Action 6.06

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.^1,2 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 6.07 and 6.08).

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 safety³ 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’.⁴ These strategies promote closed-loop communication and allow an opportunity for participants to ask questions or clarify concerns.^{4, 5, 6}

Incorporate patient identification and procedure matching into structured clinical handover processes, as required under Actions 6.07 and 6.08. 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.⁴

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.

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 safety³ 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’.⁴ These strategies promote closed-loop communication and allow an opportunity for participants to ask questions or clarify concerns.^{4, 5, 6}

Incorporate patient identification and procedure matching into structured clinical handover systems, as required under Actions 6.06 and 6.07. 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.⁴

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.

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.^{1, 2} 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 6.07 and 6.08).

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’.⁴ These strategies promote closed-loop communication and allow an opportunity for participants to ask questions or clarify concerns.^{4, 5, 6}

Incorporate patient identification and procedure matching into structured clinical handover processes, as required under Actions 6.06 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.