LABORATORY SPECIMEN RECEIVING, HANDLING, & … · (Swabs, Urine and Pap Smear ) samples, CBC,PT,...

LABORATORY SPECIMEN RECEIVING, HANDLING, &

TRANSPORTATION SOP

2019- 2021

PREPARED BY: AMNA ABDULLA M A RAEISSI- SENIOR LAB TECHNOLOGIST II REVIEWED BY: AMAL HUSSAIN ATEF- SENIOR LAB TECHNOLOGIST II

APPROVED BY: DR. ABUL JALALUDDIN BHUIYAN – HEAD OF SECTION

Updated on 13th – January - 2019

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I: SPECIMEN HANDLING AND RECEIVING :

1. PURPOSE:

1.1 The objective of this Standard Operating Procedure (SOP) is to describe

the necessary stepwise procedures relevant to receiving , handling and

transporting of specimens submitted to the Central Specimen Receiving &

Processing ( CSRP) in the Department of Laboratory Medicine and Pathology

(DLMP) located at Qatar Rehabilitation Institutes ( QRI) from all HMC internal

and external outside clients.

2. Acronym list:

QRI Qatar Rehabilitation Institutes

ACC Ambulatory Care Center

WWRC Women's Wellness and Research Centre

RRCL Rapid Response Core lab

PHCC Primary Health Care Corporation

NCCCR National Center for Cancer Care and Research

AWH Al-Wakra Hospital

AKH Al-Khor Hospital

PEC Pediatric Emergency Center

CDC Communicable Disease Center

HGH Hamad General Hospital

CCL Clinical Core Laboratory

HMGH Hazm Mebaireek General Hospital

CSRP Central Specimen, Receiving & Processing

HBK-CP Hamad Bin Khalifa- Central Processing ( Cerner encounter)

PTS Pneumatic Tubing System

3. DOCUMENTATION:

3.1 As per DLMP policies and procedures.

3.2 As per HMC corporate policies.

3.3 Rejection Sheet.

3.4 Labeling Irretrievable Specimen sheet as required

3.5 log book using only when QRI-CP received Histopathology, Non Blood

(Swabs, Urine and Pap Smear ) samples, CBC,PT, PTT(STAT samples) from

Inpatient (QRI,WWRC,ACC) and Outpatient.

3.6 Cerner Samples-Transfer List: Laboratory specimens send along with

transfer list from QRI CSRP for satellite laboratories: vice-versa from other

hospitals and PHCCs.

3.6.1 Virology & Molecular Biology lab

3.6.2 Immunology & Histocompatibility lab

3.6.3 TB Lab.

3.6.4 Metabolic Lab.

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3.6.5 Special Chemistry lab

3.6.6 Microbiology lab

3.6.7 Cytopathology lab

3.6.8 Histopathology lab

3.6.9 Al-Khor Microbiology Lab

3.6.10 Al-Wakra Laboratory.

3.6.11 NCCCR Flow cytometry Lab.

3.6.12 Hazm Mebaireek General Hospital

3.6.13 Primary Health Care Corporation

3.6.14 Pediatric Emergency Center Al Sadd & Al Rayan

4. SPECIMEN REQUIREMENTS

4.1 Handling and transportation of specimens should be by the Infection Control

standards of Practice, with particular reference of categories of Isolation

precautions as specified in Policy CL 7233.

4.2 The Central Specimen Receiving and Processing (CSRP) at Qatar

Rehabilitation Institute (QRI) located on the third floor 24hrs/ 7 days.

4.3 Each Specimen must be among an electronic order or paper request form.

5. EVENTUAL PROBLEMS OR PITFALLS:

5.1Specimens delivered to the Central Specimen Receiving and Processing

(CSRP) are rejected on rejection form and cancel it in the system. for

the following reasons:

5.1.1 Unlabeled or mismatched patient identification label.

5.1.2 Request form or Label with insufficient information.

5.1.3 Request form has no physician stamp and/or signature.

5.1.4 Request form received with no mark on the required test.

5.1.5 Wrong tubes or container.

5.1.6 Unspecific tests names mentioned in the request form.

5.1.7 Leaking or contaminated specimen.

5.1.8 Wrong request.

5.1.9 Request form received without specimens and vice versa.

5.1.10 Test requested is not available.

5.1.11 Incomplete information on Cerner specimen labels.

5.1.12 Receiving more than a single specimen in one biohazards bag.

5.1.13 Wrong Encounter, canceled order specimens, Wrong order by

physician & Stickers of completed orders.

