GLI GLI Quality Tool
GLI Quality Tool — Version 2.0

How to Implement a TB Specimen Rejection Log With Error Codes

A tuberculosis laboratory rejection log is a simple quality improvement tool with a significant operational role. It records specimens that cannot be processed, explains why they were rejected, and shows whether the same collection or transport problems keep occurring. Used consistently, the log turns isolated incidents into evidence for corrective action.

The aim is not to blame the clinician, collector, courier or referring service. A rejected sputum sample may reflect unclear instructions, an unsuitable container, delayed transport, leakage, missing identifiers or a request form that does not contain enough clinical information. Recording the event objectively helps the laboratory and its partners fix the process rather than debate individual mistakes.

For Australian laboratories, this can be especially important across wide referral networks. A specimen may travel from a regional hospital in Queensland, a remote Aboriginal Community Controlled Health Service or a metropolitan clinic in Melbourne to a public health reference laboratory. Long distances, limited courier runs and different local workflows can all affect specimen acceptability.

The GLI Quality Tool provides a practical framework for building this process into a broader quality management system. Its four-phase roadmap and twelve Quality Systems Essentials can help a laboratory connect rejection monitoring with documentation, personnel, equipment, assessment, safety and continual improvement.

Establish The Purpose And Scope

Begin by defining what the log is meant to achieve. A useful purpose statement might be: “To identify, classify and reduce preventable reasons for rejecting TB specimens while protecting result accuracy and patient safety.” This keeps the log focused on quality rather than staff performance monitoring.

Set the scope before choosing a format. Decide whether the record will cover all specimens received for tuberculosis testing or only respiratory samples for microscopy, nucleic acid amplification testing and culture. Many laboratories begin with sputum, then expand to induced sputum, bronchoalveolar lavage, gastric aspirates, tissue and other specimen types once the process is stable.

The log should capture enough information for investigation without collecting unnecessary personal data. Suitable fields include date received, specimen type, referring location, test requested, rejection decision, error code, person or team notified, corrective action and final disposition. A laboratory information system may hold the patient identifier, while the quality log uses a laboratory accession number.

Write a short procedure describing who records the rejection, when it must be entered, who reviews trends and how urgent clinical notifications are made. A high-risk issue, such as a leaking container or a sample with a compromised identity, should be communicated promptly rather than waiting for the monthly quality meeting.

Create A Practical Error Code Set

Error codes should be short, specific and easy to apply during a busy receiving shift. Avoid creating dozens of categories that staff interpret differently. A starting set could include:

The code should describe the immediate reason for rejection, not the presumed cause. For example, use “FO01: request form incomplete” rather than recording that a clinic “failed to follow instructions”. A second field can capture the contributing factor, such as outdated collection guidance, a courier delay or a misunderstanding about testing requirements.

Create written acceptance and rejection criteria beside the codes. “Insufficient volume” should have a defined threshold or test-specific rule. “Transport delay” should refer to an agreed timeframe and specimen storage condition. This prevents two staff members from making different decisions about the same sample on a Friday arvo.

Review the code list with specimen reception staff, scientists, clinicians, couriers and representatives from referring services. In Australia, include the realities of state and territory referral arrangements, where the local collection instructions may differ from those used by a national or interstate reference laboratory.

Build The Log Into Daily Workflow

The most reliable log is the one that takes seconds to complete. Add a rejection option to the laboratory information system if possible, with mandatory fields for the error code, date, specimen type and referring location. If a digital system is not available, use a controlled spreadsheet or paper form with a unique record number and restricted access.

Make the decision point clear. A trained staff member should assess every received TB specimen against the acceptance criteria, record the code immediately and notify the referring service according to the procedure. The log should also show whether recollection was requested, accepted after clarification or referred to a senior scientist for a documented exception.

Not every unsuitable specimen can simply be discarded. If a patient is seriously ill or recollection is difficult, a senior laboratory professional and the treating team may need to discuss whether testing can proceed with a qualification. The decision, risk assessment and limitations of the result must be documented. This is particularly relevant for remote communities where the next transport opportunity may be several days away.

Use the downloadable materials from the GLI Quality Tool when developing local forms, procedures and supporting documents. Adapt them to the laboratory’s information system, governance requirements and test menu rather than copying a generic template without review.

Train Staff And Communicate With Referrers

Training should explain both the technical rule and the reason behind it. Staff need to know how to identify a leaking container, reconcile labels with request forms, assess volume, check transport conditions and select the correct code. Short competency activities using realistic examples are often more useful than a long presentation.

Include reception staff, scientists, couriers, collection teams and relevant clinical contacts. A collector may need a practical reminder about sputum collection, while a clinician may need a clear explanation of why saliva is unsuitable for a particular test. Provide a concise rejection notification that states the problem, the action required and whether recollection is urgent.

Communication should be respectful and consistent. A rejection message such as “Specimen rejected: CO01, incorrect container. Please recollect in the approved sterile container and arrange transport according to the local TB collection procedure” is more useful than “sample not suitable”. Where policy permits testing to continue with a limitation, state that clearly rather than creating uncertainty.

For regional and remote services, make sure instructions fit the actual supply chain. A collection point in the Northern Territory may need extra containers, reliable packaging supplies and a planned courier pathway. An urban service in Sydney may have several daily runs and can manage a rapid recollection. The same rejection rule may require different corrective actions in each setting.

Analyse Trends And Drive Improvement

A rejection log becomes valuable when the laboratory reviews patterns rather than filing records away. At least monthly, calculate the rejection rate by specimen type, referring site, test requested and error code. A simple measure is the number of rejected specimens divided by the total number received, multiplied by 100.

Look for repeated causes and clusters. A rise in TR01 after a courier route changes may point to transport scheduling. Frequent ID02 events from one clinic may indicate a labelling workflow problem. Increased CO02 records may suggest poor packaging, damaged stock or a collection point that needs additional training.

Set a small number of improvement targets, such as reducing incomplete forms by 25 per cent over three months or eliminating recurrent leakage from a specific route. Assign an owner, due date and review method. Actions might include revising a collection guide, updating a specimen reception checklist, changing packaging, increasing courier frequency or providing feedback at a clinical network meeting.

Rejection trends should be considered alongside reporting timeliness, recollection rates and clinician notifications. The GLI Quality Tool’s reporting timeliness guide can support this wider review, since a rejected sample and delayed replacement specimen may affect the time to clinical decision-making.

Include the findings in management review and quality meetings. Preserve a record of the baseline, action taken and later result so the laboratory can demonstrate whether the change worked. For laboratories aligning their quality system with NATA expectations and ISO 15189 principles, this evidence also supports documented risk management, monitoring and continual improvement.

Use the GLI Quality Tool phase checklists to check that the rejection process is supported by appropriate documentation, trained personnel, assessment activities and improvement records. Revisit the procedure whenever a test method, referral pathway, container, courier arrangement or regulatory requirement changes.

A well-designed TB specimen rejection log should be visible in daily practice, easy to audit and linked to action. Start with a limited set of clear codes, test them with the people who receive and collect specimens, and review the data regularly. Put the approved procedure, code list and review schedule into the laboratory quality system, then use the evidence to improve collection and transport across every service area.