Standard 6: Communicating for Safety Standard

Correct identification and procedure matching

Action 6.5

The health service organisation:

a. Defines approved identifiers for patients according to best-practice guidelines

b. Requires at least three approved identifiers on registration and admission; when care, medication, therapy and other services are provided; and when clinical handover, transfer or discharge documentation is generated

Intent

A comprehensive, organisation-wide system is in place for the reliable and correct identification of patients when care, medicine, therapy and other services are provided or transferred.

Reflective questions

What processes are used to ensure consistent and correct identification at any point in a patient’s admission, care, treatment or transfer?

How are the requirements to use at least three approved patient identifiers described and monitored?

Key tasks

  • Define the approved patient identifiers for use in the organisation, according to best-practice guidelines
  • Develop or confirm an organisation-wide system for patient identification
  • Implement policies and processes that require at least three approved identifiers to be used at registration and on admission; when care, medicine, therapy or other services are provided; and whenever clinical handover or transfer occurs, or discharge documentation is generated.

Strategies for improvement

Hospitals

Develop a patient identification system

An organisation-wide patient identification system is the set of written policies, procedures and protocols that ensure the consistent and correct identification of a patient at any time during an admission or course of treatment. This system is central to efforts to ensure correct patient identification and procedure matching. Policies, procedures and protocols for specific activities (such as patient registration, or generating and checking identification bands) should be included within, or linked to, this system.

Approved patient identifiers are items of information (such as name, date of birth or healthcare record number) that can be used to identify a patient when care, medicine, therapy or services are provided.

At least three approved patient identifiers are required each time identification occurs. This provides manual and electronic patient identification systems with the best chance to correctly match a patient with their record, without imposing impracticable demands on information gathering.

Patient identifiers may include:

  • Patient name (family and given names)
  • Date of birth
  • Gender
  • Address (including postcode)
  • Healthcare record number
  • Individual Healthcare Identifier (IHI) (see Action 1.17 for more information).

Specify the data items approved for patient identification in the organisation, and use at least three identifiers:

  • On admission or at registration
  • When matching a patient’s identity to care, medicine, therapy or services
  • Whenever clinical handover or patient transfer occurs
  • Whenever discharge documentation is generated
  • In specific service settings, if they are different from those generally used across the organisation.

Where the My Health Record system is in use, include the national unique IHI as a patient identifier (see Action 1.17). Do not use identifiers such as room or bed number, because these frequently change and are not unique to patients.

Standardise patient identification bands (if used)

If the organisation uses patient identification bands, identify where these need to be used within the organisation, and what arrangements are in place for maintaining and checking the identity of people who are not wearing identification bands.

Ensure that patient identification bands are standardised and comply with the Specifications For A Standard Patient Identification Band. These specifications apply to bands that have the primary purpose of identifying the patient within the health service organisation. They do not apply to bands or bracelets that have other purposes (such as triggering an alarm when a patient leaves a certain area). Neither the NSQHS Standards nor the specifications require all people receiving care to wear identification bands.

The Commission recommends using identification bands as described in the specifications, and not to vary the specifications. The specifications were developed to minimise adverse events associated with patient identification and procedure matching, and using identification bands that do not comply with the specifications may increase the risk of such events. If it is considered necessary to use a band that differs from the specifications, assess the potential risks associated with any proposed changes, identify strategies to reduce these risks and document this process.

When disposing of patient identification bands, consider issues relating to maintaining the confidentiality and privacy of patient details.

Assess the use of coloured patient identification bands (if used)

The Commission recommends that no coloured bands are used to alert clinicians to specific clinical information (such as falls risk, allergies or resuscitation status). Using colour-coded bands to indicate clinical risk:

  • Is based on tradition rather than evidence of any patient safety benefit1,2
  • Can cause confusion and error because of inconsistencies in meaning for different colours across different organisations, especially when members of the workforce work across different health service organisations3-5
  • May not accurately reflect the patient’s clinical situation or be synchronised with the healthcare record.1,3

If it is considered necessary to have a colour system for identifying a known allergy or other known risk, the patient identification band should be red only (see Specifications for a Standard Patient Identification Band).

