A Laboratory request received with inaccurate or incomplete data is a Clinical Governance issue.
The associated risks include:
- Incorrect results assigned to the wrong Patient.
- Multiple Patient records produced for a single Patient. This is extremely time consuming for reviewing Patient records, accordingly results may be missed.
- Patient results may be inadvertently merged to the wrong patient files.
- The ability to view cumulative reports is restricted with multiple files from the same patient.
Requests for laboratory analysis within NHS Lothian may be rejected if the specimen container or the request form does not comply with the Mandatory Data Requirements.
Inadequately or wrongly labelled test requests, which have a precious specimen element, will be referred through the Laboratories specimen rejection policy.
The MDS is comprised of the following data and must be supplied on all request forms:
- Patient Identification Number - CHI (Community Health Index)
- Patient’s Surname
- Patient’s Forename
- Date of Birth
- Requesting Location (Ward/Clinic/GP)
- Requesting Clinician and Clinical area (Pathology) If the CHI is unavailable then the MDS also includes:
- Postcode and/or
- First line of patient’s address
The request form should also list all tests required (see Test Directory), Time and Date sample was collected, and any relevant clinical details. However, for Virology, the request form does not need to request a specific test and virology will decide the appropriate test, within guidelines, if symptoms and date of onset are stated.
All Pathology samples require a completed request form with no exceptions
The following information should be used for sample labelling:
3. Date of Birth
4. Sample time and date
5. Specimen type and site of sampling (For Microbiology specimens)
6. Biopsy site on the sample which must match the request form (For Pathology samples)
Blood Transfusion has specific requirements for the labelling of samples and operates a zero tolerance policy for the acceptance of mislabeled specimens. For further information on these requirements, please refer to Group and Save in the Lab Medicine test directory.
The Mandatory Data Set Requirements states does not apply to anonymous samples. For example, anonymous samples from GUM, sperm donors, etc. as data such as CHI, Forename, Surname, and other data such as Postcode, will not be known.