Diagnostic Cytology Laboratory
Sample Acceptance/Rejection Procedure 	CACD_PRE_1001JA2
I.	Purpose:
This procedure provides instructions on what to do when problems arise when receiving a sample in Diagnostic Cytology.
Refer to: CALA_001_4185 Sample Acceptance Policy
II.	Materials:
N/A
III.	Procedure:
	Action	
1.		Problem samples. Deficiency:
Note: 
•	Replaceable = sputum, rectal, nipple discharge, oral scrape and voided urine samples
•	Irreplaceable =  Fine needle aspiration, Cystoscopy/catheterized urine, bodily fluid, CSF, GI brushing and Bronchial samples	
1.		Condition	If	Then	
1.		Sample received in incorrect fixative	Replaceable
	1.	Reject specimen
2.	Accession specimen into CoPath, enter deficiency 
3.	Issue a CoPath report stating reason for rejection
4.	Voided urine and sputum specimens will be discarded. Sent-in slides will be returned to sender
5.	Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm collection and handling instructions in the report.	
1.			Irreplaceable	1.	Accept specimen
2.	Accession specimen into CoPath, enter deficiency 
3.	Process  as per Standard Operating Procedure 
4.	Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm collection and handling instructions in the report.	
1.		Container label illegible 	Replaceable	1.	Reject specimen
2.	Accession specimen into CoPath, enter deficiency 
3.	Issue a CoPath report stating reason for rejection
4.	Voided urine and sputum specimens will be discarded. Sent-in slides will be returned to sender
5.	Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm collection and handling instructions in the report.	
1.			Irreplaceable	1.	Contact ordering physician/clinician. Clinician must fill out and sign specimen declaration form. 
2.	Upon receiving declaration form, accession specimen into CoPath, enter deficiency 
Note: If declaration form is not signed and faxed back within 48 hours, specimen will be rejected and returned back to sender
3.	Process  as per Standard Operating Procedure 
4.	Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm, collection and handling instructions in the report.	
1.		Broken Slides		1.	Reject specimen
2.	Accession specimen into CoPath, enter deficiency 
3.	Issue a CoPath report stating reason for rejection
4.	Broken slides will be discarded
5.	Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm, collection and handling instructions in the report.	
1.		Incomplete / Incorrect  Requisition 
e.g.  missing DOB, PHN, misspelled name	Replaceable	1.	Contact ordering physician/clinician. Clinician must fill out and sign specimen declaration form. 
2.	Upon receiving declaration form, accession specimen into CoPath, enter deficiency 
Note: If declaration form is not signed and faxed back within 48 hours, specimen will be rejected and returned back to sender
**Replaceable samples will be discarded with the exception of slides, they will be returned to sender**
3.	Process  as per Standard Operating Procedure 
4.	Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm collection and handling instructions in the report.	
1.			Irreplaceable
 	1.	Contact ordering physician/clinician. Clinician must fill out and sign specimen declaration form. 
2.	Upon receiving declaration form, accession specimen into CoPath, enter deficiency 
Note: If declaration form is not signed and faxed back within 48 hours, specimen will be rejected and returned back to sender
3.	Process  as per Standard Operating Procedure 
4.	Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm, collection and handling instructions in the report.Follow: Receiving Diagnostic Cytology Specimens Standard Operating Procedure (Problem/Deficient specimens)	
1.		Unlabelled Slides and/or Sample Containers

**all sent-in slides must have 2 unique identifiers printed on the slide**	Replaceable	1.	Reject sample
2.	Accession specimen into CoPath, enter deficiency 
3.	Issue a CoPath report stating reason for rejection
4.	Voided urine and sputum specimens will be discarded. Sent-in slides will be returned to sender
5.	Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm, collection and handling instructions in the report.
	
1.			Irreplaceable
	1.	Contact ordering physician/clinician.  Clinician/deligate must identify the sample in person, fill and sign the declaration form in order for the lab to process the sample. If clinician cannot identify the sample, it will be returned to sender 
Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm, collection and handling instructions in the report.	
1.		Mismatched Information
Between Sample/Container Labels and Requisition	Replaceable &
Irreplaceable
	1.	If patient name on requisition does not match patient name on container label. 
a.	Discard replaceable specimen with the exception of slides. Return slides to sender. 
b.	Irreplaceable specimens: Contact ordering physician/clinician. Clinician or delegate must identify the sample in person, fill and sign the declaration form in order for the lab to process the sample. If clinician cannot identify sample it will be returned to sender 
c.	If there is only one identifier which does not match (DOB or PHN) try to verify information by faxing specimen declaration form.
Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm, collection and handling instructions in the report.	
1.		Receipt of any specimen not suitable for cytologic evaluation 
(i.e. vomit, fecal matter, insects, ticks, toe/finger nails, tampons, foreign objects, bile)		1.	Reject specimen
2.	Accession specimen into CoPath, enter deficiency 
3.	Issue a CoPath report stating reason for rejection
4.	Return specimen to sender
5.	Provide links to Rejection Policy: http://www.bccancer.bc.ca/HPI/labservices/diagcytology/default.htm, collection and handling instructions in the report.	
1.		Sample received without a requisition	Call or fax for requisition and verification
	
B.	References:
N/A
C.	Appendixes:
N/A