Take a multi-factorial approach if patient identification bands are used to manage clinical risk for patients with specific characteristics or conditions. For example:

  • Check the medication record for allergies before prescribing, dispensing or administering medicines (see the Medication Safety Standard)
  • Use a multi-factorial prevention program that involves surveillance, together with interventions such as reviewing medicines (see Action 4.10), making the environment safe (see Action 1.29), screening for infections (see Action 3.6) and minimising the use of restraints (see Action 5.35).

Consider other methods of patient identification

Specialist areas of the organisation may have specific needs regarding patient identification and procedure matching. For example, in mental health units or dialysis units, patient identification bands may be inappropriate, and other methods such as photographic identification may be required. Decide which methods for patient identification and procedure matching will be used in each service or unit, and include these in, or link to, the organisation-wide patient identification system. Consider privacy when adopting a particular method of patient identification (for example, asking for verbal confirmation of a patient’s address in an open waiting room may not be appropriate).

Day Procedure Services

Develop a patient identification system

An organisation-wide patient identification system is a set of written policies, procedures and protocols that ensure the consistent and correct identification of a patient at any time during an episode of care. This system is at the core of efforts to ensure correct patient identification and procedure matching. Policies, procedures and protocols for specific activities (such as patient registration, or generating and checking identification bands) should be included within, or linked to, this system.

Patient identifiers may include:

  • Patient name (family and given names)
  • Date of birth
  • Gender
  • Address (including postcode)
  • Healthcare record number
  • Individual Healthcare Identifier (IHI) (see Action 1.17 for more information).

Specify the data items approved for patient identification in the organisation, and use at least three identifiers:

  • On admission or at registration
  • When matching a patient’s identity to care, medicine, therapy or services
  • Whenever clinical handover or patient transfer occurs
  • Whenever discharge documentation is generated
  • In specific service settings, if they are different from those generally used across the organisation.

Standardise patient identification bands (if used)

Ensure that patient identification bands are standardised and comply with the Specifications for a Standard Patient Identification Band. These specifications apply to bands that have the primary purpose of identifying the patient within the health service organisation. They do not apply to bands or bracelets that have other purposes (such as triggering an alarm when a patient leaves a certain area). Neither the NSQHS Standards nor the specifications require all people receiving care to wear identification bands.

The Commission recommends using identification bands as described in the specifications, and not to vary the specifications. The specifications were developed to minimise adverse events associated with patient identification and procedure matching, and using identification bands that do not comply with the specifications may increase the risk of such events. If it is considered necessary to use a band that differs from the specifications, assess the potential risks associated with any proposed changes, identify strategies to reduce these risks and document this process.

When disposing of patient identification bands, consider issues relating to maintaining the confidentiality and privacy of patient details.

Assess the use of coloured patient identification bands (if used)

The Commission recommends that no coloured bands are used to alert clinicians to specific clinical information (such as falls risk, allergies or resuscitation status). Using colour-coded bands to indicate clinical risk:

  • Is based on tradition rather than evidence of any patient safety benefit1,2
  • Can cause confusion and error because of inconsistencies in meaning for different colours across different organisations, especially when members of the workforce work across different health service organisations3-5
  • May not accurately reflect the patient’s clinical situation or be synchronised with the healthcare record.1,3

If it is considered necessary to have a colour system for identifying a known allergy or other known risk, the patient identification band should be red only (see Specifications for a Standard Patient Identification Band).

