Standards › Standard 19 › Standard operating procedures (SOPs)
Procedure · SPC-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 19.5
At a glance
- Reject a specimen that is mislabelled, leaking or delayed, and do not test it.
- Record the reason on SPC-REG-002.
- Tell the requester the same day, and record how they were told.
- Arrange a new specimen where it can be collected.
- Stop and get help straight away if: a leaking specimen is tested anyway.
1. Purpose
To make sure unsuitable specimens are rejected, recorded and the requester is told (19.5).
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 mislabelled, leaking or too old must not be tested, because the result would be wrong or unsafe. Rejecting it and recording the reason is what keeps bad results out of the chart.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Collecting staff | Reject, record and notify | 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. Reject.
- Reject the unsuitable specimen and do not send it for testing.
Key point: Rejected.
Step 2. Record.
- Record the reason on SPC-REG-002.
Key point: Recorded.
Step 3. Notify.
- Tell the requester the same day and record how.
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 |
|---|---|---|---|---|
| Rejected specimens with reason and requester told | 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-REG-002 | Specimen rejection log | Register |
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
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)