5.1.14 Specimens with “dispatch” statues should be corrected by contacting

the Specimens’ collector to the log-in specimen on site.

5.1.15 Receiving one sample with more than one accession number.

5.1.16 Request form without date and time of collection.

5.1.17 Blood Bank Specimens delivered to the Central Specimen Receiving and

Processing (CSRP) are rejected on rejection paper base form:

5.1.17.1 Incomplete/Missing name/letters/sticker

5.1.17.2 No Clinical Data/ Diagnosis

5.1.17.3 No Doctors signature

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5.1.17.4 No location, no telephone number

5.1.17.5 Missing of any one of the three copies of Blood Bank request

form.

5.2 Specimen labeling correction – Irretrievable specimen

5.2.1 Under normal circumstances, the DLMP does not correct any

information on the specimen label and rejects every specimen that is not

correctly labeled.

5.2.2 In cases where a mislabeled or unlabeled specimen is irretrievable or

where recollection would jeopardize patient care (e.g. invasively

collected samples, intra-operative samples, timed samples, etc.) AND

the specimen itself can be identified with reasonable certainty;

exceptions to the above policy may be made.

5.2.3 These decisions for exception will be made on a case-by-case basis

under the responsibility of the Laboratory Director/designee, or the

Pathologist on call.

5.2.4 In cases where the sub-optimal specimen is approved for testing, the

patient’s physician or Nurse In-Charge MUST accept responsibility in

writing for the identification of the specimen being processed.

(Appendix A: Form to Verify the Accuracy of Information of

Irretrievable Specimen)

5.2.5 In case of the irretrievable specimen, the test result will carry the

following notation: “Specimen received with inadequate or discrepant

label information, testing approved by a “healthcare provider.”

5.2.6 The irretrievable specimen may include but are not limited to:

5.2.6.1 Bone marrow

5.2.6.2 Tissue

5.2.6.3 Cerebrospinal fluid (CSF)

5.2.6.4 Stones

5.2.6.5 Amniotic Fluid

5.2.6.6 Autopsy

5.2.6.7 Blood Spots (SNS Cards or Postmortem Cards)

5.2.6.8 Body Fluids

5.2.6.9 Neonatal

5.2.6.10 Blood Gas (ABG)

5.2.6.11 Blood, Spleen and/or lymph node samples from deceased

Donor.

5.2.7 If relabeling allowed, the collector is required to attend specimen

reclaiming area and relabel samples filling the (Labeling of Irretrievable

Specimens-form). Appendix .4.

5.3. How to report specimen rejections:

5.3.1 For inpatients, the laboratory staff, shall inform the Head

Nurse/Charge Nurse/Staff Nurse of the unit of the reason for rejection as

soon as possible, who shall notify the requesting physician, and a new

specimen shall be ordered and collected if needed.

5.3.2 For outpatients CSRP technical staff inform phlebotomist, then

phlebotomists / Lab Technicians shall be informed who in turn will

inform the ordering physician about the rejection and make the

arrangement for recollection.

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5.3.3 All rejections and communications must be documented. Report

incidents an electronic “Occurrence Variance Report” OVA must be

initiated with 24 hours.

6. STEP BY STEP PROCEDURE;

6.1 Specimens with Non-Electronic Lab Orders

6.1.1 Specimens are received in a rack or biohazard plastic bag in a

transportation box accompanied by a request form.

6.1.2 The specimen receiving staff receives the specimen and checks for

any leakage.

6.1.3 The specimen receiving staff placed the specimen at the assigned

racks

6.1.4 Check specimen label against the request form. The request form

should be fully completed with the following information:

6.1.4.1 Patient’s full name and HC number.

6.1.4.2 Patient’s date of birth and sex.

6.1.4.3 Date and time of collection.

6.1.4.4 Type of samples or specimen.

6.1.4.5 Location addresses and contact details.

6.1.4.6 Adequate clinical data.

6.1.4.7 Test required.

6.1.4.8 Physician stamp.

6.1.4.9 Identification of specimen for STAT

tests

6.1.4.10 Collector initial (Name & corporation

number – or signature).