Take a multi-factorial approach if patient identification bands are used to manage clinical risk for patients with specific characteristics or conditions. For example:

  • Check the medication record for allergies before prescribing, dispensing or administering medicines (see the Medication Safety Standard)
  • Use a multi-factorial prevention program that involves surveillance, together with interventions such as reviewing medicines (see Action 4.10), making the environment safe (see Action 1.29), screening for infections (see Action 3.6) and minimising the use of restraints (see Action 5.35).

Consider other methods of patient identification

Some services may have specific needs regarding patient identification and procedure matching. For example, in dialysis units, patient identification bands may be inappropriate, and other methods such as photographic identification may be required. Determine which methods for patient identification and procedure matching will be most appropriate for the service. Consider privacy when adopting a particular method of patient identification (for example, asking for verbal confirmation of a patient’s address in an open waiting room may not be appropriate).

Examples of evidence

Select only examples currently in use:

  • Policy documents for patient identification and procedure matching that
    • reference best-practice guidelines
    • specify points of care at which patient identification must occur
    • specify the three approved patient identifiers to be used on each occasion
    • require three approved patient identifiers to be recorded in the healthcare record, including the IHI
  • Policy documents that outline requirements for patient identification using at least three approved patient identifiers for
    • patient registration or admission
    • administration of care, therapy or medicines
    • clinical handover, transfer and discharge
  • Committee and meeting records that show that information about the performance of patient identification processes is routinely reported and reviewed
  • Audit results of medication management (including adverse events, incidents and near misses relating to medication errors) in relation to correct patient identification
  • Communication with the workforce about new or revised policy documents or protocols for patient identification.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established patient identification processes.

Small hospitals that are not part of a local health network or private hospital group will need to:

  • Define the approved patient identifiers for use in the organisation, according to best-practice guidelines
  • Develop or confirm an organisation-wide system for patient identification
  • Implement policies and processes that require at least three approved identifiers to be used at registration and on admission; when care, medicine, therapy or other services are provided; and whenever clinical handover or transfer occurs, or discharge documentation is generated.

Develop a patient identification system

An organisation-wide patient identification system is the set of written policies, procedures and protocols that ensure the consistent and correct identification of a patient at any time during an admission or course of treatment. This system is at the centre of efforts to ensure correct patient identification and procedure matching. Policies, procedures and protocols for specific activities (such as patient registration, or generating and checking identification bands) should be included in, or linked to, this system.

Approved patient identifiers are items of information (such as name, date of birth or healthcare record number) that can be used to identify a patient when care, medicine, therapy or services are provided.

At least three approved patient identifiers are required each time identification occurs. This provides manual and electronic patient identification systems with the best chance to correctly match a patient with their record, without imposing impracticable demands on information gathering.

Patient identifiers may include:

  • Patient name (family and given names)
  • Date of birth
  • Gender
  • Address (including postcode)
  • Healthcare record number
  • Individual Healthcare Identifier (IHI) (see Action 1.17 for more information).

Specify the data items approved for patient identification for use in the organisation, and use at least three identifiers:

  • On admission or at registration
  • When matching a patient’s identity to care, medicine, therapy or services
  • Whenever clinical handover or patient transfer occurs
  • Whenever discharge documentation is generated
  • In specific service settings, if they are different from those generally used across the organisation.

Standardise patient identification bands (if used)

If the organisation uses patient identification bands, identify where these need to be used within the organisation, and what arrangements are in place for maintaining and checking the identity of people who are not wearing identification bands.

Ensure that patient identification bands are standardised and comply with the Specifications for a Standard Patient Identification Band. These specifications apply to bands that have the primary purpose of identifying the patient within the health service organisation. They do not apply to bands or bracelets that have other purposes (such as triggering an alarm when a patient leaves a certain area). Neither the NSQHS Standards nor the specifications require all people receiving care to wear identification bands.

The Commission recommends using identification bands as described in the specifications, and not to vary the specifications. The specifications were developed to minimise adverse events associated with patient identification and procedure matching, and using identification bands that do not comply with the specifications may increase the risk of such events. If it is considered necessary to use a band that differs from the specifications, assess the potential risks associated with any proposed changes, identify strategies to reduce these risks and document this process.

