Action 6.05

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 benefit^1,2
• 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 organisations^3-5
• 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 3.06) 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).

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 benefit^1,2
• 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 organisations^3-5
• 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 3.06) 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.

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 benefit^1,2
• 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 organisations^3-5
• 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 3.06) 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).