Sop - Collection of Sample

CRITICARE SUPERSPECIALITY
HOSPITAL 01
Procedure(s) guide collection, identification,
Date 01 /04 /2022
handling, safe transportation, processing
and disposal of specimens. Page 1 of 25
AMENDMENT SHEET
Sr. Section no Details of the amendment Reasons Signature of Signature
No & page no the of the
preparatory approval
authority authority
Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Team/Policy on collection ,safe Implementation Date-4/04/2022
transportation and disposal of Version-00 Approved By:-MEDICAL DIRECTOR
specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 1
HOSPITAL 01
Date 01 /04 /2022
PURPOSE:
1.1 To provide guide collection, identification, handling, safe transportation,
processing and disposal of specimens
2.0 SCOPE:
2.1 All the patients those who avail laboratory services, the hospital ensures
availability of laboratory services commensurate with the health care service
offered
3.0 RESPONSIBILTY
specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 2
HOSPITAL 01
Date 01 /04 /2022
3.1 Head of the department, Microbiologist

3.2 Laboratory assistants
4.0 POLICY:
LABORATORY SERVICES ARE PROVIDED AS PER THE SCOPE OF HOSPITAL
SERVICES AND LABORATORY SAFETY REQUIREMENT.
IN HOUSE LABORATORY SERVICES: LCH gives in house laboratory service by Dr.Supriya

Chincholkar M.D. (PATH) and lab technician Mrs. Jayashree Chavan (CMLT., DMLT) for 24
hours.
Scope of services in LHCC as follows:
 HAEMATOLOGY: CBC ESR, Platelet count, Malaria antigen, BT CT PT, Blood group etc.
 BIOCHEMISTRY: Blood sugar, fasting and PP, HbA1C, lipid profile, liver profile, renal
profile, serum electrolyte, lipase amylase. CPK, CKMB, Troponin T.
 SEROLOGY: HIV, HBsAg, VDRL, Vidal, typhoid IgM, CRP, MT, NS1 dengue, Dengue
IgG/ IgM, Lepto IgG/ IgM.

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 3
HOSPITAL 01
Date 01 /04 /2022
 MICROBIOLOGY: Sputum routine
COLLECTION OF BLOOD SAMPLE
COLLECTION BOX
1. Sterile glass or plastic tube with screw cap.

2. Disposable syringe with needle.
3. Tourniquet.
4. Skin antiseptic solution like spirit or Sterilium.
5. Gauge pad with adhesive tape.
6. Tray for assembled blood collecting tools.
7. Rack for holding blood tubes.
specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 4
HOSPITAL 01
Date 01 /04 /2022
8. Durable marker for writing on laboratory sample.
EQUIPMENT FOR PREVENTNG INFECTION
1. Hand hygiene : Sterilium, spirit, disposable paper towel

2. PPE: Gloves, mask, cap, gown and footwear if required goggles.
3. BMW : Leak proof , puncture resistant, sharps container, two leak proof infectious waste
bags.
DOCTOR WRITTEN REQUEST:
All samples should have written request from treating doctor. Criteria for written request are as
follows
1. Name of the patient/UHID NO./OPD/IPD NO./tests required clearly indicated.
2. Name of doctor , signature , date and time
CRITERIA FOR LABELLING THE SAMPLE:
1. Name of the patient/UHID NO./OPD/IPD NO./Date and time of sample taken/bar code
sticker

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 5
HOSPITAL 01
Date 01 /04 /2022
PROCEDURE FOR COLLECTION OF BLOOD
1. Identify and prepare the patient : Introduce yourself to the patient, explain what you are
going to do with blood sample and why. Make sure that this is a correct patient from
whom you are taking the blood sample with asking general information- name, age, sex,
address and bar code sticker of the patient.
2. Select the site for collection of blood preferably at the bend of the elbow.
3. Apply tourniquet around the arm
4. Ask patient to form a fist so that veins are more prominent.
5. Disinfect the pricking area with spirit or Sterilium.
6. Anchor the vein by holding the patients arm and place thumb below the place where you
want to insert the needle.
specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 6
HOSPITAL 01
Date 01 /04 /2022
7. Perform the blood draw by entering the vein quickly at 30 degree angle.
8. When blood starts to flow, ask patient to open the fist(hand).
9. Once sufficient amount of blood has been collected(minimum 5mL) release the
tourniquet before withdrawing the needle.
10. Withdraw needle from vein gently.
11. Stop bleeding and clean the skin and put adhesive bandage at the site.
12. Withdraw needle from the syringe and pour required amount of blood in EDTA/sugar
bulb/plain.

