Standards › Standard 33 › Policies
Policy · LBT-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 33.12
At a glance
- Each result is authorised by a qualified person before release (LBT-FRM-005).
- The authoriser is competent for the test (STF-FRM-001).
- The authoriser is recorded with the result.
- No result is released by a trainee without authorisation.
- Stop and get help straight away if: a result is released with no authoriser, or by someone not competent for the test.
1. Purpose
To make sure every result is checked by a competent person before it leaves the laboratory (33.12).
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 result released without being checked by qualified staff can carry an error to the clinician. A review and authorisation before release is the last check.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Laboratory director | Names the authorisers for each test | Medical director |
| Authoriser | Checks and authorises each result | 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.
- Check the result against the quality control, the patient history and the limits.
Key point: Checked.
Step 2. Authorise.
- Authorise the result and record the authoriser (LBT-FRM-005).
Key point: Authorised.
Step 3. Release.
- Release the result only after authorisation.
Key point: Released.
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 |
|---|---|---|---|---|
| Results authorised before release | 100% | Monthly | Laboratory director | Escalate to the 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 |
|---|---|---|
| LBT-FRM-005 | Result authorisation record | Record |
| STF-FRM-001 | Staff credential register (existing, reused) | 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
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)