Uniform Labeling of Blocks and Slides in Surgical Pathology

Publication Date: December 1, 2015
Last Updated: March 14, 2022

Recommendations

Laboratories should ensure that all blocks and slides are unambiguously labeled using two patient identifiers. (Recommendation)
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Laboratories should ensure that the accession designation used on the surgical pathology report, and all blocks and slides from that accession, includes the case type (surgical pathology versus cytology or autopsy), the year, and a unique accession number. (Expert Consensus Opinion
 
)
Example: S14-9999 (Surgical Case-Year-Accession Number)
Note: Laboratories may position the information in a different format (eg, 14-9999S, 14S-9999) and may include additional letters that reflect the hospital or clinic site of origin.
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If the patient’s name is used as one of the patient identifiers, laboratories should ensure that the name format will link the blocks and slides to the correct patient. (Expert Consensus Opinion
 
)
Note: Possible formats include, but are not limited to, full last and first name, full last name with first initial, or an appropriate number of letters of the last and first names.
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When an accession number has not yet been assigned (eg, frozen sections or intraprocedural consultations), laboratories should label the blocks and slides with at least two patient identifiers, one of which is the patient name. (Recommendation)
Note: Possible additional identifiers include, but are not limited to, date of birth, medical record number, or unique health identification number.
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Laboratories should label each specimen container with a unique alpha-numeric designation that incorporates the accession designation. Each block and slide from that specimen container should be labeled with the same unique alpha-numeric designation. (Expert Consensus Opinion
 
)
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Laboratories should label each block obtained from a single specimen sequentially with a unique alpha-numeric designation that can be unambiguously linked to a gross description within the pathology report. The order should be accession designation, specimen identifier, and block identifier. Laboratories may select the format of the specimen/block identifier. (Expert Consensus Opinion
 
)
Example: For Specimen A … blocks are labeled 1, 2, 3… S14-9999 A1, A2, A3 For Specimen 1 … blocks are labeled A, B, C… S14-9999-1A, 1B, 1C
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When multiple slides are cut from a single block, laboratories should label each slide sequentially in order of cutting. This slide identifier should come after the specimen identifier and block identifier. (Expert Consensus Opinion
 
)
Example: S14-9999-A1-1, S14-9999-A1-2, S14-9999-A1-3
Note: The laboratory may determine the exact labeling format for multiple slides.
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The laboratory should label the slides with the histochemical, immunohistochemical and/or special procedure (eg, FS for frozen section, TP for touch preparation, AFB for acid fast bacteria) after the accession, specimen, block, and slide identifiers. The histochemical technique or specific antibody used should also be included when it may affect the interpretation. (Expert Consensus Opinion
 
)
Examples: S14-9999-A1-1 FS S14-9999-A1-1 Cytokeratin (AE1/AE3) S14-9999-A1-1 AFB (Ziehl-Neelsen, Wade-Fite, etc)
Note: The panel concludes that surgical pathology slides labeled with terms such as recut, level, or deeper and slides without an explicit stain name are inherently implied to be a hematoxylin and eosin stain; no additional labeling is required. The panel also concludes that the labeling of control slides or control tissue on test slides is beyond the scope of this guideline; however, the panel concludes that laboratories should establish a clear and standardized method for distinguishing control tissues from patient tissues that can be understood internally and externally.
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No recommendation is made regarding standardization of abbreviations and conventions. ()
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On paraffin blocks, the accession designation should be the most prominent printed element (ie, larger font or bolded) followed by the patient name or other second identifier. As long as the ability to read the accession designation and second identifier is not compromised, additional elements may be included as determined by the laboratory. (Expert Consensus Opinion
 
)
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On microscopic slides, the accession designation should be the most prominent printed element (ie, larger font or bolded) followed by the patient name or other second identifier and stain/procedure name. As long as the ability to read these essential elements is not compromised, additional elements may be included as determined by the laboratory. (Expert Consensus Opinion
 
)
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Laboratories should label blocks and slides received in consultation with their own institution’s accession designation. Laboratories should not obscure the original label when relabeling. (Expert Consensus Opinion
 
)
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Recommendation Grading

Overview

Title

Uniform Labeling of Blocks and Slides in Surgical Pathology

Authoring Organization

College of American Pathologists

Publication Month/Year

December 1, 2015

Last Updated Month/Year

May 31, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To develop recommendations that will address the need for adequate patient identification and provide a consistent method of identifying slides originating from a particular block.

Inclusion Criteria

Female, Male, Adult

Health Care Settings

Hospital, Laboratory services

Intended Users

Laboratory technician, clinical researcher, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management

Diseases/Conditions (MeSH)

D010338 - Pathology, Clinical

Keywords

Surgical Pathology, block and slide labeling

Supplemental Methodology Resources

Data Supplement, Methodology Supplement

Methodology

Number of Source Documents
37
Literature Search Start Date
April 1, 2012
Literature Search End Date
March 1, 2014