CHHS14/051

Canberra Hospital and Health Services

Clinical Policy
Patient Identification and Procedure Matching
Policy Statement

Confirmation of a patient’s identity must occur with the participation of the patient
wherever possible.

ACT Health staff must use three (3) patient identifiers (as outlined in Section 3 of the Patient
Identification and Procedure Matching Procedure) to ensure all patients are correctly
identified and matched to their intended health care:
 On patient registration, admission to a service, or at the beginning of a one on one
consultation
 When care, therapy, diagnostic procedures, advice or information, or other services are
provided
 When transferring responsibility of care, and
 Whenever clinical handover, patient transfer or discharge documentation is generated.

Specific ACT Health strategies which support patient identification and procedure matching
processes are:
 The requirement that inpatients must wear a patient identification band for the
duration of their hospital admission wherever possible, with the exception of patients
admitted to the Adult Mental Health Unit, Mental Health Assessment Unit and Brian
Hennessy Rehabilitation Centre.
 Compliance with the Australian Commission on Safety and Quality in Health Care
(ACSQHC) national patient identification band specifications in Attachment 1.
 The use of patient identification bands or approved alternatives, for outpatients (where
care will/may be given by multiple service providers) undergoing:
o Surgery
o Blood or blood product transfusion
o Sedation
o Invasive medication therapy with significant known risks, potential complications or
adverse health outcomes, or
o Invasive and non-invasive procedures with significant known risks, potential
complications or adverse health outcomes
 The use of the World Health Organization (WHO) Surgical Safety Checklist modified to
suit local environments where invasive procedures are performed, e.g. operating rooms
and medical imaging. The operating surgeon or clinician, is responsible for initiating and
leading Surgical Safety Checklist briefings.

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 1 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
 CHHS14/051

Purpose

In this document a health care activity refers to all clinical, non-clinical, administrative and
supportive activities performed in the provision of health care or services by ACT Health in
both acute and non-acute settings, including community settings. Examples of health care
activities are provided in Attachment 2.

Patient identification errors can occur in all types of health care activities, whether they are
diagnostic (such as radiology or pathology testing), therapeutic (medication administration,
surgery) or supportive (such as patient booking or registration processes).

These errors can become significant safety incidents which may cause considerable harm
and distress to patients, their families, carers and the health professionals involved in their
care.

Staff need to be aware that in a strange environment patients can feel frightened,
overwhelmed or intimidated and can find it daunting or feel discouraged from expressing
their concerns, pointing out a problem to staff or questioning what is happening to them.

To be successful, patient identification checks must be completed with the participation of

the patient and at the same time they are to be given the opportunity and encouraged to
ask questions about the correctness of the health care activity to be undertaken. Active
engagement in their health care is essential to achieve best possible outcomes for patients
and is in accordance with the Australian Charter of Healthcare Rights (2008).

This policy and associated procedure have been developed to:

1. Outline the process to ensure the identity of patients is known by ACT Health staff and
patients are correctly matched to the correct health care activity
2. Help staff understand and meet their responsibilities in the identification of patients in
accordance with:
 Relevant policy
 Legislation, and
 National Safety and Quality Health Service Standards (NSQHSS)
3. Provide evidence for ongoing evaluation and audit of processes and actions.

Scope

This policy aligns with the NSQHS Standard No. 5: Patient Identification and Procedure
Matching that identifies at least three (3) approved patient identifiers must be used to
confirm a patient’s identity. Associated procedures that need to be read in conjunction with
this policy are the:
 Patient Identification and Procedure Matching Procedure, and
 Patient Identification: Pathology Specimen Labelling Procedure.

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 2 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
 CHHS14/051

They provide information for use by all ACT Health staff, including clinical, non-clinical and
administrative staff and students in acute and non-acute settings, including community
settings, to ensure they know the patients identity prior to all health care activities that may
have the potential to cause unintended harm to the patient.

Other relevant NSQHS Standards that include Patient Identification and Procedure Matching
components are:
 No. 1: Governance
 No. 2: Partnering with Consumers
 No. 4: Medication Safety
 No. 6: Clinical Handover, and
 No. 7: Blood and Blood Products.

The Patient Identification and Procedure Matching eLearning tool supports this policy and
associated procedures and is highly recommended education for all ACT Health staff.

Roles & Responsibilities

All ACT Health staff involved in patient identification are responsible for becoming familiar
with this policy and related procedures. Managers must ensure staff are able to access,
interpret and apply this document and are provided with education related to this policy.

Responsibility for ensuring the correct patient undergoes the correct health care activity
rests with all staff, and each staff member is individually accountable.

The person who will perform the health care activity carries ultimate responsibility to
match the patient with the care, therapy or service being provided.

Evaluation

Outcome Measures
 Increase compliance to patient identification and procedure matching.
 There will be no incidents of patients undergoing an incorrect health care activity due to
errors in patient identification and procedure matching.

Method
 The Patient Identification and Procedure Matching Standard Group will:
o Monitor any incidents of patient misidentification and/or procedure mismatching
recorded on RiskMan
o Review results from monthly sample Patient Identification Band audits, conducted
by Canberra Hospital and Health Services (CHHS) Divisions
o Review relevant patient identification data from other monthly clinical audits
performed in CHHS Divisions

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 3 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
 CHHS14/051

 CHHS Operating Theatres will conduct monthly sample observational audits of the
Surgical Safety Checklist team briefing and report results for review by the Patient
Identification and Procedure Matching Standard Group and the Surgical Services
Taskforce.

