I walked through the accessioning area of my lab a few mornings ago. Like almost every morning for the last 6 years, my techs were standing at the accession encounter, sorting through the specimens we received. That day I took special note of a pile of specimens still bagged together with their requisitions, set off to the side. The pile was fairly large; I estimated 15 to 20 specimens.

I was curious, so I inquired. I was told they are the specimens that needed to be further investigated before they could be received and processed. –Fifteen-twenty specimens may not seem like a lot. But since we only receive 85 to 100 on an average day, this represented 20% of our daily volume.

Our lab is not special. We have a specimen rejection protocol we follow just like every other lab. The protocol ensures the pre-analytical integrity of the specimens we test is maintained. It ensures patient identification has been verified to the best of our abilities; It ensures that specimens are received during the period of viability for the test; and it ensures that the specimen collection and transport devices are suitable for testing. But we all know that every protocol has some gray area where the technologist has some discretion.  The technologist makes the final decision as to reject or not reject.

I am NOT a micro-manager! I prefer to hire competent, qualified staff and trust them to follow policy and protocol while doing their job. But on this particular morning I chose to observe the disposition of these samples. I used this as an opportunity to assess employee competency, and also see if the rejection protocol was as relevant today as when it was written. I grabbed a copy of the protocol and I sat down with the tech as she reviewed the specimens one by one.

First we looked at specimens that has been collected greater than 2 days ago. One of the tests we perform is valid on specimens less than 72 hours old. My tech explained that during the preliminary search they use the two-day benchmark so as to not miss that window.

Next she reviews all of the samples labeled incorrectly. We found samples that had no labeling at all. These were rejected outright and the doctor’s office notified buy electronic report. As per our protocol, the specimen, requisition and specimen bag were held for 7 days. Occasionally we will receive a call questioning the rejection.  Those callers want to know if we can go ahead and accept it because it was in a zip lock bag with the requisition. “Of course that is the right specimen,” they will exclaim. We even receive calls requesting the specimen be returned for correct labeling, as if the caller will be able to identify the returned sample is the one she submitted 2 days ago. Have you ever heard of anything so absurd?

Sometimes, the decision to reject or not is not as clear cut.  Some specimens were labeled with the wrong accession, but the correct patient.  These were not rejected, but it was noted on the report, and relabeled in the lab for proper analyzer ID.  Some specimens were received with no accession label, but labeled with name and a 2nd identifier.  These were also not rejected but were properly labeled and loaded on the analyzers.

The real dilemma came when we found specimens only partially labeled.  One had a patient’s first initial and last name, the other, initials only.  Since the specimens were received in individual bags, with their respective requisitions, the tech wanted to accept those specimens.  She suggested that it is inconvenient to have patient return for recollection and it was likely the correct patient.  This reminded me of a story from my early days in a reference lab draw station, so I shared this with her.

Many years ago, while working in an outpatient draw center, a husband and wife came in for testing.  In the provider’s haste, the form had the patients’ first initial and last name, with no other identifier.  The patient should have been denied service and sent back to the office for properly filled out forms.  But to avoid causing the elderly couple any inconvenience, the receptionist allowed the patients to fill in the missing information themselves. When the testing was complete, the provider discovered that the PSA level was performed on the wife and not the husband.  As it turned out, both of them had the same first initial and had inadvertently swapped forms. The husband still had to return for proper testing, and also had to return to the physician’s office again to review the results. Would refusing service per the protocol have been any less inconvenient?  Probably not.

After all of the specimens were reviewed, the rejected samples were reported out and recorded in the specimen rejection log.  The specimen rejection protocol had stood the test of time, and my employee’s competency evaluation was successful for this task.  Specimen integrity was maintained. And only 2 patients will have to return for recollection.

Consider your specimen rejection protocol.  Has it been reviewed recently?  Can it stand the test of time and still be relevant today?  You may find that an hour in the specimen accessioning area will give you and your technologists a better understanding of ‘to reject or not reject.’

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