Audit tool

Patient identification audit - JCI IPSG.1, outpatient clinics (international)

An audit tool for outpatient clinics to observe staff confirming patient identity using two identifiers before medication, tests, samples, or procedures, ensuring identifiers match requests, labels, and records.

Fill it in online - free, no account needed. 34 questions.

What it is for

This template helps outpatient clinics audit their patient identification processes to enhance patient safety.

The full question list

1. Clinic Environment and Staff Readiness

  1. Patient identification posters or guidelines are visibly displayed in patient care areas. *
  2. Staff observed are wearing identification badges. *
  3. Staff can articulate the two required patient identifiers used by the clinic. *
  4. List the two required patient identifiers stated by staff. *

2. Patient Encounter: Before Medication Administration

  1. Before administering medication, staff verbally confirm the patient's full name. *
  2. Before administering medication, staff verbally confirm a second patient identifier (e.g., date of birth). *
  3. The identifiers confirmed by staff match the medication label. *
  4. The identifiers confirmed by staff match the patient's record. *
  5. Staff do not use room or bed number as an identifier. *
  6. Notes on medication administration observation.

3. Patient Encounter: Before Diagnostic Test

  1. Before a diagnostic test, staff verbally confirm the patient's full name. *
  2. Before a diagnostic test, staff verbally confirm a second patient identifier (e.g., date of birth). *
  3. The identifiers confirmed by staff match the test request form. *
  4. The identifiers confirmed by staff match the patient's record. *
  5. Notes on diagnostic test observation.

4. Patient Encounter: Before Sample Collection

  1. Before collecting a sample, staff verbally confirm the patient's full name. *
  2. Before collecting a sample, staff verbally confirm a second patient identifier (e.g., date of birth). *
  3. The identifiers confirmed by staff match the sample label. *
  4. The identifiers confirmed by staff match the patient's record. *
  5. Notes on sample collection observation.

5. Patient Encounter: Before Procedure

  1. Before a procedure, staff verbally confirm the patient's full name. *
  2. Before a procedure, staff verbally confirm a second patient identifier (e.g., date of birth). *
  3. The identifiers confirmed by staff match the procedure consent form. *
  4. The identifiers confirmed by staff match the patient's record. *
  5. Notes on procedure observation.

6. Records and Documentation

  1. Patient identifiers are consistently recorded in the patient's electronic or paper record. *
  2. Any discrepancies in patient identification were documented and resolved. *
  3. Number of patient records reviewed for identification consistency. *

7. Follow-up and Training

  1. Staff demonstrate understanding of the clinic's policy on patient identification. *
  2. Staff confirm they have received training on patient identification procedures within the last 12 months. *
  3. Any identified areas for improvement in patient identification processes.

8. Sign-off

  1. Completed by (Name) *
  2. Date of completion *
  3. Signature *

References

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 is the purpose of this audit?

This audit helps verify that staff in outpatient clinics correctly identify patients using two identifiers before administering medications, performing tests, collecting samples, or conducting procedures, aligning with JCI IPSG.1 standards.

How often should this audit be conducted?

The frequency of this audit depends on the clinic's internal quality improvement schedule, but regular audits (e.g., quarterly or bi-annually) are recommended to maintain high standards of patient safety.