Standards › Standard 33 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · LBT-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 33.7
At a glance
- Each specimen is checked against the acceptance criteria on receipt (LBT-REG-005).
- A specimen with no valid identifier is rejected.
- Every rejection records the reason and the notice given to the requester.
- Accepted specimens are logged with their identifiers.
- Stop and get help straight away if: a specimen with no valid patient identifier is accepted and tested.
1. Purpose
To make sure only specimens that meet the defined criteria are tested, and every rejection is explained (33.7).
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
A specimen that is haemolysed, clotted or too small can give a wrong result. Written rejection criteria, applied the same way by everyone, stop it being tested.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Laboratory reception staff | Check, accept, log or reject each specimen | Senior scientist |
| Senior scientist | Keeps the acceptance criteria current | Laboratory director |
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. Check on receipt.
- Check the identifier, the specimen type, the container and the time against the criteria.
Key point: Checked.
Step 2. Accept or reject.
- Accept and log the specimen, or reject it with the reason.
Key point: Accepted or rejected.
Step 3. Notify.
- Notify the requester of any rejection and record the notice (LBT-REG-005).
Key point: Notified.
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 |
|---|---|---|---|---|
| Rejections with reason and notice recorded | 100% | Monthly | Senior scientist | Escalate to the laboratory 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 |
|---|---|---|
| LBT-REG-005 | Specimen receipt and rejection log | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 15189:2022 Medical laboratories: requirements for quality and competence, ISO 9001:2015 for supplier control, and the Global Patient Safety Action Plan 2021–2030 for critical results. |
| 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
- Equipment, Reagents & Traceability (LAB-04)
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)