Standard 5:
Patient Identification and
Procedure Matching
Nicola Dunbar, Accrediting Agencies Surveyor Workshop, 10 July 2012
Why have a Standard about patient
identification?

Correctly identifying patients and matching them to their
treatment is fundamental to safe care

Risks occur when there is a mismatch between a given
patient and components of their care – diagnostic,
therapeutic, supportive

Patient identification is such a routine process – can be
seen as unimportant

Putting systems in place to ensure patients are correctly
matched to their care means that more attention can be
paid to more complex tasks
The Standard

Clinical leaders and senior managers of a health service
organisation establish systems to ensure the correct
identification of a patients and correct matching of
patients with their intended treatment. Clinicians and
other members of the workforce use the patients
identification and procedure matching system.

Two overarching Standards:
• Standard 1: Governance for Safety and Quality
• Standard 2: Partnering with Consumers
Three criteria
1.
Identification of individual patients
•
2.
Processes to transfer care
•
3.
At least approved patients identifiers are used when providing care,
therapy or services
A patient’s identity is confirmed using three approved patient
identifiers when transferring responsibility for care
Processes to match patients to their care
•
Health service organisations have explicit processes to correctly
match patients with their intended care
1. Identification of individual patients

5.1 Developing, implementing and regularly reviewing the effectiveness of a
patient identification system including the associated policies, procedures
and/or protocols that:
• define approved patient identifiers
• require at least three approved patient identifiers on registration and
admission
• require at least three approved patient identifiers when care therapy or
other services are provided
• require at least three approved patient identifiers whenever clinical
handover, patient transfer or discharge documentation is generated

Why?
• Systematic approach is needed to ensure resources and
procedures are organised, integrated, regulated and
administered to achieve objective of correctly identifying
patients
1. Identification of individual patients

What?
• Develop or confirm organisation-wide system for patient
identification and describe key requirements for
monitoring effectiveness
• Agree on strategies for evaluating the patient identification
system
• Identify where responsibility sits for the patient
identification system
• Use data from the monitoring system to guide
improvements
1. Identification of individual patients

Issues
• What is an “organisation-wide patient identification
system”?
• a system of explicit policies, procedures and protocols that apply
across the organisation and cover:
• consistent and correct identification of patients
• matching identity using at least three identifiers
• should include processes for patient identification:
• at admission or registration
• when matching a patient’s identity to care, therapy or services
• whenever clinical handover, patient transfer or discharge documentation
is generated
• in specific service settings if they are different from those generally
used across the organisation
1. Identification of individual patients

Issues
• What are “approved patient identifiers”?
•
•
•
•
•
•
patient name (family and given names)
date of birth
gender
address
medical record number
Individual Healthcare Identifier
• room and bed number should not be used as they are frequently
changed and not intrinsically linked to an individual
1. Identification of individual patients

Issues
• Documentation could include:
• policy framework and governance (5.1.1):
• policies and procedures regarding patient identification and matching of
patients to their care that apply across the organisation
• policies and procedures for specific clinical areas (eg outpatients)
• identification of where responsibility for patient identification sits within
the governance framework, eg terms of reference, position descriptions,
committee papers etc
• evaluation of performance (5.1.1):
• plans and audit schedules regarding evaluation and audit of
performance of patient identification and procedure matching policies
• reports of audits, reviews and evaluation of compliance with and
performance of patient identification system
• taking action to improve performance (5.1.2):
• examples of improvement activities
• education and training records
1. Identification of individual patients

5.2 Implementing a robust organisation-wide system of reporting, investigation
and change management to respond to any patient care mismatching events

Why?
• Although efforts to eliminate mismatching events have been
in place for some time, these types of patient safety
incidents continue to occur
• When these incidents occur they can provide useful
information about how systems can be improved

What?
• Establish / confirm incident reporting system that captures
data on patient mismatching events and near misses
• Use information from the incident reporting system to
improve performance
1. Identification of individual patients