6.1.4.11 Timestamp the received request forms.

6.1.4.12 Specimen registration at CSRP by

clerical staff as (table.1)

6.1.4.13 Technical Staff at CSRP must verify the

patient information and the requested test

before labeling the sample.

Laboratory Section

Registration time

during working

hours

After Working

hours / Weekends Storage/handling

CCL specimens From

7:00am-5:00pm

After 5:00 pm done

by CCL special

Handling bench for

Chemistry samples.

Hematology

samples registered

in hematology lab.

NA

Virology specimens

From 7:00am-

5:00pm

log-in as ( HBKCP)

At CSRP, at 2-8C

For the next day

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Microbiology

specimens

From 7:00am-

5:00pm

log-in as ( HBKCP)

Urgent specimens

sent to HG Micro.

Routine specimens: at

CSRP, at 2-8C

For the next day

Immunology and

Histocompatibility

specimens

From 7:00am-

5:00pm

log-in as ( HBKCP)

At CSRP, at 2-8C

For the next day

Lymphocyte

specimen stored at

room temperature.

Molecular Biology

specimens Send to Virology lab at Medical City for registration

Molecular Genetic,

Cytogentic, and

Cytopathology

From Sunday to Thursday after 2:30 PM store the samples at CSRP

fridge2-8C.

Friday & Saturday store the samples at CSRP fridge2-8C.

Special Chemistry

From Sunday to Thursday after 2:30 PM the samples store at CSRP

fridge2-8C.

Friday and Saturday after 12:30 PM the samples store at CSRP

fridge2-8C.

TB


fridge2-8C.

Friday and Saturday after 1:30 PM the samples store at CSRP

fridge2-8C.

Histopathology


fridge2-8C.

Friday and Saturday sample will be sent according to the availability

of Histopathology staff.

Table 1 Specimen Registration

Note: Registration at CSRP Sunday to Thursday from 7:00AM-5:00PM and Saturday

from 7:00AM-3:00PM by clerical staff. On Friday the registration done by CSRP

technical staff only for STAT Chemistry samples.

6.1.5 Arrange all specimens in the proper racks and send to the designated

section.

6.1.6 STAT Samples from Phlebotomy Labs at QRI, ACC, and WWRC

specimens sent immediately by Lab aide or PTS to CSRP.

6.1.7 The minimum requirements for the specimen labeling of specimens

received from outside organizations which need to be processed in HMC

DLMP and/or to be sent out to referral labs are the following:

6.1.7.1 Patient Name

6.1.7.2 Qatar ID. No / Passport

6.1.7.3 Date of birth

6.1.7.4 Medical records (MR) number (as applicable)

6.1.7.5 Date and Time of specimen collection.

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6.2 Electronic System (Cerner):

6.2.1 Check the Cerner specimen label if the test and sample are matching

with the container/Tube

6.2.2 Specimens build for CCL lab has (HBKCCL) log-in encounter.

6.2.3 In case of a different encounter, do below steps:

Figure 1. Log-in encounters

6.2.4 Log- in specimens:

6.2.5 Create Transfer List for satellites labs along with sending specimens. The list

must be signed by the receiver with date, time, and initial.

6.3 Exceptions for Laboratory Sections:

6.3.1 Special Chemistry Lab:

6.3.1.1 All specimens received from Sunday – Thursday after working

hours 2:00PM and weekends after 12:30PM stored in CSRP at (2-

8◦C) till the next day, then will be sent to Special Chemistry Lab.

6.3.2 Microbiology Lab:

6.3.2.1 Specimens sent every one hour with a transfer list to

Microbiology Lab at HGH. STAT specimen must send

Specimens from HGH Rapid

Response Core Lab (RRCL)

Re-Routing Specimens

Specimens from Cuban - PHCC

Re-Order Lab Test Sent to other facility

Specimens for: AWH – AKH -

NCCCR

If Not HBKCCL log-in encounter

Figure 2. Log-in at CCL types

Specimen Login at CCL

Auto-login

All blood samples

Manual log-in

Microtainer-QFT-in ice tubes- protect from light(Vitamin A&E)-zink-copper-

Gray- Non programmed tubes-All fluids

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immediately ex. CSF, Body Fluids, Eye swab (below 1

month).

