Provision of key clinical information on laboratory specimen request forms

Health and Safety Executive - Safety alert

Introduction:

The purpose of this Safety Notice is to alert health and social care services to potential risks to laboratory staff, if specimen request forms do not contain relevant details.

It will be of particular relevance to medical staff within organisations that provide specimens from patients to laboratories for testing. This will include all persons who have direct patient contact who complete the electronic or paper specimen request forms eg clinicians, nurses and General Practitioners.

Following reports made under The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR), HSE's Biological Agents Unit (BAU) have conducted a number of investigations at Clinical Diagnostic Laboratories.

A common theme is the lack of sufficient relevant clinical details being provided on specimen request forms. This has resulted in samples being handled at the wrong biological containment level with resulting increased risk of infection to laboratory staff.

Medical staff should ensure that appropriate information, including relevant travel history is provided in order to alert laboratory staff of potential dangers.

The most common occurrences have been in relation to the isolation and handling of Hazard Group 3 agents, Brucella or Salmonella spp from clinical samples that were initially processed at Containment Level 2. Similar problems could also occur when handling specimens that may contain other Hazard Group 3 or 4 Biological Agents.

Where appropriate arrangements have not been implemented; HSE Inspectors will take appropriate enforcement action in line with our enforcement policies and procedures.

Background

Where a laboratory sample or specimen is considered likely to contain a human pathogen, it is important that the appropriate level of laboratory containment is provided in order to ensure the effective control of the risk of exposure / infection.

Specimens processed for microbiological analysis and considered likely to contain Hazard Group 3 or 4 pathogens must be processed within appropriate containment conditions.

Specimens liable to result in propagation or culture of Hazard Group 3 pathogens for example must be processed in a Containment Level 3 laboratory with associated management arrangements.

Specimens should be supplied with relevant clinical details from requesting clinicians. This can be used to inform the assessment and further laboratory processing eg the types of organisms that might be present in specimens from a returning traveller or those associated with an outbreak scenario.

In clinical laboratories, specimens are sorted and processed on the basis of the information provided. If clinical details are inaccurate or incomplete or there is delay in disclosing new information to the laboratory then this can result in specimens being processed under insufficient laboratory containment conditions.

In a number of recent investigations this has resulted in laboratory staff being placed at increased risk of infection by hazard group 3 agents such as Brucella spp. and Salmonella typhi.

Had the relevant clinical information been included on the initial form, then the specimen is likely to have been processed using appropriate containment with all protective control measures in place.

Action required:

• Ensure that clear guidelines for the completion of specimen request forms are in place, along with measures to provide assurance that guidelines are followed.
• Ensure that procedures are reviewed to ensure that they adequately cover the completion of specimen request documentation eg recent history of relevant foreign travel that may increase the likelihood of exotic agents being present.
• Ensure that clinical details supplied on specimen request forms contain clear information regarding the nature of test being requested and sufficient detail to inform laboratory staff upon the safety precautions they need to take in order to process the specimen without risk of infection.
• Ensure that guidelines include a system to link different specimens from a patient so that all contain the same information in relation to safety.
• Ensure that if, during patient intervention, further information becomes available that has implications for the safety of laboratory staff then this is communicated immediately to the laboratory so that appropriate steps regarding containment can be taken.
• Ensure that key personnel involved in the collection of relevant clinical details and the completion of specimen request documentation receive appropriate training, including refresher training.
• Ensure that a system is in place for monitoring and auditing the correct completion of specimen request documentation and for taking appropriate action.

Relevant legal documents:

• The Health and Safety at Work etc Act 1974
• The Management of Health and Safety at Work Regulations 1999
• The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
• The Control of Substances Hazardous to Health Regulations 2002

References:

Safe working and the prevention of infection in clinical laboratories and similar facilities

Further information:

Biological Agents Unit
Health and Safety Executive
Hazardous Installations Directorate
5S.2 Redgrave Court
Merton Road
Bootle
Merseyside
L20 7HS

HSE: www.hse.gov.uk
Biological Agents Unit: www.hse.gov.uk/biosafety/
E mail: [email protected]

General note:

Please pass this information to a colleague who may operate this type of process.