When disposing of patient identification bands, consider issues relating to maintaining the confidentiality and privacy of patient details.

Assess the use of coloured patient identification bands (if used)

The Commission recommends that no coloured bands are used to alert clinicians to specific clinical information (such as falls risk, allergies or resuscitation status). Using colour-coded bands to indicate clinical risk:

  • Is based on tradition rather than evidence of any patient safety benefit1,2
  • Can cause confusion and error because of inconsistencies in meaning for different colours across different organisations, especially when members of the workforce work across different health service organisations3-5
  • May not accurately reflect the patient’s clinical situation or be synchronised with the healthcare record.1,3

If it is considered necessary to have a colour system for identifying a known allergy or other known risk, the patient identification band should be red only (see Specifications for a Standard Patient Identification Band).

Take a multi-factorial approach if patient identification bands are used to manage clinical risk for patients with specific characteristics or conditions. For example:

  • Check the medication record for allergies before prescribing, dispensing or administering medicines (see the Medication Safety Standard)
  • Use a multi-factorial prevention program that involves surveillance, together with interventions such as reviewing medicines (see Action 4.10), making the environment safe (see Action 1.29), screening for infections (see Action 3.6) and minimising the use of restraints (see Action 5.35).

Consider other methods of patient identification

Specialist areas of the organisation may have specific needs regarding patient identification and procedure matching. For example, in mental health units, dialysis units or aged care sections, patient identification bands may be inappropriate, and other methods such as photographic identification may be required. Determine which methods for patient identification and procedure matching will be used in each service or unit, and include these in, or link to, the organisation-wide patient identification system. Consider privacy when adopting a particular method of patient identification (for example, asking for verbal confirmation of a patient’s address in an open waiting room may not be appropriate).

Action 6.6

The health service organisation specifies the:

a. Processes to correctly match patients to their care

b. Information should be documented about the process of correctly matching patients to their intended care

Intent

Explicit processes are in place to correctly match patients with their intended care, to ensure that the right patient receives the right care.

Reflective questions

How are the processes for matching a patient to their intended care described?

How does the health service organisation ensure that the workforce is using these processes?

Key tasks

  • Develop explicit, documented protocols that outline the process of matching a patient to their intended treatment, tailored to the procedure and organisation
  • Check that these processes align with nationally agreed policies, if they exist
  • Ensure that policies specify which information should be documented about the process of identification and procedure matching.

Strategies for improvement

Hospitals

Resources and procedures should be organised, integrated, regulated and administered to correctly identify patients at any point during an admission or course of treatment. Document and implement these so that all members of the workforce clearly understand their responsibilities and accountabilities.

Correct identification is particularly important at transitions of care, where there is an increased risk of information being miscommunicated or lost.6,7 Transitions of care occur frequently in health care and include situations when a patient’s care is transferred between members of the clinical workforce, to another health service organisation or to their primary care clinician. At these times, information about a person’s identity is critical to ensuring safe patient care. Consider this action alongside other actions within this standard (in particular, Actions 6.7 and 6.8).

The type of patient identification and procedure-matching process will depend on the type of procedure, the design of workflow in a particular area or organisation, and the risks for the patient. Clearly document the process for how patient identification and procedure matching are performed in each specialist area to ensure that no requirements are overlooked. For example, in most procedural areas, ‘timeouts’ are required with the whole team before a procedure can begin. In other situations (such as radiology, where there may be only a single operator), this could be done as a ‘stop to verify’ that all requirements are correct.

Align protocols with agreed policies, where they exist. A set of procedure-matching protocols for specific therapeutic and diagnostic areas such as surgery, nuclear medicine and radiation therapy is available on the Commission’s website.

