Audit tool
High-alert medication management audit - JCI IPSG.2.1, clinics (international)
Audit how a clinic manages high-alert medications, covering identification, storage, administration, staff knowledge, and documentation to enhance patient safety.
Fill it in online - free, no account needed. 22 questions.
What it is for
This template provides a structured audit for high-alert medication management in clinics.
- Assess compliance with JCI IPSG.2.1 for high-alert medications
- Identify risks in medication storage and labelling
- Verify proper administration protocols for high-alert drugs
- Evaluate staff knowledge and training on high-alert medications
- Document observations and areas for improvement in medication safety
The full question list
1. Clinic Information
- Clinic name *
- Area/Department audited *
- Date and time of audit *
2. High-Alert Medication List
- A current, clinic-specific list of high-alert medications is readily available. *
- Date of last review/update of the high-alert medication list *
- The list includes examples of high-alert medications relevant to the clinic's services (e.g., concentrated electrolytes, insulin, anticoagulants, sedatives). *
3. Storage and Labelling
- High-alert medications are stored in a manner that differentiates them from other medications. *
- High-alert medications are clearly labelled as such. *
- Concentrated electrolytes are not stored in patient care areas unless clinically necessary and clearly labelled. *
- Number of high-alert medications observed without clear labelling *
4. Administration Process
- A second independent check is performed before administering high-alert medications. *
- Method of second check observed (if applicable) *
- The 'five rights' of medication administration (right patient, right drug, right dose, right route, right time) are consistently checked for high-alert medications. *
5. Staff Knowledge and Training
- Staff interviewed can correctly identify at least three high-alert medications used in this clinic. *
- Staff interviewed can describe the clinic's policy for the safe storage of high-alert medications. *
- Staff interviewed can describe the clinic's policy for the second check of high-alert medications before administration. *
- Number of staff interviewed *
6. Documentation and Follow-up
- Medication administration records (MARs) for high-alert medications clearly document the second check. *
- Any incidents or near misses related to high-alert medications are reported and reviewed. *
- Observations and comments (e.g., areas for improvement, good practices observed)
7. Sign-off
- Completed by (Name) *
- Signature *
References
- Supports evidence for: Joint Commission International Accreditation Standards for Ambulatory Care, IPSG.2.1 (4th Edition)
AccrediMe is not affiliated with or endorsed by Joint Commission International (JCI). Standards are cited by identifier only; the standards are JCI's and are not reproduced.
Read the source - Required by: Joint Commission International Accreditation Standards for Ambulatory Care, IPSG.2.1 (4th Edition)
AccrediMe is not affiliated with or endorsed by Joint Commission International (JCI). Standards are cited by identifier only; the standards are JCI's and are not reproduced.
Read the source
How the score works
The score is the share of scored questions that pass. N/A is left out of the score; text, dates and signatures are recorded but not scored. A completed template is a record of what you checked; it is not an inspection by a regulator or an accreditation body.
Questions
What are high-alert medications?
High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Examples include concentrated electrolytes, insulin, anticoagulants, and sedatives.
How often should this audit be conducted?
The frequency of this audit depends on clinic policy and risk assessment, but it is recommended to conduct it regularly, such as quarterly or bi-annually, and after any significant medication-related incidents.