A CCRE DI TA TI ON STANDARD S
Patient Safety
SPECIMEN HANDLING
Specimens are safely and appropriately handled. Handling includes identifying, collecting,
labeling, preserving, storing, preparing for transport, documenting and communicating.
Specimens include blood, body fluids, tissue or other specimen types removed from the patient
including those sent for pathological or gross examination, culture, and sensitivity or other
studies.
Safe and appropriate specimen handling is supported through documented
processes and procedures
INDICATORS:
 Written policy and procedures for safe and appropriate handling of specimens include but
are not limited to:
•
a statement that all surgical specimens shall be saved unless designated for discard
by provincial legislation and/or facility policy
•
surgical specimens designated for discard are listed in facility policy
•
specimen containment
•
specimen identification
•
specimen transfer from the sterile field
•
specimen labeling on and off the sterile field
•
chain of custody for the specimen, including any differences between private vs.
contracted cases
•
documentation including laboratory requisition, health care record, chain of
custody, verbal/written communication
•
verification of correct information before transferring the specimen (e.g. specimen
type, patient information)
•
storage and maintenance of specimens until transfer
•
transfer or facilitation of transfer of the specimen for examination including name
and address of receiving laboratory
•
contact information for the laboratory should specimen handling questions arise
•
responsibility for ensuring that reports are received by the appropriate individuals
•
reporting and responding to specimen handling errors and near misses
SPECIMEN HANDLING
ACCREDITATION STANDARDS
Patient Safety
 Procedures for the safe and appropriate handling of specimens are followed
 Staff are educated regarding the safe and appropriate handling of specimens at orientation,
annually and when policy and procedures are updated
Specimen collection procedures ensure patient identification and specimen
quality
INDICATORS:
 Specimen collection and handling needs are verified prior to procedure start
 Collection containers are of an adequate size to easily contain a specimen
 A separate container is provided for each specimen as appropriate
 Specimens are handed off the sterile field as soon as possible
 Specimen containers are labeled immediately when a specimen is delivered to any container
or contained area on or off the sterile field
 Specimen identity and required testing is confirmed with the surgeon
 Specimens are sequentially numbered as appropriate
 Fixative/preservatives are stored and handled in a safe manner
 Appropriate fixative/preservatives are added to the specimen container
 Specimen labeling includes but is not limited to:
•
patient identification using a minimum of two identifiers
•
specimen type and site/source, as appropriate
•
date and time of collection
•
sequential number, as appropriate
•
fixative/preservative hazard label, as appropriate
•
biohazard label, as appropriate
 A complete, accurate and legible requisition accompanies the specimen
 Requisition identifiers match the specimen and health care record identifiers
Specimen collection and chain of custody is appropriately documented
INDICATORS:
 Specimens are accurately and legibly labeled at each step of the process
 Type/source and number of specimens sent to the lab are documented in the health care
record
 Chain of custody is kept as simple as possible in order to limit the number of specimen
handoffs
NHMSFP – College of Physicians and Surgeons of British Columbia
November 2011
Page 2 of 4
SPECIMEN HANDLING
ACCREDITATION STANDARDS
Patient Safety
 A log tracking specimens from the OR to the laboratory is maintained and includes but is not
limited to:
•
patient identification
•
specimen type and site/source, as appropriate
•
date and time of specimen log in
•
name of each surgical team member involved in specimen handling
•
name and signature of person sending the specimen
•
time of transfer of specimen to laboratory
•
name of laboratory receiving the specimen
•
name of person in lab receiving the specimen
Specimen transportation procedures ensure specimen quality and integrity
INDICATORS:
 Specimens are held and transported at appropriate temperatures
 Acceptable time limits between collection and delivery to a laboratory are established
 The responsibility for delivery of specimens to the laboratory is clearly defined
 Transportation is in compliance with the Transportation of Dangerous Goods Regulations
and other legislation
 Courier systems, if used, are monitored to ensure staff and appropriate transportation and
delivery
Specimen results are reviewed
INDICATORS:
 Reports are received by the appropriate individuals
 An audit process is in place to ensure the receipt of reports
 Reports are reviewed by the appropriate individuals
 Patients are notified of specimen results as appropriate
NHMSFP – College of Physicians and Surgeons of British Columbia
November 2011
Page 3 of 4
SPECIMEN HANDLING
ACCREDITATION STANDARDS
Patient Safety
REFERENCES
AORN guidance statement: safe specimen identification, collection, and handling in
perioperative practice settings. AORN Journal. 2004;80(4):734-6.
Association of Surgical Technologists. 7 Steps to effective specimen handling. Outpatient Surgery
Magazine – News August 2011 [Internet]. 2011 Aug 26 [cited 2012 Feb 2]. Available from:
http://www.outpatientsurgery.net/news/2011/08/20-7-Steps-to-Effective-Specimen-Handling
Diagnostic Accreditation Program; College of Physicians and Surgeons of British Columbia.
Laboratory medicine anatomic pathology accreditation standards 2010 [Internet]. Vancouver:
Diagnostic Accreditation Program; 2010 [cited 2012 Feb2]. Available online:
http://www.dap.org/CmsFiles/file/2010%20Laboratory%20Medicine%20Accreditation%20Stand
ards/Anatomic%20Pathology%20updated%208%20Sep%2011.pdf
LifeLabs. Histology specimen handling & collection instructions [Internet]. Toronto: LifeLabs;
2010 [cited 2012 Feb 2]. Available from:
http://www.lifelabs.com/files/Ontario_QRA_files/Specimen_HandlingCollection/08_HISTOPATHOLOGY_-_SPECIMEN_HANDLING___COLLECTION_INSTRUCTIONS.pdf
Operating Room Nurses Association of Canada (ORNAC). Standards guidelines and position
statements for perioperative registered nursing practice.10th ed. Halifax: ORNAC; 2011. Section
3: Safety/Risk prevention and management - Specimen management; p. 190-2.
National Cancer Institute. Laboratory of pathology online policy manual [Internet]. Bethesda,
MD: National Cancer Institute; 2009 [cited 2012 Feb 2]. Available from:
http://home.ccr.cancer.gov/LOP/intranet/PolicyManual/SpecimenCollection/specimenhand.asp
Taking steps to protect patients from specimen-handling errors. OR Manager. 2008;24(12):1-3.
Watson DS, Crum BSG. Patient safety first. Improving specimen practices to reduce errors. AORN
Journal. 2005;82(6):1051, 1053-4.
NHMSFP – College of Physicians and Surgeons of British Columbia
November 2011
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