Standards › Standard 19 › Standard operating procedures (SOPs)
Procedure · SPC-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 19.7
At a glance
- Check the tracking register each working day for any specimen with no arrival or no result.
- Follow up each missing result with the laboratory the same day.
- Tell the requester if the result is delayed.
- Record each follow-up and its outcome on SPC-REG-003.
- Stop and get help straight away if: a patient never receives a result for a specimen sent a week earlier.
1. Purpose
To make sure every specimen reaches the laboratory and its result reaches the requester (19.7).
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 reaches the lab but is never linked to a result leaves the patient waiting, and no one notices. Confirming arrival and returning results is what closes the loop.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Collection point lead | Owns the tracking and follow-up | Clinician or manager |
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 daily.
- Check SPC-REG-003 each working day for missing arrivals and results.
Key point: Checked.
Step 2. Follow up.
- Contact the laboratory the same day for each missing result.
Key point: Followed up.
Step 3. Tell and record.
- Tell the requester of any delay and record the outcome.
Key point: Recorded.
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 |
|---|---|---|---|---|
| Specimens with result returned to the requester | 98% | 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-003 | Specimen tracking register | 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)