Phlebotomy Specimen Collection Audit

Inspection template for auditing phlebotomy specimen collection practices, including patient identification, order verification, tube selection, labeling accuracy, and chain of custody.

Audit Details

• Collection site and audit date recorded
  Document the unit, clinic, room, or draw station being audited and the date/time of observation.
• Inspector name and role documented
  Record the auditor's name, title, and department.
• Observed phlebotomist identified
  Record the staff member performing the collection, if permitted by facility policy.
• Collection type identified
  Select the observed collection workflow.
• Applicable SOP or reference document available
  Reference the local specimen collection SOP, if used during the audit.

Patient Identification

• Two patient identifiers verified before collection
  Confirm use of two approved identifiers before any specimen is drawn.
• Patient identity matched to wristband or source document
  Confirm the patient identifiers matched the wristband, requisition, or LIS source used at the bedside.
• Patient asked to state identifiers when able
  Patient was actively involved in identity confirmation when clinically appropriate.
• Unidentified or altered patient identity issue escalated
  Any discrepancy, unreadable wristband, or mismatch was stopped and escalated before collection proceeded.

Order Verification and Test Preparation

• Order verified against requisition or LIS before draw
  Confirm the collector checked the active order before specimen collection.
• Specimen type and test requirements reviewed
  Collector confirmed special handling needs such as fasting, timed draw, protected from light, chilled transport, or STAT priority.
• Collection timing requirements met
  Timed, pre-dose, post-dose, or fasting requirements were followed as ordered.
• Rejected or duplicate orders identified before collection
  Collector checked for duplicate, canceled, or invalid orders before drawing specimens.
• Special handling instructions documented
  Any special handling instructions were documented and communicated to transport or receiving staff.

Tube Selection and Collection Technique

• Correct tube type selected for ordered tests
  Verify the tube color/additive matched the test order and facility collection guide.
• Order of draw followed
  Confirm the collector followed the approved order of draw to reduce additive carryover.
• Tube fill volume acceptable
  Record the observed fill volume or assess whether the tube was filled to the acceptable range for the additive.
• Specimen collected using aseptic and safe technique
  Collector used appropriate skin antisepsis, maintained specimen integrity, and followed safe sharps handling practices.
• Collection site complications documented
  Any hemolysis risk, difficult draw, multiple attempts, or adverse patient reaction was documented per policy.

Labeling and Specimen Identification

• Specimen labeled immediately after collection at bedside
  Confirm the specimen was labeled in the presence of the patient immediately after collection and before leaving the bedside or draw area.
• Label matches patient identifiers and order
  Verify the label contains the correct patient name, second identifier, date/time of collection, and collector identification as required by policy.
• Label legible, complete, and securely affixed
  Label is readable, not wrinkled or peeling, and does not obscure specimen information.
• Unlabeled or mislabeled specimen prevented from release
  Any unlabeled, partially labeled, or mismatched specimen was held, rejected, or recollected per policy.

Chain of Custody and Transport

• Chain-of-custody requirements identified when applicable
  Confirm chain-of-custody procedures were used for specimens requiring legal, forensic, or controlled handling.
• Specimen handoff documented to receiving staff or transport
  Documented transfer occurred according to facility process, including date/time and recipient when required.
• Transport conditions maintained
  Specimen was placed in the correct bag/container and maintained required temperature, light protection, or urgency status.
• Specimen rejection or incident escalated
  Any transport delay, leakage, breakage, or custody discrepancy was escalated and documented.