6.3.2.2 QRI CP send transfer list along with samples, in order to

keep a track / record of the receipt and delivery of samples

between both sites, which will be handed over in the next

trip. Transfer list must be signed by Microbiology technical

staff with:

6.3.2.2.1 Name

6.3.2.2.2 Signature

6.3.2.2.3 Corporation number

6.3.2.2.4 Date

6.3.2.2.5 Time

6.3.2.2. Outside clients’ specimens send to AKH for registration and

processing, except Fungal test will send to HG Microbiology Lab.

6.3.3 Blood Bank Lab:

6.3.3.1 Specimens from HGH inpatient, HGH OPD labs, Private Hospitals

sending directly to HGH Blood Bank Lab.

6.3.3.2 Specimens received at CSRP –CCL from PHCC, and Non-HMC

Clients’ must be received at CSRP and sent to HGH Blood Bank Lab after

time-stamping on the request forms.

6.3.3.3 Specimens received from QRI, ACC, WWRC locations received at

CSRP, then sent directly to QRI-Blood Bank.

6.3.4 Histopathology Lab:

6.3.4.1 CSRP –CCL received Histopathology samples for 24 hours from

QRI, WWRC, ACC, and outside clients up to 3:00 PM, from Sunday to

Thursday.

6.3.4.2 On weekends, specimens logged at CSRP upon receiving then

stored at CSRP at (2-8◦C). The sample will be sent on Sunday at 7:00

AM- 2:30 PM to HGH Histo.

6.3.4.3 Histopathology specimens with (Fresh or Normal saline) must be stored

at CSRP, in (2-8◦C), and contact Histopathology Lab on-call staff.

6.3.4.4 Frozen sections delivered directly to HGH Histopathology Laboratory.

6.3.4.5 Friday and Saturday sample will be sent according to the availability of

Histopathology staff.

6.3.5 Molecular Biology / Virology Lab:

6.3.5.1 During working days Blood specimens received after 1:30 PM must

be stored at CSRP, till next day morning will be sent by the driver.

6.3.5.2 Respiratory and CSF samples must be stored in the CSRP

refrigerator after 8:00 PM.

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6.3.6 Diagnostic Genetic Division (DGD):

3.6.6.1 Specimens sent to DGD lab from 7:00 AM to 2:30 PM from Sunday to

Thursday.

3.6.6.2 After 2:30 PM and during weekends, samples are stored at CSRP at 2-8◦C

till next day morning

3.6.6.3 Bone Marrow samples from (NCCCR) ONCP must be delivered directly

from ONCP to Cytogenetics Lab.

6.3.7. Cytopathology Lab:

6.3.7.1 All Cytopathology samples receive at CSRP should log-in and forward

to Cytopathology lab along with Transfer list.

6.3.7.2 Specimens received after 2:00 pm must be stored in CSRP, at 2-8

C.

6.3.7.3 For CSF and stat samples received at CSRP after 2:00 PM; CSRP

staff should inform the Cytopathology lab to decide to send or to store the

sample to the next day.

6.3.8 Immunology and Histocompatibility Lab:

6.3.8.1 Samples received after 2:30 pm must be stored in CSRP until 07:00 AM

the next day.

6.3.8.2 Quantiferon (QFT) samples are received only from Sunday to Wednesday from

7:00 AM 3:00 PM. After 3:00 PM, contact immunology lab, to confirm receiving of the

specimens before sending.

6.3.9 Metabolic Lab samples:

6.3.9.1 Metabolic lab’s Lab Aid received Guthrie Cards for Newborn

screenings at CSRP from Sunday to Thursday & Saturday at 7:00AM-

8:00AM and 10:00AM-11:00AM.

6.3.9.2 Any Guthrie Cards for Newborn screenings received in the afternoon,

night and weekends are kept in metabolic lab tray at CSRP at room temperature for

the next day.

6.3.9.3 For Stat samples must contact technician On Call from Metabolic Lab.

6.3.9.4 Amino Acid samples sent to Metabolic Lab from Saturday to Thursday up to

02:30 PM. Any samples received after 2:30 PM should be sent to the Special

Handling Bench for centrifuging and storing the samples until next day morning.

