Standards › Standard 19 › Policies
Policy · SPC-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 19.2
At a glance
- Each specimen type has a written collection procedure, from the receiving laboratory.
- The procedure names the right container, the correct timing and the right preservation.
- Staff collect only the specimen types they have a procedure for.
- A procedure that is missing for a type is raised with the laboratory before collection.
- Stop and get help straight away if: a specimen is collected with no procedure, or in the wrong container.
1. Purpose
To make sure every specimen is collected in the right container, at the right time and with the right preservation (19.2).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Each specimen type needs its own container, timing and handling. Collecting it wrongly gives a result that is false, even though the sample looks fine.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Collection point lead | Owns the procedures and their use | Clinician or manager |
| Collecting staff | Follow the procedure for each specimen | Staff |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Use the procedure.
- Use the written procedure for the specimen type being collected.
Key point: Procedure used.
Step 2. Check container and timing.
- Check the container, the timing and the preservation before collection.
Key point: Checked.
Step 3. Raise gaps.
- Raise any missing procedure with the receiving laboratory before collection.
Key point: Raised.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Collections made to the written procedure | 100% | Monthly | Collection point lead | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| SPC-FRM-002 | Collection audit record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 15189:2022 (pre-examination processes) and the WHO Patient Safety Curriculum Guide (2011). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
- Pre-Examination: Specimen Pathway (LAB-06)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)