Sending a Specimen to Pathology

CHI/Unique identifier, Surname & Forename or if no CHI/unique identifier, the Surname, Forename and Date of Birth must be provided.

A minimum of 3 matching patient identifiers across both the specimen pot labels and forms are required to accept a specimen and meet legislative requirements.

Only Specimen containers and Forms that satisfy the essential criteria listed below can be accepted into the department.

Request Form

Essential:-

• CHI Number or a temporary unique identifier (e.g. ZP number)
• Patient’s Full Name or unique coded identifier
• Date of Birth
• Nature of Specimen including qualifying details (Any Danger of Infection information is essential)

Desirable:-

• Patient’s Address including Postcode (essential if no CHI number)
• Clinical Information/history including risk/danger of infection (essential for fresh tissue and frozen section)
• Date and time of sampling
• Practitioner’s contact number (bleep or extension)
• Gender
• Location and destination of report
• Requesting Practitioner
• Investigation Required

Sample Container

Essential:-

• CHI number or a temporary unique identifier (e.g. ZP number)
• Patient’s Full name or unique coded identifier
• Date of Birth
• Nature of Specimen or identifier including qualifying details
• Labelling to indicate if there is a risk/danger of infection

Desirable:-

• Date and Time of Sampling

Other Essential Information

The full address to which the report should be sent must also be included.

N.B: Pre-printed labels do not indicate the address to which the report should be sent.

A short clinical history must also be provided.

A brief clinical history is invaluable in the interpretation of the histological findings and should be given in every case.

As many pathology cases require considerable clinico-pathological discussion before a diagnosis can be reached, it is essential that the name of the patient’s consultant, the name of the requesting doctor and the contact telephone or page numbers are put on the request form where asked.

If the report is required urgently this should be stated on the request form along with a contact telephone number or page number.

The laboratory cannot supply a report on unlabelled specimens or specimens received without request forms.

Failure to provide the required information may result in delays in processing specimens and/or in the provision of a Pathology report to the appropriate location.

Normally, specimens should be transferred in a sealed container with 10% neutral buffered formalin, which prevents tissue decay, ideally the volume of formalin should be at least 10 times the volume of the specimen, but for major resections this may not be possible. Please ensure that containers are properly sealed before dispatch as leaking specimens will not be picked up by Transport/ Facilities staff. If you have a Formalin spill, follow your own spill procedures. 

No fixative should be added if:

• a frozen section is requested (including: brain biopsies taken mid surgery for smear analysis, muscle biopsies and paediatric rectal biopsies – see individual sections for more information)
• the specimen is thought to be a lymphoma – whole lymph nodes only
• there is a need to collect and process fresh surplus tissue for medical research purposes
• The sample is for Immunofluorescence 

Sending Fresh Tissue

All fresh tissue must be delivered to the Pathology Department immediately and Pathology Specimen Reception should be notified that fresh tissue has been sent.

Tel:  0141 354 9513 (89513) or 0141 354 9514 (89514)

If you are unsure of the correct procedure, contact Pathology Specimen Reception for advice on the telephone numbers above.

Delay in receipt of a “fresh” specimen may make diagnosis impossible.

Fixatives and specimen jars are available from:

Specimen Reception (L3/B/021),

NHSGGC Pathology Department

Level 3, Laboratory Medicine and Facilities Management Building

Queen Elizabeth University Hospital

Tel:  0141 354 9513 (89513) or 0141 354 9514 (89514)

Requests for urgent results should be clearly marked on the request form and contact telephone or page number provided.

The consultant pathologist should be notified before the specimen is sent if an urgent result is required.

It is the responsibility of the clinical team to ensure that emergency/urgent specimens are transported urgently to the Pathology Laboratory.

In practice, these are specimens that carry the risk of transmitting Hepatitis B virus, Hepatitis C virus, HIV, M. tuberculosis and other category III pathogens.

The Clinical Microbiology Department should be contacted where there is any uncertainty.

Such specimens, include those from confirmed or suspected cases of the disease, known carriers (e.g. those known to be hepatitis antibody or antigen positive), as well as patients from an ‘at risk’ group (e.g. drug abusers).

‘Danger of infection’ (DOI) stickers must be put on the specimen bag, the request form and the specimen container.

If the nature of the DOI is known please include this in the clinical details.

Specimen bags should be sealed so that they can be opened without the use of sharp or pointed instruments.

For large specimens, containers should be enclosed in individual plastic sacks tied at the neck. The request form should be placed in a plastic envelope which is then securely tied to the neck of the sack.

“Danger of Infection” specimens should always be sent in an adequate volume of buffered formalin.

If a specimen is received in Pathology and the specimen and/or request form has been mislabelled, is unlabelled or there are discrepancies between the request form and specimen container, the Laboratory staff will make every attempt to contact the sender to clarify the error, including telephoning the source and contacting requesting clinician etc. identified from any information that has been supplied.

If the Laboratory staff are unable to rectify the problem by telephone, a “Non-conformance letter” will be sent to the requesting clinician.

This letter is accompanied by the request form and identifies the nature of the non-conformance with a request that this is rectified, and the requesting clinician takes responsibility for the changes.

Specimens will not be returned but will be kept in Pathology Specimen Reception labelled with the appropriate non-conformance number, until the non-conformance has been resolved.

The laboratory cannot supply a report on unlabelled specimens or specimens received without request forms. Failure to provide the required information may result in delays in processing specimens and/or in the provision of a pathology report to the appropriate location.

In the event of an urgent specimen being received in diagnostic cytology, where the specimen and/or request form has been mislabelled, the technical staff in the lab will make every attempt to contact the sender and clarify the mislabelling error, including telephoning the source and contacting the requesting clinician etc. identified from any information that has been supplied.

In the event of there being insufficient information to allow cytology to contact the sender, the specimen will be kept refrigerated for one week, in the hope that the lab will be contacted. If no contact has been made at the end of this period, the specimen will be discarded.