Tool 3

Patient
identification and
matching to
intended care

Tool 3 of the Clinical Communication and

Patient Identification Clinical Directive
Toolkit
Tool 3 Patient Identification and matching to intended care

Contents
Contents .................................................................................................................................................. 2
Purpose of Tool 3 .................................................................................................................................... 3
Safe Systems for patient identification .................................................................................................... 3
Checking the patient’s identity at commencement of an episode of care ........................................... 4
Checking the patient’s identity during an episode of care ................................................................... 4
Approved Patient Identifiers ................................................................................................................ 5
Patient Identification bands ................................................................................................................. 5
Exemptions and alternatives to patient identification bands ............................................................... 6
Patients unable to provide identifying information ............................................................................... 7
Identification within mental health services ......................................................................................... 7
Identification of Aboriginal people ....................................................................................................... 7
Matching Patients and procedures (intended care) ................................................................................ 8
Matching patients to prescribed medications and intravenous fluid .................................................... 8
Patient Identification and blood transfusion......................................................................................... 8
Pathology and specimen collection and labelling ................................................................................ 8
Interventional or diagnostic procedures .............................................................................................. 9
Surgical Team Safety Checklist ........................................................................................................ 10
Monitoring.............................................................................................................................................. 11
Recording patient incidents relating to mis–identification or mis-matching with intended care ............ 12

This Tool must be read in conjunction with the SA Health Clinical Communication and
Patient Identification Clinical Directive and the accompanying toolkit;
Tool 1 – Clinical communication and teamwork
Tool 2 – Using My Health Record in clinical communication
Tool 3 – Patient identification and matching to intended care.

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Tool 3 Patient Identification and matching to intended care

Purpose of Tool 3
Patient identification throughout the episode of care, and across episodes is important for a variety of
purposes including funding, billing and demographics, but primarily for safe patient care and ensuring
continuity of care.

The failure to correctly identify patients and match that information to an intended clinical intervention
can result in harm. In a situation of mis-identification there can be two patients harmed by the one
error.

This tool provides additional information to support health services to ensure excellence in the
governance, practices and systems of patient identification and care matching as part of clinical
communication between SA Health services and other health providers so that;

> patient confidentiality and privacy requirements are respected

> SA Health services meet the requirements of National Safety and Quality Health Service
Standards (NSQHSS) second edition
> health practitioner’s meet the requirements of their professional codes of practice, conduct and
legislative requirements around clinical handover and transfer of care.

Safe systems for patient identification

Health services must design and implement robust systems, in consultation with stakeholders, to
support reliable management and verification of patient identification, specifically;

> at the beginning of a care episode

> before seeking consent or providing treatment, diagnostic procedures and any other patient related
activity; and
> for all occasions of clinical communication, handover, transfer, discharge, referral, and whenever
patient information is being integrated between multiple information systems.
Patient safety will be improved by health services developing, implementing and evaluating
procedures that describe the responsibilities, skills and knowledge and training required by staff for ;

> using agreed identifiers, standardisation of processes, and development of safety routines for
common patient identification tasks
> matching and verifying patient identification and the currency of patient information including
critical clinical information such as risks or alerts in health records and other administrative
systems, and at all occasions of handover and transfer of care including discharge
> detecting, reporting and resolution of data discrepancies, such as inaccuracies, omissions, errors,
out of date information, duplications in data
> evaluating actual and potential risks for patient mis-identification and mis-matching of care, and
acting to reduce risk through quality improvement activities
> accurate integration of health information from multiple systems, and reducing delays or failures in
the systems of exchange and documentation of clinical information.
Procedures for patient identification in health services must include, but not be limited to these tasks;

> confirmation or establishment of identity on entry to the service, registration, admission or

acceptance for treatment and readmission
> linking a baby to its mother during its birth admission

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Tool 3 Patient Identification and matching to intended care

