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)
322689
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.
322689
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.
322689
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.
322689
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
)
)
322689
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
322689
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.
322689
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.
322689
No recommendation is made regarding standardization of abbreviations and conventions. ()
322689
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
)
)
322689
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
)
)
322689
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
)
)
322689
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
Methodology
Number of Source Documents
37
Literature Search Start Date
April 1, 2012
Literature Search End Date
March 1, 2014