What should I do with a blood specimen labeled as 'John Doe' but has a slip with 'Jane Doe'?

Handling Specimen Labeling Discrepancies in the Laboratory

When faced with a blood specimen labeled "John Doe" with a requisition slip labeled "Jane Doe," you must reject the sample and request recollection to ensure patient safety and prevent potential harm from misidentification.

Rationale for Sample Rejection

Laboratory guidelines clearly dictate that proper specimen identification is critical for patient safety. When there is a discrepancy between the specimen label and the requisition slip, the specimen integrity is compromised, not in terms of its physical properties but in terms of its identification reliability.

According to CDC guidelines for laboratory specimens, all specimens must be labeled with a unique patient identifier 1. The discrepancy between "John Doe" on the specimen and "Jane Doe" on the requisition creates uncertainty about the specimen's origin, which could lead to:

• Incorrect results being reported for a patient
• Inappropriate medical decisions based on those results
• Potential harm to both patients involved (John and Jane Doe)

Laboratory Protocol for Specimen Rejection

The proper procedure in this case follows this algorithm:

1. Identify the discrepancy between the specimen label and requisition slip
2. Document the rejection in the laboratory information system
3. Reject the specimen completely - do not process it under any circumstances
4. Notify the unit that submitted the specimen about the rejection
5. Request recollection with proper identification

Impact of Specimen Rejection

While specimen rejection may seem inconvenient, research shows significant clinical consequences when proper identification procedures are not followed:

• Recollection causes a median delay of 65 minutes in result availability 2
• Specimen mislabeling poses a substantial risk to patient safety
• Allowing relabeling of incorrectly labeled specimens is a dangerous practice with little measurable benefit 2

Common Pitfalls to Avoid

1. Do not attempt to relabel the specimen based on assumptions about which identifier is correct
2. Do not process the specimen even with a note about the discrepancy
3. Do not accept verbal confirmation of patient identity without proper documentation
4. Do not make exceptions based on specimen type or test urgency

Quality Improvement Considerations

Research shows that targeted training can significantly reduce specimen rejection rates 3. Laboratory policies should include:

• Regular training for phlebotomy and laboratory staff
• Clear protocols for specimen identification
• Documentation of rejection incidents for quality improvement
• Feedback mechanisms to clinical units with high rejection rates

By strictly adhering to proper specimen handling procedures, laboratories can ensure accurate results that properly guide clinical decisions and protect patient safety.