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의료기관 컴플라이언스 12개 항목

Patient Identification & Specimen Labeling Audit

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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? *

Patient Identification & Specimen Labeling Audit 체크리스트 전체 다운로드

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