Specimen acceptance policy: histology and cytology

Principles

This procedure represents the specimen acceptance criteria of the Department and supports the Directorate Specimen Acceptance Policy. It has been written to meet the CPA Standards for Medical Laboratories and ensure that all specimens received by the laboratory are correctly identified and are adequate for their purpose, and that appropriate reports are sent to the correct destination. Because of the critical role of histology reports, it is more stringent than the criteria in the other pathology disciplines.

We strongly advise against labelling batches of specimen pots for multiple patients in advance of a clinic: this creates a risk of putting the wrong specimen in the wrong pot. Please label each pot only as it is used. Although the labelling of pots and the writing of cards is often delegated, the primary responsibility for insuring that the information is correct is that of the practitioner who procures the specimen. If delegating, always check that the card and pot bear correct information before signing the card.

The WHO SURGICAL SAFETY CHECKLIST includes specimen labelling, stating "Incorrect labelling of pathological specimens is potentially disastrous for a patient and has been shown to be a frequent source of laboratory error."

Hospital Histology Specimens

BOTH the card and specimen container must have the following information:

• Surname
  

• Forename
  

• Date of birth
  

• Unique identifier (usually UR number or casualty number)
  

• Anatomical site of origin of the specimen: for multispecimen submissions, there should be a one-to-one correspondence between the list on the card and the details on the pots
  

• Type of biopsy

Specimens from the GUM clinic will be accepted if they are labelled with the GUM clinic number and date of birth.

The request card must also have:

• Consultant's name or code
  

• Location code or address code for the report destination
  

• Risk of infection status
  

• All relevant clinical information ( The Pathologist will judge this at cut-up )

If any of the above are missing or there is a discrepancy, the requesting Clinician will be contacted and asked to attend the laboratory to rectify the problem. Should the problem be unresolved after a week, the laboratory will instigate a HIRS report and the Pathologist will contact the requesting Clinician.

GP Histology Specimens

BOTH the card and specimen container must have the following information:

• Surname
  

• Forename
  

• Date of birth
  

• An additional identifier (NHS/Hospital number or a further identifier such as 1st line of address or post code)

The request card must also have:

• First line of patient's address or the post code
  

• GP code/Surgery for the report destination

Where any of the above information is missing, a slip highlighting the deficiency is filled in and the specimen and request card will be returned to the surgery via the HPA drivers. If the address and practice code is missing, the case will be passed to a senior member of the laboratory staff for investigation and action.

Cytology Specimens

The identification criteria are the same as those above. Given the nature of cytology specimens, in that they are unfixed, where there is sufficient information to match specimen to card, preparations should be made and stained. As with surgical specimens a photocopy of the form will be faxed to the appropriate clinic or ward. If the problem has not been rectified within a week, the case will be passed to the Pathologist to contact the requesting consultant. At this point the lab will generate a HIRS report.

For GPs, it is not feasible to return cytology specimens. In these instances a repeat will be requested with an accompanying explanation of the need for the repeat.