Specimen and sample collection is a routine and essential part of medical care, allowing for laboratory analysis to inform diagnosis, treatment, and monitoring of medical conditions. However, errors during specimen and sample collection, including labelling, can cause delays in the processing of tests and, if not recognised, can lead to the issue of incorrect results, diagnostic error, delayed or incorrect treatment or transfusion of incompatible blood. These errors have the potential to place service users at the risk of significant delays, errors and harm in their care and treatment.

Incidents relating to the specimen/sample collection process reported on NIMS, the National Incident Management System, include:

• mislabeling, where the service user’s identification is incorrect or there is labelling with another service user’s details
• incidents when the specimen or sample is not labelled
• non-compliance with policies and procedures whereby not all unique service user identifiers (full name, date of birth, medical record number) are present or when testing laboratory requirements are not met
• incidents where the incorrect type of sample/specimen container/tube is used
• incidents where the specimen/sample is taken from the wrong patient

Risk considerations

A number of risk factors have been identified, which may contribute to the occurrence of incorrect specimen/sample collection and labelling:

• Lack of positive service user/patient identification while taking the sample
• Specimen/sample not labelled at the service user’s bedside or place of collection
• Addressograph stickers/chart confused with another service user’s
• Failure to check or change incorrect details on identification wristband
• No wristband present
• Service user’s details on specimen/sample not cross checked with accompanying paperwork or referral forms
• Maternal and baby samples confused
• Obscuring service user’s addressograph on the specimen with barcode/other sticker
• Use of pre-labelled specimen containers resulting in wrong service user details for the specimen collected
• Distractions or interruptions during the labelling process

How to reduce the risk of specimen/sample collection errors

• Ensure uninterrupted collection and labelling of specimens/samples as one continuum at the service user’s bedside or place of collection^1,2
• Ensure positive patient identification by confirming identification on service user’s wristband and asking service user to confirm their details¹
• Check that the service user details on the specimen/sample match the details on the referral/request form³
• Implement point-of-care-testing barcoding systems where available⁴
• Optimise availability of appropriate equipment used in sample labelling (label printers, computer terminals)¹
• Consult with testing laboratory policy or guidelines on the acceptance and rejection of specimen samples, on minimum requirements for collection and acceptable labelling criteria
• Undertake training to ensure awareness of risks associated with labelling errors, in particular with healthcare professionals responsible for taking specimens/samples

References available on request.

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