The purpose of this guideline is to provide guidance about blood tests at Great Ormond Street Hospital (GOSH).
Mislabelled/unlabelled samples cannot be processed by the laboratories (Rationale 1).
Process for taking and labelling all patient samples
Tests must be requested on the appropriate electronic requesting system, which will generate an appropriate request form. It will also indicate any special requirements (e.g. timing/transport) of samples. Care must be taken to adhere to these (Rationale 2).
Clinical details must be included on all requests (Rationale 3).
In the event of the electronic requesting system being down, handwritten "downtime" forms must be used.
If tests are being undertaken on a relative (for example mum, dad, sibling) they must be registered on PIMS and electronic requests made as for patients. Full name and DOB must be used on forms (Not “mother of”). It is NEVER acceptable to use patient forms/stickers with the name changed (Rationale 4).
The completed request form must be taken to the patient and checked against the wristband or other suitable identification (a verbal check of name and DOB may be used for parents/siblings) (Rationale 5).
Sample collection and labelling
All equipment, unlabelled tubes a pen and forms must be taken to the patient’s side.
Use of Trust standard equipment is best practice; for Great Ormond Street Trust, the current standard equipment is the S-Monovette® System (Rationale 6).
For blood samples, samples must be drawn/put into bottles in the correct order (Rationale 7)
GOSH order of draw for the S-Monovette® System
|Order of draw / Collection sequence|
|2||Brown||Serum gel||Biochemistry, Immunology, Microbiology and Virology|
|4||Orange||Lithium heparin||Biochemistry, Immunology and Microbiology assay|
|5||Red||EDTA||Biochemistry, Haematology, Immunology, Microbiology PCR and Virology PCR|
|6||Blue||EDTA for blood transfusion||Blood Transfusion – Blood group and crossmatch|
|7||Yellow||Sodium fluoride||Biochemistry – Glucose and lactate|
Bottles must be labelled immediately after filling and at the patient’s side (Rationale 8).
Electronically generated sticky labels from PIMS can be used for all samples EXCEPT Blood Transfusion. If electronically generated labels are not available at the time of blood draw, tubes must be labelled immediately at the patient’s side with a pen (Rationale 9).
Blood Transfusion samples should be labelled as follows:
a) With blood track labels created by scanning the ID badge of the phlebotomist and the barcode from the wristband, using the handheld Blood Tracking device with an attached printer. Wristband MUST be attached to patient except for agreed exceptions e.g. photo ID.
Attach the label, ensuring that there is a clear view of the blood level in the bottle.
b) If blood track is unavailable or the phlebotomist is not trained to use the device, the label on the sample bottle must be handwritten and signed by the phlebotomist. It is not acceptable to use the ID badge of another member of staff.
For all first time GOSH patients requiring a transfusion of any component, (if method b) is employed, a second SEPARATE sample will be required for Blood Group confirmation. Ideally the confirmatory sample should be taken by a different phlebotomist and at least 10 minutes after the first sample to ensure that positive patient identification is completed accurately. (Rationale 10):
If forms cannot be taken into a room (e.g. for infection control reasons), the blood bottles should be labelled by hand with cross-reference to the patient’s identification wristband before leaving the room (Rationale 8). Aseptic non touch technique should be used at all times and appropriate infection control measures should be taken for blood track device and printer when taking blood transfusion samples.
Minimum labelling requirements are (Rationale 11):
• hospital number
• NHS number where available or private patient number (PX private patient number CANNOT be used instead of a hospital number for blood transfusion purposes)
• date of birth
• first name
• date/time of sample
• signature of phlebotomist if not using blood track handheld device (for blood transfusion)
Several systems rely upon the GOS Hospital Number for clinical care, including Blood Tracking system. For the safety of patients it is therefore essential that the Hospital Number appears on private patients’ wristbands – in addition to the PX number. Therefore, please add the following step whenever printing a wristband for a private patient: On PiMS Under ‘Patient ID’ in the ‘Print Document’ box, please change the default ‘Use private patient number’ to ‘Use main hospital number’ every time.
• label bottles prior to venesection
• label or sign a sample or form for someone else
• leave unlabelled samples lying around
• label samples away from the patient
• lend your ID badge to anyone for use in blood track
Samples will be accepted without a hospital number if the patient has not been registered on PIMS/ electronic ordering system (e.g. parent, emergency) but only if all other details (see above) are complete (this does not apply for blood transfusion).
High risk samples* must be labelled appropriately using a yellow “biohazard” sticker.
‘High Risk’ samples are those which are suspected of containing a hazard group 3 or 4 pathogen.
• Hepatitis B
• Hepatitis C
• multi drug resistant tuberculosis
All samples must be sent to the laboratory in a suitable specimen bag with the form separate from the sample.
Ensure sample lids are tightly secured before sending. Samples which have leaked in transit may be discarded.
Rationale 1: Errors in requesting, inadequate patient identification and incorrect sample labelling can lead to significant risk to patients. This guideline details best practice in this area.
Rationale 2: To ensure correct samples are obtained and necessary details are included in test request.
Rationale 3: Inadequate details may result in inappropriate tests being done.
Rationale 4: Samples arriving in the lab with altered patient PIMS forms/stickers will not be processed.
Rationale 5: Positive patient identification is ESSENTIAL.
Rationale 6: For staff safety.
Rationale 7: To avoid cross contamination which can lead to erroneous results.
Rationale 8: To avoid wrongly/unlabelled samples being sent to lab.
Rationale 9: To ensure correct identification of samples.
Rationale 10: To comply with BCSH Guidelines (2012) to prevent wrong blood in tube events which could lead to ABO incompatible transfusion.
Rationale 11: Unlabeled samples will be discarded, the appropriate ward/doctor telephoned and an incident form completed. Inadequately/wrongly labeled samples may be accepted (if the discrepancy can be adequately explained) following consultation with the clinical team, but the laboratories reserve the right to discard the sample if there is any suspicion (are not convinced) that the correct patient has been sampled (Blood transfusion operate a zero tolerance policy for labelling and inadequately/wrongly labelled samples cannot be accepted under ANY circumstances)
British Committee for Standards in Haematology (November 2012) Guidelines for pre-transfusion compatibility procedures in Blood Transfusion laboratories. [Last accessed 25/11/15]
Advisory Committee on Dangerous Pathogens (2012) Protection against blood-borne infections in the workplace: HIV and hepatitis. London, HMSO. [last accessed 25/11/15]
British Committee for Standards in Haematology (December 2009). Guideline on the administration of blood components. [Last accessed 2/11/15]
GOSH (2014) Blood sampling from central venous access devices (CVADs) Clinical Guideline. London, Great Ormond Street Hospital
GOSH (2015) Aseptic non touch technique (ANTT®) for intravenous therapy Clinical Guideline. London, Great Ormond Street Hospital
Health Advisory Committee (2003) Safe working and the prevention of infection in clinical laboratories. London, HMSO
McCelland DBL (2013) Handbook of Transfusion Medicine (5th edition). London, HMSO
NICE Clinical Guidelines (2011) Tuberculosis: Clinical diagnosis and management of tuberculosis, and measures for its prevention and control. Manchester, NICE
Thomas D (chair) (2015) SHOT Annual Report 2014. Published July 2015. London, SHOT Steering Group