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Run: Phlebotomy Specimen Collection Audit

Audit phlebotomy collection steps to reduce labeling errors, support specimen integrity, and document every handoff from draw to transport.

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Patient Identification

Confirm at least two approved identifiers were used, such as full name and date of birth.
Verify the patient information on the order, wristband, and verbal confirmation are consistent.
Confirm the patient was actively involved in identity verification when able to respond.

Order Verification and Test Preparation

Verify the requisition or electronic order was checked prior to specimen collection.
Confirm any fasting, timing, transport, protection from light, or temperature requirements were reviewed.
Confirm the correct order of draw was followed for the tubes collected.

Tube Selection and Collection Technique

Verify the tube color/additive matched the test requirements.
Confirm tubes were filled according to manufacturer requirements to ensure specimen integrity.
Verify additive tubes were gently inverted the correct number of times after collection.
Confirm the venipuncture or capillary collection site and technique were appropriate and documented when needed.

Labeling and Specimen Identification

Verify labeling occurred in the presence of the patient and before leaving the collection area.
Confirm labels include required patient identifiers and collection details per policy.
Verify the label information matches the specimen type and the collection order without discrepancies.
Confirm no specimen was left unlabeled or labeled before the patient was present.

Chain of Custody and Transport

Confirm custody documentation was completed for specimens requiring legal or forensic traceability.
Verify specimen transfer to courier, lab staff, or transport container was documented according to policy.
Confirm specimens were transported under required conditions and within acceptable time limits.

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