Healthcare Facility Compliance 12 items
Patient Identification & Specimen Labeling Audit
Audit of two-identifier patient verification and specimen labeling at the point of collection to prevent misidentification and mislabeled specimens.
TJC NPSG.01.01.01CAP GEN.40490CLIA 42 CFR 493.1242
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Patient Identification
- Are at least two patient identifiers (e.g., name and date of birth) used before care, treatment, or specimen collection? *
- Is the room or bed number prohibited as a patient identifier? *
- Is the patient (or wristband) actively verified rather than assumed at the point of collection? *
Specimen Labeling
- Are specimen containers labeled in the presence of the patient at the time of collection? *
- Does each specimen label include at least two identifiers plus collection date and time and collector ID? *
- Are blood bank specimens labeled per additional requirements before leaving the patient? *
Rejection & Error Handling
- Are specimen rejection criteria for mislabeled or unlabeled specimens defined and enforced? *
- Are mislabeling and identification errors reported and tracked for improvement? *
- Is barcode-assisted identification used at collection and administration where available?
Competency & Oversight
- Are staff who collect specimens trained and competency-assessed on identification and labeling? *
- Is a corrective action process in place for repeat mislabeling by an individual or unit? *
- Are transfusion misidentification events treated as sentinel/serious events and reviewed? *
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