6.3.10. Referral Lab. Specimens:

6.3.10.1 Receiving and log-in the specimens at CSRP from 7:00AM-2:30

PM at CSRP.

6.3.10.2 Specimens received after 2:30 PM, which needs to be centrifuged

are forwarded to the Special Handling Bench.

6.3.10.3 After 2:30 PM Specimens are stored in CSRP refrigerator or Freezer

until next day.

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6.3.11 Premarital samples:

6.3.11.1 Molecular Genetic samples: Premarital samples send directly

from Health Centers to Molecular Genetic lab except after 3:00 PM stored

at CSRP refrigerator 2-8◦C.

6.3.12. TB samples:

6.3.12.1 All TB samples are received at CSRP and logged in manually up to

2:00 PM.

6.3.12.2 After 2:00 PM samples are received at CSRP, logged in and stored at

CSRP refrigerator. Next day.

6.3.12.3 Non-Cerner Clients specimens send to TB lab to register and process

6.3.13. NCCCR-Flow Cytometry

5.3.13.1 Flow-Cytometry samples received at CSRP must be logged in

and prepared transfer list to NCCCR

6.3.14 Rapid Response Core Lab (RRCL) :

6.3.14.1 Blood Gas Specimens Venous Blood Gas received from OPD (QRI,

ACC, WWRC) must be delivered directly to the RRL lab

7 EVENTUAL SAFETY ISSUES;

7.1 All samples must be considered potential biohazards high risk, and universal

precaution should be taken while handling.

7.2 All individuals dealing with samples must be wearing Personal Protective

Equipment (PPE).

7.3 Smoking, eating, drinking and using make-up and mobile phones in the

technical work areas are strictly prohibited. Additionally, food must not be

stored in technical refrigerators and working area

7.4 Use of Laboratory coats is required. Sandals or shoes with open toes or negative

heels are not recommended.

7.5 Apply Hands Hygiene before and after removing gloves and before leaving the

Laboratory.

8 REFERENCES;

8.1 Policy CL 7067: Management of laboratory Specimens Policy.

8.2 Policy CL 7026: Patient Identification

8.3 College of American Pathologists (CAP) All Common Check List, Version

08.21.2017, 325 Waukegan Road, Northfield, IL 60093-2750

8.4 LIS_IM_002_045_000 Cerner Add an Encounter SOP.

8.5 LIS_IM_002_100_000 Cerner LIS department order entry Placing orders SO

9 APPENDIX;

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9.1 SPECIMEN LOG-IN PROCEDURE:

9.2 TRANSFER OF SPECIMENS CERNER STEPS

9.3 QRI WORKFLOW CASCADE FOR LABORATORY SPECIMENS:

9.4 FORM TO VERIFY THE ACCURACY OF INFORMATION OF

IRRETRIEVABLE SAMPLES.

9.5 SPECIMEN REGISTRATION STEPS AND HC NUMBER CREATION.

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APPENDIX 1: SPECIMEN LOG-IN PROCEDURE:

Click on log In specimen button.

Pathnet Collections Specimen Log-In window will appear. Press Retrieve

button.

Log-In by accession window will appear. Make sure that the specimen is

labeled correctly and the location is HG CP. Using a barcode reader, scan

the accession number of the specimen received.

Scan continuously the accession numbers of the specimens received. The

status of each sample should read as “collected.”

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Press the log in the button when scanning of all the received

specimens is completed.

Press the refresh button from the AppBar to clear the Log In

accession window.

Segregate and distribute the received specimens to differentiate sections for

processing.

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APPENDIX 2: TRANSFER OF SPECIMENS CERNER STEPS

1- Click on “Transfer Specimens and Click on New button

2- Scan Accession Number and after then Save button

3- Click On Transfer Window

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APPENDIX 3: QRI WORKFLOW CASCADE FOR LABORATORY SPECIMENS :

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APPENDIX 4: FORM TO VERIFY THE ACCURACY OF INFORMATION OF

IRRETRIEVABLE SAMPLES.