> linking a patient to their health record, intended treatment, diagnostic tests and procedures,
medications, blood and pathology sampling and testing, and any other patient related activity
> discharge, transfer or referral processes
> filing, recording, documentation, storage and other record-keeping (in accordance with Health
Record Management Policy Directive
> minimising the possibility of identifiable data or patient information being inappropriately shared
with, or accessed by another patient or a staff member not involved in that patient’s care
> ensuring the validity of legal processes such as obtaining informed consent, and making mental
health treatment orders
> ensuring that appropriate verification is made of documents such as Advance Care Directives,
court orders and legal directions.
There are known strategies to support accurate patient identification and procedure matching in
health IT systems (Health IT Safe Practices: Toolkit for the Safe Use of Health IT for Patient
Identification). These include design elements such as formats and the order and structure of fields,
and built-in checking and verification systems and prompts. Health services must consider these in
the procedures for use of IT systems.

Checking the patient’s identity at commencement of an episode of care

Health service procedures for the confirmation or establishment of patient identification on
registration, admission or point of entry to the service must meet the requirements of the South
Australian Client Identification Data Standards and must specify at a minimum;

> responsibility for the preparation and placement of patient identification bands (or equivalent) in a
timely fashion for inpatient settings
> processes to confirm that the patient’s details on patient identification bands (or equivalent) are
correct for inpatient settings
> responsibility for, and processes to confirm identification for services that are not required to use
patient identification bands, such as services provided in the person’s home
> processes to amend identification information that is found to be incorrect
> processes to admit a person who does not have, or cannot provide, identifying information, who
has an alias, or who requires alternative forms of patient identification during care
> the skills and knowledge staff require to perform their roles
> how the processes are monitored and evaluated.
Checking the patient’s identity during an episode of care
Health service procedures to verify patient identification throughout the episode of care must specify:

> when, and how, patient identification is checked, and by whom

> the three patient identifiers that are to be used
> processes to replace the identification band (or equivalent) if it falls off, is removed, lost or
becomes illegible during an inpatient episode of care
> processes to amend information that is found to be incorrect
> processes to verify patient identification if the digital IT system is not available or not working
> other patient identification processes
> the skills and knowledge staff require to perform their roles
> how the processes are monitored and evaluated.

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Tool 3 Patient Identification and matching to intended care

When verifying patient identification

DO DO NOT

> ask the patient to state (and where > ask the patient ‘are you Mr Jones? (for
possible/practical spell) their full name and example)’ because the patient may have
date of birth misheard and mistakenly agree
> check this against the patient identification > use identifiers such as room or bed number
band (or equivalent), which must say exactly > assume the patient is in the right bed,
the same. treatment room, prison cell or that the name
tag above the bed is correct

Approved Patient Identifiers

Health services are responsible for specifying the identifiers and the physical means of identifying
patients that are approved for patient identification and procedure matching, in their clinical context.
Identifiers such as room or bed number must not be used.

At least three patient identifiers must be used to verify the identity of the patient. Where practicable,
these must be the 3 nationally agreed core patient identifiers that are required for patient identification
bands in SA Health. These are

> name (family and given names);

> date of birth; and
> healthcare record number (URN or MRN).
Other approved identifiers are sex, address, and individual healthcare identifier or Medicare number.

Where the My Health Record system is in use, the national unique IHI (Individual Healthcare
Identifier) can be used as a patient identifier (NSQHSS action 1.17).

Mechanisms for registration of individuals with aliases/preferred names must be in place within all
sites as part of medical record management. South Australian Client Identification Data Standards.
Once the aliases are known the generated documents/MRN are merged in accordance with
established procedures.

Electronic and manual patient master indexes and medical records must contain at least the three
nationally agreed core patient identifiers. Barcoding systems used in the patient identification process
must be linked to this information in the electronic patient master index.

Patient Identification bands

Unless there is an exemption, patients must wear a patient identification band, this includes;

> all inpatients of SA Health services

> all same day patients, day surgery, haemodialysis patients and others administered a general
anaesthetic.
Patient identification bands must be applied on presentation, or as soon as practicable on the
admission of a patient or after the birth of a baby. They do not have to be worn on the wrist.