Issues
• Incident reporting system included in this criterion should
be part of the broader system required as part of Criterion
1.14
• Actions to improve performance relevant here and for 5.1
1. Identification of individual patients

5.3 Ensuring that when a patient identification band is used, it meets the
national specifications for patient identification bands

Why?
• Specifications for standard patient identification bands are
evidence-based and were endorsed by Australian Health
Ministers in 2008

What?
• Introduce / confirm that the identification bands used in your
organisation meet the national specifications
1. Identification of individual patients

Issues
• Specifications for standard patient identification band
relate to:
•
•
•
•
•
•
•
colour
size
comfort
usability
method for recording patient identifiers
information presentation
new technology
1. Identification of individual patients

Issues
• Most implementation issues have related to:
• colour of the band:
• recommend one white band only
• if considered necessary to have a coloured alert band – should be red
only
• information included on the band:
• core patient identifiers only – name, date of birth, medical record
number
• Identification bands may not be needed for all parts of the
health service eg outpatients, mental health
• these areas should still be included as part of the organisation-wide
patient identification system required as part of 5.1
• Documentation:
• bands that comply with the specifications
• policies / components of policies that include identification bands
(5.1)
2. Processes to transfer care

5.4 Developing, implementing and regularly reviewing the effectiveness of the
patient identification and matching system at patient handover, transfer and
discharge

Why?
• There are significant patient safety risks at transitions of
care
• Ensuring the identity of the patient is maintained during the
transition will reduce this risk

What?
• Introduce / confirm structures handover, transfer and
discharge processes that include the use of three patient
identifiers for each patient
2. Processes to transfer care

Issues
• Patient identification and use of three identifiers should be
included in structured clinical handover system introduced
as part of Standard 6
• Documentation will be based on policies, procedures and
protocols required for Standard 6:
• need to ensure that these include patient identification and use of
three identifiers
3. Processes to match patients and their care

5.5 Developing and implementing a documented process to match patients to
their intended procedure, treatment or investigation and implementing the
consistent national guidelines for patient procedure matching protocol or other
relevant protocols

Why?
• The use of protocols and checklists provide patient safety
benefits
• These tools can be effectively applied to patient
identification processes

What?
• Develop / adapt and implement protocols for matching
patients to their intended treatment
• Monitor compliance with protocols and take action to
improve performance
3. Processes to match patients and their care

Issues
• Protocols for matching patients and their care:
• Ensuring Correct Patient Correct Site Correct Procedure:
• originally developed by Australian Council on Safety and Quality in
Health Care and RACS (2004)
• jurisdictional / regional / hospital policies based on original protocol
• additional protocols developed for specific areas outside surgery (2008)
– radiology, nuclear medicine, radiation therapy, oral surgery
• WHO Surgical Safety Checklist:
• adapted by RACS use in Australia
• includes patient identification
• key steps:
•
•
•
•
•
marking site (if necessary)
verification of identity
verification of procedure / site etc
time out
confirmation of all documentation post-procedure
3. Processes to match patients to their care

Issues
• Processes to match patient to their care should be
included in organisation-wide patient identification system
• Evaluation and improvement processes should be linked
to overarching system (see 5.1)
• Documentation:
• protocols / templates for matching patients to their care
• may have specific protocols for specific clinical areas (such as
surgery, radiology etc)
• policies / components of policies that include processes for
matching patients to their care (see 5.1)
Resources

Safety and Quality Improvement Guide for Standard 5

Specifications for standard patient identification bands –
and FAQs and fact sheets

Patient and procedure matching protocols

Jurisdictional policies and protocols
Summary

Patient identification is a basic clinical process and
needs to be done properly to ensure safety

Purpose of the Standard is to improve outcomes for
patients by setting out basic requirements for patient
identification processes

Standard based on a systems approach – rather than
what is often ad hoc