Amhara Public Health Institute Dessie Branch

Regional Reference Laboratory

Standard Operating Procedure for Specimen

Management
Compiled by : Abebe Eyasu Signature:

Approved by: Aynalem Mohammed Signature:

Effective date: January 1/ 2020 Version No. 01

Document No: APHIDBL -ALS- SOP5.4-01 Copy No. _____

Date of Discontinuation: _____________________________________

 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory
Title: Standard Operating Procedure Document No: APHIDBL-ALS- SOP5.4-01
for Specimen Management Version No: 01
Section: All Laboratory Sections Page No: 1 of 5 Effective date: January 1/ 2020

A. Annual Review of Document

Reviewed by: Approved by:
Revision No. Review Date
Name Signature Name Signature

B. Version Change History/Description

Version. Effective Description of Version Change Name & Name &
No. Date Signature of Signature of
Reviewer approval

C. Amendment
Rev. Page Description of Amendment Amendment Effective Name &
No. No Date Date Signature of
approval

Authority for Issue: APHIDBL Authorized Date: December15/ 2019

This is a controlled document for internal use only
 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory
Title: Standard Operating Procedure Document No: APHIDBL-ALS- SOP5.4-01
for Specimen Management Version No: 01
Section: All Laboratory Sections Page No: 2 of 5 Effective date: January 1/ 2020

1. Purpose:
This procedure gives instructions on how samples at APHIDBL are handled from collection to
final disposal after testing
2. Scope:
This procedure applies to all samples that are analyzed at APHIDBL
3. Responsibility:
It is the responsibility of the team leaders to ensure this procedure is effectively implemented
and maintained
4. Abbreviations:
ALS All Laboratory Sections
APHIDBL Amhara Public Health Institute Dessie Branch Laboratory
SOP Standard Operating Procedure

5. Definitions: NA
6. Activity description:
A. Sample collection
Samples are collected in the APHIDBL specimen’s collection area and some specimens are
collected inside hospital by physicians and outside referral sites sample. Details for sample
collection are given in the laboratory handbook
B. Sample handling and transportation
Samples from hospitals and health centres are transported to APHIDBL reception in a cooler
box with the request forms held separately. Refer to laboratory handbook for specific
instructions on sample storage and stability.
C. Registration of samples into LIS – Sample identification
Following collection, samples are booked in the specimen log .LIS system at the laboratory
reception and assigned unique identification numbers. Instructions on how to register samples
are stated in the LIS operator manual. If the LIS is not functional, samples are registered
manually in the specimen log at the reception and a unique sample number is assigned.
D. Handling samples at the reception
 Health facilities/postal service deliver samples to the laboratory reception with a delivery
form .
Authority for Issue: APHIDBL Authorized Date: December15/ 2019
This is a controlled document for internal use only
 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory
Title: Standard Operating Procedure Document No: APHIDBL-ALS- SOP5.4-01
for Specimen Management Version No: 01
Section: All Laboratory Sections Page No: 3 of 5 Effective date: January 1/ 2020

 The reception staff signs off the delivery form after receiving the sample.
 The reception staff checks the samples and request forms to ensure they are acceptable
according to instructions of the laboratory handbook
 Samples not meeting the requirements of the laboratory handbook are rejected and
recorded.
 Criteria for sample rejection are given in the laboratory handbook.
 Sample and result tracking form (APHIDBL-AL-F5.7-01) is generated which list down
the sample assigned to analytical workstation and result return to reception.
E. Sample handling in sections
 Samples are received in the section by verification of Sample and result tracking form.
 Samples are analyzed according to the technical procedures in the respective sections.
 Where samples are split, the different aliquots are labelled with the same identification
number as on the original sample.
F. Handling of compromised but irreplaceable samples
 Irreplaceable samples such as CSF or neonatal samples are not rejected as other samples.
 If the sample or request form is not properly labelled, it is processed but results are
retained until the identification process is clarified with the requesting clinicians.
 If the sample itself is compromised the technical staff proceed with analysis and comment
on the patient report stating in which way the sample was compromised and how that
might have affected the results.
G. Handling urgent samples
 Requesting clinicians identify the urgent samples by indicating the “Urgent’’ option on
the request form.
 Reception staff prioritizes urgent samples during registration and immediately forwards
the sample to the section.
 The technical staffs process the sample within the shortest possible time.
H. Sample indexing
 Sample racks used for keeping blood samples are labelled with days and or dates. Slides
are kept on racks also labelled with days and or dates. Urine, stool and sputum samples
are not kept on any racks therefore they do not have further indexing.
I. Sample retention after testing
 Samples are retained for periods as defined on the sample retention schedule.
J. Treating Human sample
Authority for Issue: APHIDBL Authorized Date: December15/ 2019
This is a controlled document for internal use only
 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory
Title: Standard Operating Procedure Document No: APHIDBL-ALS- SOP5.4-01
for Specimen Management Version No: 01
Section: All Laboratory Sections Page No: 4 of 5 Effective date: January 1/ 2020

All human clinical samples treated according to ethical conduct, safety manual and FMOH
regulation.
K. Safe disposal of samples
When the retention times of samples have elapsed, they are disposed of as biological waste.
The waste is then secured and transported to the incinerator for destruction.
Refer to the safety manual for more details on waste management.

7. Supporting documents:
S. No. Document Name Document Unique ID
2 Safety manual APHIDBLL-ALS- MAN 5.2-01
4 Sample tracking form APHIDBL-ALS- F5.4-08
5 Sample Tracking Log APHIDBL-ALS- F5.4-07

8. References:
ISO Standard 15189:2012 Medical Laboratories-Requirements for Quality and competence

Authority for Issue: APHIDBL Authorized Date: December15/ 2019

This is a controlled document for internal use only
 Amhara Public Health Institute Dessie Branch Regional Reference Laboratory
Title: Standard Operating Procedure Document No: APHIDBL-ALS- SOP5.4-01
for Specimen Management Version No: 01
Section: All Laboratory Sections Page No: 5 of 5 Effective date: January 1/ 2020

9. Declaration
I, the undersigned laboratory personnel, certify that I am conducting every steps of the procedures
incorporated in this SOP after a prior reading.
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Authority for Issue: APHIDBL Authorized Date: December15/ 2019

This is a controlled document for internal use only