Consideration must be given to the use of patient identification bands or another form of patient
identification in other healthcare settings such as outpatients for any patient who is provided any
therapy or interventional procedure, for example;

> local anaesthesia with or without surgical treatment

> blood or blood product transfusion

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Tool 3 Patient Identification and matching to intended care

> any form of medication therapy

> diagnostic test/procedure that involves injection or irradiation
> any other treatment where there is potential for it to adversely affect their health status.
If the patient identification band needs to be removed prior to a therapeutic procedure, supplemental
identification and labelling of the patient must be made prior to the ID band being removed. A staff
member who removes an ID band is responsible for ensuring another is applied immediately after the
procedure.

Staff who find a patient identification band that is illegible, missing or incorrect are responsible for
replacing it immediately in accordance with local procedure.

Patient identification bands must be disposed of in a way that maintains the patient’s confidentiality
and privacy.

Exemptions and alternatives to patient identification bands

If patient identification bands are not practicable or appropriate, health services may use equivalent
means of identification. Any alternatives must contain the three nationally agreed core patient
identifiers (name, date of birth and medical record number).

Premature babies may be unable to wear an ID band because of the risk of skin injury; in this case
other checking procedures must be specified, and monitored, by the health service

If the patient refuses (after the importance of the identification band has been explained to them), or it
is not possible or practical for a patient to wear an identification band, staff must document the
alternative form of patient identification that is implemented in the health record, and this must be
communicated to relevant clinicians at each occasion of handover.

Alternative forms of patient identification are;

> photographs with a patient ID label on the back

> lanyards with safe design
> attaching identification label to patient’s right shoulder and covering/affixing with opsite or
alternative waterproof transparent adhesive.
If a photograph is used for identification, processes must be put in place to ensure that;

> consent is obtained to take the photograph, if required or able to be obtained

> the photograph provides a clear and current image that allows ready identification of the patient.
This means;
o take a new photograph at every admission, or at least every 12 months, or if there is
a significant change to the appearance of the person, whichever comes first
o use a front view close-up of the head and shoulders
Prisoner-patients have identification cards that they must carry at all times. This card is an approved
form of identification for SA Health (Prisoners Care and Treatment in SA Health Services Policy
Directive), as it includes;

> a photo
> name as per SAPOL Shield Profile or Warrant as per the South Australian Courts/Sheriff’s Office
and Department for Correctional Services
> date of birth as per SAPOL Shield Profile or Warrant as per the South Australian Courts/Sheriff’s
Office and Department for Correctional Services

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> Department for Correctional Services unique identification number.

Patients unable to provide identifying information
If a patient is unable to communicate for themselves, as they are too young, confused, unconscious
or don’t have English as a first language, the patient must be registered with default values as set out
by the South Australian Client Identification Data Standards, until identifying details can be verified.
When the patient’s identity is established health services must ensure that all records are amended.

This may apply to patients transported by Emergency Services, and also to groups of patients in the
case of an external emergency or disaster (Code Brown). The South Australian Client Identification
Data Standards – Appendix E – Disaster Management requirements provides further information.

In an emergency, patients who are unable to provide identifying information or give consent must
receive treatment prior to identification if the treatment is necessary to meet an imminent risk to life or
health. This will be done in the manner provided for by Division 5 of the Consent to Medical Treatment
and Palliative Care Act 1995 (SA) and the Consent to Medical Treatment and Health Care Policy
Guideline.
All reasonable attempts must be made by the health service to verify the patient’s identification.
Where none of the 3 core patient identifiers are available, available information must be recorded on
all relevant documentation and become part of the medical record. This may include;

> asking an accompanying adult to confirm the patient’s details and identity
> cross-checking with other identification, for example driver’s licence
> via an credentialed interpreter, where appropriate
> the location and time that the person was attended by SA Ambulance Service, or the SA
Ambulance Services event number / dispatch number
> a physical description of the person.
Identification within mental health services
To improve continuity of care, any patient of a mental health service that uses an electronic health
record (Sunrise EMR (EPAS)) must also be registered on either the Community Based Information
System (CBIS) for metropolitan mental health services, or Country Consolidated Client Management
Engine (CCCME) for country mental health, and have their alternate identification (Alt-ID) recorded in
Sunrise EMR (EPAS).

