1 Specimen Identification and Labeling

Why identification matters

Accurate specimen identification connects a laboratory result to the correct patient. Identification or labeling errors can lead to incorrect results, delayed care, or treatment of the wrong person. Follow the laboratory’s current procedure and the test-specific collection instructions because requirements may differ by specimen and test.

Specimen types and preparation

A Specimen is material collected for examination. Common types include:

• Blood: whole blood, plasma, or serum collected in a tube appropriate for the test.

• Urine: a single void, clean-catch sample, or timed collection.

• Stool: collected in the specified container, without contamination from urine or toilet water when the test instructions require it.

• Respiratory specimens: sputum or a nasal or throat swab.

• Other specimens: tissue, cells, body fluids, and swabs from specific anatomical sites.

The requested test determines the appropriate container, additive or transport medium, amount, collection method, and handling conditions. Confirm these requirements before collection.

Identification and labeling workflow

Use the laboratory’s current procedure and the test-specific instructions throughout the process. Confirm the requested tests, specimen type and source, container, required volume, timing, and any special handling before collecting.

Ask the patient to state identifying information when possible, then compare it with the order and wristband or approved record. Use at least Two person-specific identifiers, such as name and medical record number or date of birth. A room number or location is not an identifier.

Collect using the correct method and container. Keep specimens separate and prevent contamination or mix-ups. Label each container immediately after collection and in the patient’s presence; match the label to the patient and order before leaving the collection area. Do not collect specimens from several patients and label them later. Pre-labeling blood tubes before seeing the patient and matching them afterward is not acceptable under Joint Commission guidance.

Before transport, check that the container label agrees with the accompanying order or requisition. Package and transport specimens according to laboratory instructions. If a portion is transferred, keep each Aliquot traceable to the original specimen.

At receipt, check identity, specimen type, container, amount, condition, and required timing or temperature before processing. Laboratory policy determines whether a specimen can be accepted, corrected through an approved process, or must be rejected.

Label content and placement

Use the facility-approved label and procedure. A specimen label commonly includes the patient’s name and a unique identifier, collection date and time, and collector identification. Include the specimen source or other details when required by the test or local policy.

Place the label on the container itself, not only on the lid. Keep it readable and scannable: do not cover important markings, obscure the specimen, or wrap the label so tightly that it cannot be read. Label each container separately when one patient has multiple containers, and identify the source when needed. Keep labels and orders clearly matched throughout processing.

Errors and discrepancy response

Common errors include:

• Wrong patient: the identifiers on the label do not match the patient or order.

• Missing or inadequate identifiers: one or more required identifiers are absent, incomplete, or illegible.

• Unlabeled or mislabeled specimen: the container has no label, has conflicting labels, or bears a label belonging to another patient.

• Label applied too early or later from memory: the specimen is separated from the patient before its identity is securely confirmed.

• Incorrect collection details: the date or time, specimen type, or anatomical source is wrong.

• Labeling only the cap: the container can become separated from its identity if the cap is removed or exchanged.

• Container and paperwork mismatch: the label and order or requisition describe different patients or specimens.

Do not guess, overwrite conflicting identifiers, or relabel a specimen based only on an assumption. Secure it, follow the organization’s discrepancy procedure, and contact the appropriate laboratory or clinical staff. Written laboratory criteria govern how unlabeled, mislabeled, or otherwise unacceptable specimens are handled; recollection may be necessary.