Related Policies, Procedures, Guidelines and Legislation

Policies
Clinical Handover Policy
Medication Management Policy
Clinical Records Management Policy
Consent and Treatment Policy
Incident Management Policy

Procedures
Patient Identification and Procedure Matching SOP
Patient Identification: Pathology Specimen Labelling SOP
Clinical Record Documentation SOP
Consent and Treatment SOP
Consent and Treatment: Capacity and Substitute Decision Maker SOP
Consent for a Child or Young Person SOP
Incident Management Policy and SOP
Significant Incident SOP
Patient Identification - Surgical Safety Checklist SOP

Legislation
Health Practitioner Regulation National Law (ACT) Act 2010
Health Records (Privacy and Access) Act 1997
Health Regulation (Maternal Health Information) Act 1998
Human Rights Act 2004
Privacy Act 2014
Carers Recognition Act 2010
Children and Young Peoples Act 2008
Guardianship and Management of Property Act 1991
Medical Treatment (Health Directions) Act 2006
Mental Health Act 2015
Powers of Attorney Act 2006

Definition of Terms

Clinical Handover - Is the communication process that enables the ‘transfer of professional
responsibility and accountability for some or all aspects of care for a patient, or group of
patients, to another person or professional group on a temporary or permanent basis’. This

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 4 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
 CHHS14/051

is an all encompassing statement intended to include all interactions relating to the care of
an individual patient.

Incident – An event or circumstance which could have resulted in (near miss), or did result,
in unintended or unnecessary:
 Harm:
o to a worker
o to a patient, client, consumer
 Complaint, loss or damage:
o to property and services (including infrastructure)
o to the environment
o regarding financial management
o regarding information management
o regarding the reputation of the organisation
 Deviations
o from endorsed plans, processes.

Patient - In this document the term ‘patient’ refers to patients, consumers and clients
receiving health care from ACT Health.

Transfer of care - Any instance where the responsibility for care of a patient passes from one
individual or team to another. This includes nursing and medical changes of shift, transfer of
care to another area of the health service or to another medical officer or primary care
practitioner and transfer of a patient to another health facility.

References

1. Australian Commission on Safety and Quality in Health Care National Health Service
Standards, (September 2011).
2. Specifications for a standard patient identification band – Specifications, Fact Sheet
and FAQs, Australian Commission on Safety and Quality in Health Care 2009.
3. Protocol ‘Ensuring Correct Patient, Correct Site, Correct Procedure’, Australian Council
on Safety and Quality, 2004.
4. WHO Surgical Safety Checklist 2009.
5. Australia and New Zealand Surgical Safety Checklist 2009.
6. Patient Identification Policy and Guideline, Version 3.0 Government of South Australia,
Department of Health and Ageing, Public Health and Clinical Systems, 2013.
7. Surgical Team Safety Checklist Policy Directive, Version 2.0 Government of South
Australia, Department of Health and Ageing, Public Health and Clinical Coordination,
2012.
8. Australian Charter of Healthcare Rights 2008.
9. Towards Culturally Appropriate and Inclusive Services; A Co-ordinating Framework for
ACT Health 2014-2018, ACT Government Health.
10. National Standards for Mental Health Services 2010.

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 5 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
 CHHS14/051

11. Diagnostic Imaging Accreditation Scheme (DIAS) Stage 11 Standards – Part 2, Standard
2.3. Patient Identification and Procedure Matching Standard, Commonwealth of
Australia, 2010.

Attachments

Attachment 1: National Patient Identification Band Specifications

Attachment 2: Examples of Health Care Activities

Disclaimer: This document has been developed by ACT Health, specifically for its own use. Use of this document
and any reliance on the information contained therein by any third party is at his or her own risk and Health
Directorate assumes no responsibility whatsoever.

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 6 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
 CHHS14/051

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 7 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
 CHHS14/051

Attachment 1: National Patient Identification Band Specifications

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 8 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
 CHHS14/051

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 9 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
 CHHS14/051

Attachment 2: Examples of Health Care Activities

Invasive:
 Taking a specimen of blood
 Giving medication via an intravenous, intramuscular or subcutaneous route
 Inserting an intravenous cannula
 Dental extraction
 Performing a surgical procedure, including a surgical procedure performed in Medical
Imaging or in an outpatient setting such as Radiation Oncology.

Non-invasive:
 Cognitive interventions such as evaluating, advising, planning, e.g.
o Dietary education
o Physiotherapy assessment
o Crisis intervention
o Bereavement counselling
 A procedure in medical imaging
 Bedside scan
 Electrocardiograph
 Giving medication.

Supportive:
 Administrative staff loading or updating patient information in the ACT Patient
Administration System (ACTPAS) on admission to an ACT Health service
 Application of a patient identification band
 Admitting a patient to a ward or service
 Collection and transport of patients by wardpersons
 Providing copies of patient test results.

Doc Number Version Issued Review Date Area Responsible Page

CHHS14/051 X 28 November 28 November HCID 10 of 10
2014 2019
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register