Specimen Collection Checklist

Patient and Specimen Identification

• Two patient identifiers are verified verbally and/or against the wristband prior to collection to ensure accuracy.
• Patient wristband barcode scanning is used as an enhanced safety feature.
• Specimens are labeled in the presence of the patient.
• The specimen is matched to the order before leaving the bedside.
• Specimen label barcode scanning is used during collection for specimen verification.
• A protocol exists for handling identifier mismatches (patient and specimen).
• Misidentification events are reported promptly and reviewed for process improvements.

Timeliness of Specimen Collection 

• STAT collections are communicated to caregiver in real time to ensure prompt collection.
• STAT collections can be easily identified by the caregiver to ensure prompt collection.
• Timed draws can be easily identified by the caregiver to ensure collections are performed at the ordered time.
• Priority lab tests are easily identified by the caregiver to enable the caregiver to integrate these into their workflow appropriately.

Special Collection Alerts

• Information indicating the correct order of draw is readily available during collection.
• Specimen collection instructions are provided at the time of collection (i.e., if the specimen needs to be placed on ice).
• Patient status requirements are viewable at the time of collection (i.e., Fasting).

Repeat and Unnecessary Venipunctures

• Current and future orders are easily viewable during the collection process for the caregiver to consider all collections that can be completed simultaneously.
• Past and future specimen collection orders are easily viewed during the collection process for caregivers to consider if there is an opportunity for an “add-on” lab.
• A defined process exists for managing add-on orders.

Necessary Label Information

• Two patient identifiers (e.g., full name and DOB or MRN).
• Order test and order number.
• Barcode of order number.
• Container type.
• Collection date and time.
• Caregiver identification.
• Stat and Timed specimen label identifier.

Mislabeling

• Specimen labels are printed at the time and location of collection to ensure accuracy.
• Wrong patient alerts are provided during patient verification to eliminate incorrect collections.
• Wrong specimen alerts are provided during specimen verification, to eliminate specimen labeling errors.
• Tubes are never pre-labeled prior to collection to avoid mislabeling errors.
• Unreadable or damaged labels are rejected and replaced appropriately to avoid mislabeling errors and/or incorrect collection documentation.
• A defined process exists for managing relabeling errors or mislabeled specimens.

Workflow Efficiency

• Caregiver can easily identify which containers will be needed for collection.
• STAT collections are communicated to caregiver in real time to ensure prompt collection.
• Collection list can be individualized to meet the needs of the caregiver.
• Past and future specimen collection orders are easily viewed during the collection process.
• Specimen collection instructions are provided at the time of collection to stay top of mind for caregivers.
• Electronic method of communication with other team members regarding collections is readily available (i.e., unable to collect).
• Method of documentation of collection activities (not collected reasons, collection comments) is readily available during a collection to ensure accurate reporting and follow up.

Documentation Considerations

• Date and time of collection are documented accurately and legibly at the time of collection.
• Caregiver identification is documented accurately and legibly at the time of collection.
• Collection site is documented when required.
• Unsuccessful attempts, patient refusals and other reasons specimens are not collected are documented.
• Other collection events are documented as required (i.e., extra tubes collected).

Reporting Considerations

• Full specimen traceability is possible (collection → labeling → user → timestamp) to ensure patient safety through caregiver accountability.
• Adherence to expected processes can be monitored, while incorrect or incomplete processes are noted for workflow improvements.
• Not collected reasons can be monitored.
• Use of demographic labels instead of specimen specific labels can be monitored.
• Extra tube collections can be monitored.
• Patient and specimen identification errors can be monitored.
• Patient and specimen verification method can be monitored.
• Specimen turnaround times/productivity can be monitored.