Standards › Standard 33 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · LBT-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 33.8
At a glance
- Specimens are packed and labelled to preserve their integrity.
- Temperature and time limits are kept and recorded (LBT-FRM-003).
- Every deviation is recorded and the specimen is assessed.
- Staff who transport specimens are trained.
- Stop and get help straight away if: a specimen outside its temperature or time limit is tested with no deviation recorded.
1. Purpose
To make sure specimens arrive in the condition they were collected in (33.8).
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
Some specimens change in transit if they are too warm, too cold, or left too long. The transport conditions must keep the specimen as it was taken.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Collection and transport staff | Pack, label, record and transport the specimen | Senior scientist |
| Senior scientist | Sets the limits for each specimen type | 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. Pack and label.
- Pack and label each specimen to the standard for its type.
Key point: Packed.
Step 2. Transport and record.
- Transport within the time and temperature limits and record them (LBT-FRM-003).
Key point: Transported.
Step 3. Assess deviations.
- Record any deviation and decide whether the specimen can be tested.
Key point: Assessed.
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 |
|---|---|---|---|---|
| Transport records within limits | 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-FRM-003 | Specimen transport record | Record |
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)