The WHO Surgical Safety Checklist has been demonstrated to improve patient safety8 and is widely used in Australia. This checklist includes elements relating to patient identification and procedure matching, and can be used as the patient identification and procedure-matching protocol. There is also an Australian and New Zealand version of this checklist.

The key steps that underlie these protocols of care are:

  • If necessary, mark the site of the procedure
  • Verify the identity of the patient
  • Verify the details of the procedure being undertaken, including the site of the procedure
  • Take a timeout or similar stop with all members of the team to do a final check before starting the procedure
  • Confirm all documentation, samples, and other information and materials following completion of the procedure.

To develop protocols for other clinical situations, involve those with local knowledge of the process to adapt the patient identification and procedure-matching protocols for their specific requirements. When deciding which clinical areas should have their own specific patient- or procedure-matching protocol, focus on areas of higher risk for patients and the organisation.

Support communication among clinicians and with patients

Supporting team participation and communication in safety checks is key to achieving a shared understanding of what is required and improving patient safety. Communication strategies used during the checking processes could include ‘making sure, double checking’, ‘verbalising information’ and ‘deliberate confirmation of checklist items with oral validation’.195 These strategies promote closed-loop communication and allow an opportunity for participants to ask questions or clarify concerns.195,295,296

Incorporate patient identification and procedure matching into structured clinical handover processes, as required under Actions 6.7 and 6.8. Ensure that the documentation required for patient identification at handover, transfer and discharge is determined by these policies, procedures and protocols.

If appropriate, support patients, carers and families to take part in the processes to correctly match patients to their care. This may include asking a patient to confirm details about their identity, or asking the patient, family or carer to confirm details about care. For surgical safety checks, the timeout check could be done while the patient is still awake to enable them to contribute to the conversation, rather than performing it after the anaesthetic is given.195

Specify the information that needs to be documented about the processes to correctly match patients to their intended care

Ensure that policies describe what documentation is needed about the processes to correctly match a patient to their intended care. The requirements for documentation will depend on the situation. For example, it is not feasible or necessary to record that three identifiers have been used to check the identity of each patient who has been administered a medicine. However, if the surgical safety checklist is used in operating theatres, documented confirmation that it has been used, or the completed checklist itself, can be kept in the patient’s healthcare record.

Day Procedure Services

The type of patient identification and procedure-matching process will depend on the type of procedure and the risks for the patient. Clearly document the process for how patient identification and procedure matching are performed in each specialist area to ensure that no requirements are overlooked. For example, in most procedural areas, ‘timeouts’ are required with the whole team before a procedure can commence. In other situations (such as radiology, where there may be only a single operator), this could be done as a ‘stop to verify’ that all requirements are correct.

Align protocols with agreed policies, where they exist. A set of procedure-matching protocols for specific therapeutic and diagnostic areas such as surgery, nuclear medicine and radiation therapy is available on the Commission’s website.

The WHO Surgical Safety Checklist has been demonstrated to improve patient safety187 and is widely used in Australia. This checklist includes elements relating to patient identification and procedure matching, and can be used as the patient–procedure matching protocol. There is also an Australian and New Zealand version of this checklist.

The key steps that underlie these protocols of care are:

  • If necessary, mark the site of the procedure
  • Verify the identity of the patient
  • Verify the details of the procedure being undertaken, including the site of the procedure
  • Take a timeout or similar stop with all members of the team to do a final check before starting the procedure
  • Confirm all documentation, samples, and other information and materials following completion of the procedure.

To develop protocols for other clinical situations, involve those with local knowledge of the process to adapt the patient identification and procedure-matching protocols for their specific requirements.