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 7
HOSPITAL 01
Date 01 /04 /2022
13. Tube as per test to be done and screw cap on each tube and shake EDTA and sugar tube
and place the plain tube in tube rack.
14. Remove the needle from the syringe and put needle into leakage proof and puncture
resistant sharps container.
15. Put all waste material in yellow bag as per BMW norms 2018.
16. Blood holder tray and rack will needed to be disinfected after use by Sterilium or spirit.
17. Minimum of 5mL of blood should be collected from each patient at a time.
IDENIFICATION OF PATIENT FOR BLOOD COLLECTION
1. Identification of patient whose blood collection is going to be done by asking orally name,
age.
2. General information of patient on wrist band and barcode.

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 8
HOSPITAL 01
Date 01 /04 /2022
3. General information on written request from treating doctors.
All above information of patient should match with each other.
Identification of blood sample is done by help of label information and barcode on blood sample
tube.
HANDLING AND SAFE TRANSPORTATION OF BLOOD SAMPLE.
1. Take the blood sample tube from the tray and wipe the blood on test tube with disposable
paper Towel.
2. Place all item that can come in contact with blood, dispose BMW various bags for disposal.
3. Protect the sample from breaking during transport by wrapping the blood sample tube in a
paper towel or place in a rack
4. Store the sample at room temperature for up to 24 hours. If you want to store a sample for 1
week,
5. Store between 0 to -5 degree Celsius or for more than 1 week store at -20 degree Celsius.
6. All testing and processing is done as per every test protocol.
specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 9
HOSPITAL 01
Date 01 /04 /2022
7. Disposal of balance blood specimen is done as per MPSE-BMW 2016 rules and
regulations.
LABORARTORY RESULTS ARE AVAILABLE WITHIN A DEFINITE TIME FRAME.
1. TAT-Turn Around Time: TAT start from registration, barcode printing, collection of
sample, testing of sample and results of sample, routine TAT time is less than 60 minutes
for IPD and OPD patients. For emergency blood testing do as early as possible.
2. Laboratory reports are issued within the defined time frame from 5 pm to 8 pm and for
special tests as per test result received from outside pathology like METRO/SRL,ETC.
3. Critical results defined and displayed: If any critical results are reported then that critical
results should be informed immediately to treating doctor/RMO/nurses through telephone
or mobile. This is responsibility of laboratory staff.
LABORATORY PERSONS ARE TRAINED IN A SAFE PRACTICE AND PROVIDED WITH SAFETY
EQUIPMENTS.
1. PPE: Personal Protecting Equipments like gloves, cap, mask, apron, goggle, footwear
should be used during the blood collection.
2. Universal precautions should be taken during blood collection.
3. Safe protection from hazardous materials
specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 10
HOSPITAL 01
Date 01 /04 /2022
4. Prevention of needle stick injury

5. Safe discard of waste materials.
6. Safe handling of waste materials.
7. Training to laboratory persons for safe practice with safety equipments.
TESTS THAT ARE NOT DONE IN THE HOSPITAL(OUTSOURCING)
1. Hematology: Hb Electrophoresis/D-Dimer, CD-4/CD-8, Viral load

2. Biochemistry: Ion studies, vitamin B12, FOLIC ACID, VITAMIN D, HOMOCYSTEINE,
Blood Gas analysis, protein Electrophoresis, Quantitative Trop T
3. Clinical Pathology; 24hour urine protein, Fluid routine and microscopy ADA
4. Serology: ELISA for HIV, Anti CCP Antibody, IgM HAV/HEV, Serum IGE
5. Microbiology: Sputum for Gene Expert, Blood/Stool/Urine Culture and sensitivity.
6. Hormones: T3, T4, TSH, FSH, LH, Serum Prolactin, Ca 125, Double Marker/Triple
Marker
7. Above test are carried out as outsourced from METRO/SRL/QUALILIFE/AASHIRVAAD
Lab.
8. MOU with these laboratories for outsourced tests is done.
OUTSOURCE TEST REGISTER IS MAINTAINED WITH FOLLOWING DETAILS:

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 11
HOSPITAL 01
Date 01 /04 /2022
1. LAB NO.
2. Name of patients, age, sex, UHID NO.,OPD/IPD NO.
3. Name of consultant who has written the request of tests.
4. Signature of person sending the sample.
5. Signature of person receiving the test report.
Above record is maintained in separate outsourced test register.

