Collection conundrum: What's the proper procedure for labeling blood tubes?

Q I was always trained to draw blood on a patient and label the tube immediately after. Our new laboratory director insists that we label the tubes first, then draw the patient. I think this takes too much time and wastes tubes and labels when, for some reason, there is a difficult draw or the tube vacuum fails. What's the correct procedure?

A The short answer to your question is that you should follow the procedures outlined by your facility. Failing to perform according to established procedures creates an unnecessary legal risk for the institution, challenges the authority of the director, and sets the staff up for discord and disorder. If you sincerely believe that the new policy is detrimental to patient care -- not to your own sense of order or your need for administrative efficiency -- you should raise this issue with your laboratory director. In fairness to your director, be prepared to offer suggestions that change the procedure in a way that preserves specimen integrity.

It might be more instructive, however, to look at the reasons your director might have for insisting that tubes be labeled before the draw. The most important step in managing laboratory specimens is the proper identification of tubes. A mislabeled tube can result in serious consequences -- even death -- to the patient, as, for example, when a tube for type and cross-match is identified by the wrong name. Any procedures for labeling specimens should minimize the chances of the wrong name being attached to the tube, as well as the chances of the identification becoming separated from the specimen.

From that perspective, good collection procedures require that the requisition be checked against the patient's identification, and that, once proper identification is made, the specimens are labeled in such a way that makes confusion, mislabeling or mix-up unlikely. There are several ways to accomplish this.

Your director apparently feels that the best way to avoid mix-up is for tubes to be labeled before use, and I am assuming that this also means that you are required to check the labeled tube against both the test request and the patient arm band before drawing. The advantage of such a system is that, if followed, it insures that no tube will ever be mislabeled, and, just as important, no tube will come to the lab unlabeled. It's the system I personally prefer. Incidentally, it is not sufficient to obtain verbal confirmation of identification from the patient or from other staff -- too many patients share similar names, and in the hospital setting, there is always a population of patients too confused or medicated to reliably identify themselves.

Almost the same result can be accomplished if patients are drawn one at a time, and tubes are labeled immediately after, again insuring that the label is verified against the test request and the patient arm band. The caveat here is that a busy phlebotomist, with two patients to draw in the same room, may be tempted to draw both patients first, keeping the specimens separate for later labeling. Any time unlabeled tubes -- or unaffixed labels -- from more than one patient exist in the same general vicinity, there exists also the possibility for mix-up, and even the most conscientious phlebotomist will occasionally err under those circumstances.

When proper procedures are followed under either system, the chance of mislabeling a tube is nearly zero. Unfortunately, rigid adherence to procedure isn't always the case. Every laboratory director has had the experience of confirming the fact that a specimen has been mislabeled, despite the protestations of the phlebotomist or technologist (or physician) responsible for collecting it that no mistake could have been made.

Labels must be affixed in such a way that they are unlikely to be disconnected from the specimen: directly on the tube for venipuncture specimens, and on the container -- rather than the lid -- for other specimens. In general, attaching a label prior to collecting a blood specimen should not cause difficulty in specimen collection. Labels can be spiraled around a tube, or the loose ends wrapped tightly and affixed with a piece of tape if necessary, so that the presence of the label does not impede proper searing of the tube on the drawing needle. If there is a misdraw, both tube and label must be discarded, but that's a small price to pay for proper specimen identification. In that case if no additional pre-printed labels are available to use, a new tube can be hand labeled with the patient's name and date and time of draw. A new printed label can be generated and affixed upon return to the lab.

A parallel question arises when an unlabeled specimen arrives in the lab, or when the tubes attached to the test requisition do not match the tests ordered. Caution dictates that when there is any question about the integrity of the specimen, it must be discarded and recollected. It has always been my policy as a laboratory director to discard without exception confused or unlabeled specimens once they are received in the laboratory, as well as nor to permit "correction" of labels once they are affixed.

In summary, any process that guarantees the integrity of collected specimens is appropriate, and the fewer the chances for error, the better. Most important of all, the laboratory director must insure that written policies are enforced and that whenever there are mistakes, the source of the error must be identified and the responsible employee counseled how to avoid similar errors in the future.

Author's Note: Recent HIPAA guidelines (July 6, 2001) regarding management of prescription vials shed some light on the question posed about taking labels off specimen bottles and may make it easier for laboratories to comply with confidentiality rules without needless handling of bottles and obscuring of labels. The Department of Health and Human Services (HHS) indicatesthat covered entities do not need to shred empty prescription vials, but does require them to take "reasonable steps" to protect them from being accessible to the public. Assuming similar logic applies to laboratory specimen bottles, and it should, a business agreement with the disposal company to protect confidentiality prior to incineration and proper packaging in biohazard containers during transport is likely to be sufficient under HIPAA. HHS has indicated it will issue rules which are expected to clarify such situations -- something laboratorians will look forward to.

Barbara Harty-Golder is a pathologist-attorney in Sarasota. FL. She directs the clinical laboratory at Health South Rehabilitation Hospital in Sarasota, as well as maintaining a law practice with a special interest in medical law. She writes and lectures extensively on healthcare law, risk management, and human resources management.