Support communication among clinicians and with patients

Supporting team participation and communication in safety checks is key to achieving a shared understanding of what is required and improving patient safety. Communication strategies used during the checking processes could include ‘making sure, double checking’, ‘verbalising information’ and ‘deliberate confirmation of checklist items with oral validation’.136 These strategies promote closed-loop communication and allow an opportunity for participants to ask questions or clarify concerns.136,188,189

Incorporate patient identification and procedure matching into structured clinical handover systems, as required under Actions 6.6 and 6.7. Ensure that the documentation required for patient identification at handover, transfer and discharge is determined by these policies, procedures and protocols, and reflected in the organisation-wide patient identification and procedure-matching system.

If appropriate, support patients, carers and families to take part in the processes to correctly match patients to their care. This may include asking the patient to confirm details about their identity; or asking the patient, family or carer to confirm details about care. For surgical safety checks, the timeout check could be done while the patient is still awake to enable them to contribute to the conversation, rather than performing it after the anaesthetic is given.136

Specify the information that needs to be documented about the processes to correctly match patients to their intended care

Ensure that policies describe what documentation is needed about the processes to correctly match a patient to their intended care. The requirements for documentation will depend on the situation. For example, it is not feasible or necessary to record that three identifiers have been used to check the identity of each patient who has been administered a medicine. However, if the surgical safety checklist is used in operating theatres, documented confirmation that it has been used, or the completed checklist itself, can be kept in the patient’s healthcare record.

Examples of evidence

Select only examples currently in use:

  • Policy documents that outline
    • the points of care when procedure matching is required
    • processes for matching patients to their care, including the use of three approved identifiers
    • the documentation to be included in the patient’s healthcare record that demonstrates correct procedure matching
  • Standardised templates for documenting procedure-matching processes, such as surgical safety checklists, consent forms, medication management plans and handover checklists, that are updated in line with identified risks, consumer feedback and committee recommendations
  • Training documents about processes to correctly match patients to their intended care, therapy or treatment
  • Communication with the workforce about new or revised policy documents for procedure matching.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established processes for correctly matching patient to their care.

Small hospitals that are not part of a local health network or private hospital group may need to:

  • Develop explicit, documented protocols that outline the process of matching a patient to their intended treatment, tailored to the procedure and organisation
  • Check that these processes align with nationally agreed policies, if they exist
  • Ensure that policies specify which information should be documented about the process of identification and procedure matching.

Correct identification is especially important at transitions of care, where there is an increased risk of information being miscommunicated or lost.208,226 Transitions of care occur often in health care and include situations in which a patient’s care is transferred between members of the clinical workforce, to another health service organisation or to their primary care clinician. At these times, information about a person’s identity is critical to ensuring safe patient care. Consider this action alongside other actions in this standard (especially Actions 6.7 and 6.8).

The type of patient identification and procedure-matching process will depend on the type of procedure, the design of workflow in a particular area or organisation, and the risks for the patient. Clearly document the process for how patient identification and procedure matching are performed in each specialist area to ensure that no requirements are overlooked. For example, in most procedural areas, ‘timeouts’ are required with the whole team before a procedure can start. In other situations (such as radiology, where there may be only a single operator), this could be done as a ‘stop to verify’ that all requirements are correct.

Support communication among clinicians and with patients

Supporting team participation and communication in safety checks is key to achieving a shared understanding of what is required and improving patient safety. Communication strategies used during the checking processes could include ‘making sure, double-checking’, ‘verbalising information’ and ‘deliberate confirmation of checklist items with oral validation’.133 These strategies promote closed-loop communication and allow an opportunity for participants to ask questions or clarify concerns.133,227,228

Incorporate patient identification and procedure matching into structured clinical handover processes, as required under Actions 6.6 and 6.7. Ensure that the documentation required for patient identification at handover, transfer and discharge is determined by these policies, procedures and protocols.

If appropriate, support patients, carers and families to take part in the processes to correctly match patients to their care.

Specify the information that needs to be documented about the processes to correctly match patients to their intended care

Ensure that policies describe what documentation is needed about the processes to correctly match a patient to their intended care. The requirements for documentation will depend on the situation.

Last updated 30th May, 2018 at 12:24am
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References

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