Identification of Aboriginal people

There are cultural differences in use of names. If there is difficulty in verifying the necessary
identification, consult with an Aboriginal Health Worker or Counsellor or the appropriate Aboriginal
Health Clinic in the person’s community.

Health services in the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands have established
procedures to check patient identification for Aboriginal children and adults. The following approach
may assist other services.

> Where a relationship has been established with the patient, the clinician will identify them by their
preferred or commonly known name eg “sister of …” or last known name. Clinicians must note
any changes to the name in the relevant electronic and/or hard copy record.
> Where possible, call the client by their name and note any discrepancies as above.
> If no relationship has been identified with the client, check with other known services. for
identification (for example school, Aboriginal health service or relatives).

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> For adults, check Centrelink card or Genopro if available. If being seen at Aboriginal health
service, check with clinic staff that the right client is being provided a service.
> For children, check Children and Families Health Service – cross reference carer’s details with
the child’s eCHIMS number (blue book). If visiting at the school, check with school staff that the
right client is being provided a service.
> Document any relevant information that will support client identification in the future.

Matching patients and procedures (intended care)

Failure to correctly identify patients and match that information to their intended care is a serious risk
to patient safety, and can be a serious organisational and legal risk.

The patient must be identified and matched with the prescribed medication, therapy, planned
procedure, investigation, or transfusion of blood products prior to commencement. This includes
confirmation that consent has been obtained from the correct patient or Substitute Decision
Maker/Guardian for the correct procedure.

Confirmation of pregnancy/absence of pregnancy is important because of possible effects of some

investigations, medications and treatments on the developing foetus.

Matching patients to prescribed medications and intravenous fluid

Health services must have procedures that describe prescribing, supply and administration of the
correct medication and intravenous fluids to the correct patient. There are National standards and an
SA Health policy directive for user-applied labelling of injectable medicines, fluids and lines, as well as
Spell it out: Standardised terminology, abbreviations and symbols to be used when communicating
about medicines Policy Directive. Relevant NSQHS Standards are 4.5 - 4.8, 4.11 and 4.12b.

Patient Identification and blood transfusion

Health services may receive blood for transfusion to an SA Health patient, where the cross matched
blood arrives with the patient name and date of birth, but without an SA Health medical record
number. This can occur when the specimen collection and cross matching are performed by private
providers in the community, usually arranged by a GP some days before transfusion.

In these circumstances, the transfusion can proceed with 2 identifiers only in accordance with
Australian and New Zealand Society of Blood Transfusion guidelines. However, these health services
must establish processes whereby the matching of blood with patient identification is supported by
use of a third identifier that is readily available to both the pathology service doing the specimen
collection and the health service performing the transfusion, for example the patients current address,
or Medicare number.
Health services must have processes that describe checking before transfusion proceeds, that there
is;

> the correct product – check against blood product orders and IV fluid orders
> the correct patient – check patient identifiers for the patient and for the blood product.
In situations when emergency blood transfusion is required and where patient’s identity cannot be
reliably confirmed, patients must be registered according to documented hospital procedure.

Pathology and specimen collection and labelling

Health services must document the process for how patient identification and pathology/specimen
collection, labelling and matching is performed in each specialist area, the responsibility of clinicians
involved and what training is required.

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The correct identification of any samples / specimens requires adherence to standard procedures at
the point of collection; before and during testing; at reporting; and on receipt of results.
This will ensure that;

> the patient is correctly identified, with at least the 3 national identifiers
> all containers are accurately labelled with at least the 3 national identifiers
> all request forms have correct patient information and the correct request.
Interventional or diagnostic procedures
These are any procedure used for diagnosis or treatment that involves incision, puncture, entry into a
body cavity or the use of ionising or electromagnetic energy, and includes dialysis and chemotherapy.