STANDARD OPERARTING PROCEDURE FOR THE DISPOSAL OF PATHOLOGICAL
WASTE AT LHCC
Laboratory Departments : 1) Haematology.

2) Clinical Biochemistry.
3) Clinical Pathology.
TYPES OF WASTE GENERATED:
Solid Waste: Glass Tubes, Cover Slips, Syringes with Needles, Glass Slides, Broken Glass
Pipettes.

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 12
HOSPITAL 01
Date 01 /04 /2022
Collected In Approved in White Plastic Sharps Container Upto ¾ Th Of Capacity And Kept In
Designated BMW Area For Disposal By Housekeeping.
Liquid Waste: 1) Leftover Blood Samples
2) Leftover Urine, Stool And Semen Samples.
 Leftover Blood Samples Are First Treated With 1/10 Bleach /Water Solution (Made Daily)
For 20 Min. Properly Capped And Collected In Yellow Disposal Containers With Yellow
Liners/Plastic
 Bags Tied And Kept In Designated Area For Disposal By Housekeeping.
 Leftover Urine Samples Are Carefully Disposed Off Down The Sink With Copius Amount
Of Water.
 Stool And Semen Samples Are Tightly Capped, Collected In Black Plastic Liner/Bag. Bags
Are Tied Properly And Disposed Off In Municipal Waste Trash .

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 13
HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
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HOSPITAL 01
Date 01 /04 /2022

specimen Date-00
Name: JAYASHREE
CHAVAN Signature:
Sign:
Page 24

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CRITICARE SUPERSPECIALITY

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

3.1 Head of the department, Microbiologist

IN HOUSE LABORATORY SERVICES: LCH gives in house laboratory service by Dr.Supriya

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

 MICROBIOLOGY: Sputum routine

COLLECTION OF BLOOD SAMPLE

1. Sterile glass or plastic tube with screw cap.

8. Durable marker for writing on laboratory sample.

EQUIPMENT FOR PREVENTNG INFECTION

1. Hand hygiene : Sterilium, spirit, disposable paper towel

DOCTOR WRITTEN REQUEST:

1. Name of the patient/UHID NO./OPD/IPD NO./tests required clearly indicated.

2. Name of doctor , signature , date and time

CRITERIA FOR LABELLING THE SAMPLE:

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

PROCEDURE FOR COLLECTION OF BLOOD

3. Apply tourniquet around the arm

4. Ask patient to form a fist so that veins are more prominent.

5. Disinfect the pricking area with spirit or Sterilium.

8. When blood starts to flow, ask patient to open the fist(hand).

10. Withdraw needle from vein gently.

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

IDENIFICATION OF PATIENT FOR BLOOD COLLECTION

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

3. General information on written request from treating doctors.

All above information of patient should match with each other.

HANDLING AND SAFE TRANSPORTATION OF BLOOD SAMPLE.

LABORARTORY RESULTS ARE AVAILABLE WITHIN A DEFINITE TIME FRAME.

4. Prevention of needle stick injury

TESTS THAT ARE NOT DONE IN THE HOSPITAL(OUTSOURCING)

1. Hematology: Hb Electrophoresis/D-Dimer, CD-4/CD-8, Viral load

OUTSOURCE TEST REGISTER IS MAINTAINED WITH FOLLOWING DETAILS:

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Above record is maintained in separate outsourced test register.

Laboratory Departments : 1) Haematology.

TYPES OF WASTE GENERATED:

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Liquid Waste: 1) Leftover Blood Samples

2) Leftover Urine, Stool And Semen Samples.

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

Prepared by :- Quality ISSUE NO-01 Dated-01/04/2022 Issued By:-QUALITY TEAM

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