimise or where possible, eliminate recurrence.

Depending upon the seriousness of the incident, laboratory staff may raise a Datix incident
report (e.g. spillage/leakage of specimen in a public place) and communication with the
sender may be either by telephone call or by way of a comment on the pathology report.

3.2 Reporting of Incidents Relating to Specimen Packing & Transportation

Any adverse incident which occurs in the course of dispatching and transporting pathology
specimens to the laboratory must be recorded using the NDHT’s incident reporting system.
Examples of types of incidents include:-

 Leaking specimens and associated contamination

 Serious delay in transportation of specimens
 Breakdown of vehicles transporting specimens
 Incorrect storage of specimens prior to transportation (e.g. specimens left on a radiator
overnight).

Advice on completing incident forms is available from the Corporate Affairs Department,
Munro House, North Devon District Hospital. Telephone: via switchboard 01271 322577 or
extension 0 from within NDDH.

LABORATORY PROCEDURAL INFORMATION