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APPENDIX5: SPECIMEN REGISTRATION STEPS AND HC NUMBER CREATION

01. Go to HICT Gate on the desktop

02. From Group list select “Cerner” Application

03. From Application list select “Cerner APPs”

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04. A new window opens. Log in by HMC user name and password

05. Click “App BAR”

06. Enter user name “HMC & user name and password’’

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07. Click on my experience user console

08. Select on MPI Supervisor & Save and then click on logout

09. Click Save Conversation Launcher minimizes then clicks on logout in display

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10. Double click on Add person then come display in person search chart,

11. The in-person search at the display

12. Type QID No/ Passport No you will find in display patient HC # If there is no HC #

Click on Add person.

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13. Select facility name as “HAMAD BIN KHALIFA MEDICAL CITY” then Click “ok”

then you can find display add person chart.

14. Type patient details (yellow cells are mandatory) then click “ok” you can find patient

HC# of the display then write the request form.

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II: SPECIMEN TRANSPORTATION:

1. PURPOSE:

1.1 The purpose of SOP is to explain how specimen transports with appropriate

safety, stability, integrity and packaging procedures suitable to specimen type

and distance.

2. PRINCIPLE:

2.1 The DLMP has a written procedure defining the criteria for packaging

and labeling the different type of specimen.

2.2 The DLMP packages and ships infectious material by applicable HMC, local,

and international regulations

2.3 Specimen must be handled the safely upright position in a rack and according to

applicable legal requirements or guidance

2.4 The transport box should be robust enough for its capacity and intended use,

and be made of a material that can be cleaned and disinfected.

2.5 The lid/cover of the transport box should be closed properly and securely

during transport.

2.6 Transport boxes must be handled gently with care during the whole transport

process. Throwing, dropping or dragging the transport boxes on the floor is

prohibited.

2.7 Specimens must be handled in a safe manner, upright position

2.8 Laboratory specimen transported via trained personnel, PTS, or vehicles.

2.9 Specimen should be transported at room temperature (20-25◦C) in a specimen

box, Which must be labeled outside as biohazard, with a fastened lid.

Use robust Thermo

Transport Container with

Biohazard label.

Upright position

PTS Capsule

Figure 3. Types of Specimen Transportation methods

3. Safety Guidelines During Transportation:

3.1 The DLMP ensures that the person who involved in the transportation of

laboratory specimens are trained on appropriate safety procedures suitable to

specimen type and transporting distances with an appropriately labeled

container with a secure lid to prevent leakage during transporting.

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3.2 All specimens must be secured in the appropriate specimen container; ensuring

that the lid of the container is properly closed and will not leak

3.3 Apply Safety standards during handling and transportation specimens

3.3.1 All carriers (Laboratory Aide) must wear their photo identification

badges and uniform.

3.3.2 Wear proper PPE when packaging for sending and specimen receiving.

3.3.3 Do not wear gloves in both hands considering the safe movement of the

public when transport specimen from specimen receiving to the laboratory

section and vice versa.

3.3.4 Do not touch door handles with gloves.

3.3.5 Do not use mobile while handling the specimens.

3.3.6 Working benches areas and transportation trolley must clean and

wipe the with 0.1% sodium hypochlorite solution before

starting and leave duty, and when needed.

3.3.7 Do not leave a box containing specimens in an unlocked car.

3.3.8 Drivers should not open the specimen transportation box.

3.3.9 Each vehicle must have contact device (mobile phone –

emergency contact numbers), hand rub dispenser, biological

skill kit, gloves, emergency outfit, temp monitoring

thermometer devices

3.3.10 Smoking and Eating are strictly forbidden in the car with or

without carrying sample boxes.

3.3.11 In the case of an accident, drivers must contact the specimen

transportation manager immediately.

3.3.12 In the case of blood spillage, follow the simple steps: S.P.I.L

procedure.

3.3.13 Report any incident to the supervisor or designee.

4. Temperature Monitoring

4.1 Pays specific attention to maintaining the temperature of the specimen according

to established protocols A Thermometer must be attached with the Thermo box

to monitor the temperature

4.2 Temperature monitoring system applied for specimen transportation boxes and

vehicles.

4.3 The temperature of the thermos box monitored for each trip by data loggers or

manually by drivers.

4.4 Manual Temperature recorders submitted to the transport manager on monthly

basis for review.

5. Specimen Tracking

5.1 The tracking system allows for documentation of time of dispatch and receipt, as

well as the condition of specimens upon receipt.

5.2 A transfer list (prepared by CSRP or other client or courier) with each batch of

client specimens, that checked against the specimens received by the

laboratory.