Health services must clearly document the process for how patient identification and procedure
matching is performed in each specialist area, the responsibility of clinicians involved and what
training is required (NSQHS Standard 6.6). The specific process in use will depend on the type of
procedure, the design of the workflow in a particular work area or organisation, and the risks for the
patient.

The use of a safety checklist prior to commencing a procedure supports teamwork and ensures;

> correct identification of all patients

> a positive confirmation that the procedure about to be performed is the procedure that is intended
for that patient, and the correct site and side
> any required or anticipated special equipment, imaging, antibiotic or thrombolytic prophylaxis and
blood supplies have been arranged
> any surgical, anaesthetic or nursing requirements or concerns have been addressed
> the team is aware of patient’s wishes regarding treatment limitations
Perioperative procedures must also review documentation of any treatment limitations that are
already in place, such as a Resuscitation Alert-7 Step Pathway or others documented in an Advance
Care Directive or Advance Care Plan. The medical practitioner responsible for obtaining informed
consent (including explaining potential risks) for the procedure must clarify the intent of any
instructions documented on a currently valid Resuscitation Plan-7 Step Pathway, Advance Care
Directive or Advance Care Plan with the patient and/or their Substitute Decision-Maker/Person
Responsible to ensure that any resuscitation or treatment limitation instructions are fully understood in
the context of the surgical/invasive procedure (Resuscitation Planning 7 Step Pathway Policy
Directive 4.7.2).

Protocols, fact sheets and FAQs to support correct matching of patients and their care in the specific
areas of radiology, nuclear medicine, radiation therapy and oral surgery are provided by the
Australian Commission on Safety and Quality in Health Care. These emphasise the confirmation of
pregnancy/absence of pregnancy. The Standards of Practice for Diagnostic and Interventional
Radiology, Version 10.2 provides additional information, as does the Diagnostic Imaging Accreditation
Standards (Standard 2.3).

In most procedural areas ‘time outs’ with the whole team are required before the procedure can
commence. In other situations, such as radiology where there may only be a single operator, this
could be done as a stop to verify that all requirements are correct. SA Medical Imaging (SAMI)
Ionising Radiation Management Plan V5.1

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Tool 3 Patient Identification and matching to intended care

Surgical Team Safety Checklist

The operating surgeon, or practitioner carrying out the procedure must lead the completion of the
Surgical Team Safety Checklist (MR 87 or SA Health approved equivalent). The entire team must
participate. The checklist must be completed during this process, and no other activities must be
undertaken during this time.

Prior to commencement

There are two steps prior to commencement. Initially (pre induction), two team members must;

> verbally confirm with the patient (or if this is not possible, with their representative);
o the identity of the patient
o what procedure they are having done
o that informed consent for the procedure has been obtained
> if relevant, confirm that the health practitioner performing the procedure has marked the site in
accordance with local procedures
> use an appropriate checklist or document in the health record that the check was completed. The
entry must be signed by both the team members who performed the check
> confirm any resuscitation or treatment limitation instructions.
Then, immediately prior to the procedure commencing (pre incision), a team member must state, and
ask for the agreement of the other team members, information in relation to;

> the identity of the patient (if the patient is not sedated they must also be asked to confirm their
identity)
> the procedure to be performed, including dosage if relevant
> the site of the procedure
> all other items on the relevant checklist.
The team must confirm that all critical elements that may influence the safe provision of the procedure
or surgery and the outcome or recovery of the patient have been considered and attended to, where
appropriate.

In addition, during a surgical or interventional procedure there must be a structured team approach to
safeguard the patient, through situational awareness and cross monitoring.

After the procedure

The Surgical Team Safety Checklist (MR 87 or approved equivalent) must be completed immediately
after completion of a procedure before unscrubbing to ensure;

> the name of the procedure has been recorded

> that instruments, sponge, needles and other counts are correct
> that any specimens are labelled correctly
> that any specific post operative recovery instructions are documented and included in clinical
handover.
The appropriate post procedure/sign out section of the relevant checklist must be completed and
signed prior to the patient or the team leaving the room. During this process all team members must
participate, and no other activities should be undertaken.

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Tool 3 Patient Identification and matching to intended care

Discrepancies

All team members have a responsibility to request a review if they, or the checklist, detects;

> a discrepancy in information

> doubt in verification of the procedure
> a failure or unreasonable threat to the safety of the patient or other staff associated with the
planned procedure.
The procedure must be delayed until the issue is resolved. If the discrepancy or doubt remains, then
the justification for proceeding is to be documented in the health record, and the event reported into
the Safety Learning System (SLS).

In an emergency situation the senior person of the team responsible for the patient will make the
decision on the most appropriate course of action.

Monitoring
Health services must establish clinical governance structures and processes and evaluate the safety
and effectiveness of clinical communication and patient identification. Evaluation measures require
audit of practice and procedures, recording of completed training, and analysis of incident data.

Health services undertake audits and regular monitoring and evaluation to demonstrate that they
meet the requirements of the NSQHSS Standard 6 Communicating for Safety. And report clinical
communication incidents to the SLS.

Example measures to indicate safety and quality of patient identification are as follows.

Patient identification and procedure matching Data Source

Use of standard All patient identification bands used in SA Health will Audit
patient identification comply with the SA Health Patient Identification Band
armband Standard.
Initial patient All initial patient registration is complete and Audit
registration accurate.
At all times, all Evidence that core patient identifiers used: Audit
patients must be able
> when collecting, registering or updating patient
to be correctly
information for the purpose of patient registration
identified using three or making bookings / appointments or waiting
core approved patient lists
identifiers
> prior to any care, treatment, procedures or
services taking place to correctly match patients
with their intended care
> at clinical handover, when transferring
responsibility for care.
Use of Surgical Team Evidence that Surgical Team Safety Checklist is used Clinical audit
Safety Checklist for all interventional procedures.
Use of safety Evidence that Safety Checklists are used for all Clinical audit
checklists for other interventional procedures.
interventional
procedures
Incidents relating to Numbers and rates of incidents. SLS – patient
patient mismatching incidents
module

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Tool 3 Patient Identification and matching to intended care

Patient identification and procedure matching Data Source

Incidents relating to Numbers and rates of incidents- ACD, Consent, 7 SLS – patient
alerts / critical step and others incidents
information module

Recording patient incidents relating to mis–identification or mis-matching

with intended care
The Safety Learning System records the number of patient incidents and also consumer (patient)
feedback records (complaints) received in relation to clinical communication.

In a situation of mis-identification there can be two patients harmed by the one error. This means that
there may need to be 2 incidents entered – one for each patient, in order to record the outcome and
open disclosure for both patients.

Incidents involving Patient misidentification can be classified under the following levels 1, 2 and 3
> Clinical Assessment
o Images for diagnosis (scan.xray) > Diagnostic images– mislabelled / unlabelled
o Laboratory investigations > Specimens – mislabelled / unlabelled
> Communication and teamwork
o Communication with the patient > Patient incorrectly identified
> Medication
o Prescribing of medication > incorrect patient identification
o Supply of medication > incorrect patient identification
o Administration of medication > incorrect patient identification
> Patient Information > all level 2 classifications, under patient incorrectly identified or record
mislabelled
o Patient Identification> several
o Patient’s case notes or records or
o Electronic patient records .mislabelled
> Treatment, Procedure
o Select body part >- Treatment, Procedure inappropriate /wrong
o Connected with the management of operations /treatment >
Patient incorrectly identified >
treatment, procedure inappropriate/wrong >
Wrong body part / side / site
Operative site not marked
The Quality Information and Performance Hub (QIP Hub) is used to display this information. An
annual review of this data is published in the SA Health Patient Safety Report.

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For more information

Department for Health and Wellbeing
Safety and Quality Unit
PO Box 287, Rundle Mall
Adelaide SA 5000
Telephone: 82266334
www.sahealth.sa.gov.au
Confidentiality Public:I1_A1

© Department for Health and Wellbeing, Government of South Australia. All rights reserved