5.3 Log-sheet that records sending and receiving lab names, date and time to

calculate transit time, and driver's name with appropriate persons' signatures

(transfer list ID#)

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6. STEP BY STEP PROCEDURE;

6.1 Internal Specimen Transportation Procedure

6.1.1 Trained personnel transfers specimen from WWRC outpatient

Emergency Phlebotomy lab, QRI, ACC to CSRP at QRI.

6.1.2 Specimen received by PTS through capsule from QRI, ACC, &

WWRC locations to CSRP. Refer to policy PTS

6.1.3 Laboratory samples should be transported appropriately from CSRP

area to the concerned analytical Sections (QRI-Blood Bank, Molecular

and Cytogenetic (DGD) at QRI by laboratory Aide.

6.2 External Specimen Transportation Procedure:

6.2.1 External Specimen Transportation Service starts from QRI-CP, AWK

and AKH Area at 6:00AM

6.2.2 Drivers transfer Specimen from QRI-CP area to Virology &

Molecular Biology, Immunology and Histocompatibility,

Microbiology, RRCL, Cytopathology, Special Chemistry, Al Amal

Flow cytometry, TB, METABOLIC lab, HGH(Blood Bank) and

Referral lab.

6.2.3 Drivers transfer Specimen from PEC Al Sadd, Genetic Center

&SMC, and Psychiatry, OPD Annex, HGH (OPD), Al Amal

Hospital, FBJ, TB phlebotomy lab and RRCL.

6.2.4 Delivering special test samples of Al Khor and Al Wakra to Blood Bank

-HGH, collects samples from QRI-CP and then goes back to their

respective locations.

6.2.5 The driver assigned for AKH, collects Health Center urine and stool

samples from QRI-CP area and then returns back to Al Khor.

6.2.6 An out-sourced company leading the external transportation services

to all facility under HMC.

6.2.7 All drivers must be trained and competency assessment applied as

per DLMP policies.

6.2.8 Urine and stool samples for (H. pylori) for PHCC, transported

from CSRP to AKH.

6.2.9 External Specimen Transportation Service is 24hrs / 7 days :

Date Time slot *Number of vehicles

Sunday -Thursday 6:00AM-3:00PM 8

3:00PM-6:00PM 6

6:00PM-6:00AM 2

Weekend 6:00AM-6:00PM 3

6:00PM-6:00AM 2

Table 2. External Specimen Transportation Service Working hours

Total numbers of vehicles:

CSRP area 8 vehicles

Blood Bank lab 4 vehicles

Al Khor Lab 1vehicle

Al Wakra Lab 1vehicle

Total 14 vehicles

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*Numbers subject to changes according to services contracts.

6.2.10 AWH Histopathology samples are transported directly to AKH lab.

7. LIMITATIONS OF THE PROCEDURE;

7.1 Lack of thermo boxes or packaging box for specimen transportation

7.2 Lack of wireless Thermometers data loggers.

7.3 The uncontrolled temperature during summer time especially.

7.4 Increase the number of trips because of a sudden shortage of reagents,

pandemic, or holidays.

8. References:

8.1 Management of laboratory Specimens Policy CL 7067.

8.2 LMP_PM_001_001_000_02 Process Management

8.3 PCR_PS_001_000_000_01 Competency of Laboratory Services

8.4 PCR_PS_001_001_000_01 Laboratory Services Training and Competency

Program

8.5 CL 6064: PNEUMATIC TUBE SYSTEM (PTS).

8.6 CL 7026 Patient Identification.

8.7 CL 7067: MANAGEMENT OF LABORATORY SPECIMENS

8.8 OP 4070: REPORTING OF OCCURRENCES, VARIANCES AND ACCIDENTS.

8.9 College of American Pathologists (CAP) Laboratory General Check List, Version

08.22 .2018, 325 Waukegan Road, Northfield, IL 60093-2750.

9. Appendixes

9.1 Distribution Cascade for OPDs routine specimens

9.2 External Specimen Transportation Schedule

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Appendix 1 : Distribution Cascade for OPDs routine specimens

LABORATORY SPECIMEN RECEIVING, HANDLING, & … · (Swabs, Urine and Pap Smear ) samples, CBC,PT,...

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