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CHHS14/052

Canberra Hospital and Health ServicesClinical ProcedurePatient Identification and Procedure MatchingContents

Contents...................................................................................................................................1

Purpose.................................................................................................................................... 3

Alerts........................................................................................................................................3

Scope........................................................................................................................................4

Section 1 – Patient identification and procedure matching in an emergency..........................5

Section 2 – When to confirm a patient’s identity.....................................................................5

Section 3 – How to confirm a patient’s identity.......................................................................5

Section 4 – Patients with communication and/or cognitive difficulties....................................6

Section 5 – Patients from culturally and linguistically diverse backgrounds and/or with limited English proficiency.......................................................................................................7

Section 6 – Matching the patient to a health care activity.......................................................8

Section 7 – Use of patient identification bands......................................................................11

Section 8 – Acceptable alternatives to wearing a patient identification band.......................12

Section 9 – Patient Identification in Mental Health, Justice Health and Alcohol and Drug Services (MHJHADS) Inpatient Units......................................................................................13

Section 10 – Department of Neonatology: Identification bands............................................16

Section 11 – Patient identification in the Peri Operative Unit................................................17

Section 12 – Patient identification procedures in Medical Imaging.......................................18

Section 13 – Patient identification procedures for patients receiving cytotoxic medications in Outpatient Day Therapy Units................................................................................................21

Section 14 – Patient identification procedures for providing correct meal to correct patient - Food Services......................................................................................................................... 23

Section 15 – Patient identification processes for unknown patients......................................25

Section 16 – Non-compliance with patient identification safety systems..............................26

Section 17 – Patient identification labels on ACT Health clinical records...............................26

Implementation......................................................................................................................27

Related Policies, Procedures, Guidelines and Legislation.......................................................27

References..............................................................................................................................28

Definition of Terms.................................................................................................................28Doc Number Version Issued Review Date Area Responsible PageCHHS14/052 1.1 28 November

201428 November 2019

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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

CHHS14/052

Search Terms..........................................................................................................................29

Attachments...........................................................................................................................30

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Purpose

To describe the process, undertaken with the patient, to establish or confirm the identity of ACT Health patients and match the correct patient to an intended health care activity using a minimum of three (3) patient identifiers:

For inpatients: Full Name Date of birth, and Medical Record Number (MRN) allocated by the ACT Patient Administration System

(ACTPAS).

A patient’s address or identified gender may be used as the third identifier, in addition to their name and date of birth if a patient does not have an existing MRN. For example: If a patient is accessing an ACT Health service for the first time, i.e. registration or

admission, or They are attending a service as an outpatient, e.g. ACT Pathology, or Is accessing a service that doesn’t use the ACT Patient Administration System (ACTPAS).

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. Examples of health care activities are provided in Attachment 1.

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Scope

Alerts

1. All staff are responsible and accountable for correct identification of the patient. The person who performs the health care activity carries ultimate responsibility to match the patient with the care, therapy or services being provided.

Staff are responsible for: Checking identity of the patient using a minimum of three patient identifiers to

correctly match patients to an intended health care activity Stopping the health care activity from proceeding if patient identification

discrepancies are identified, until these are resolved Explaining to patients why they may be asked to repeatedly identify themselves

and reassuring patients that this is a measure to ensure their safety Providing opportunities and encouraging patients to ask questions about their

health care and to speak up if they have any concerns Complying with the Australian Commission on Safety and Quality in Health Care

(ACSQHC) national patient identification band specifications, and



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Submitting an incident report to the RiskMan Incident Management System when discrepancies are identified.

2. If at any time an infant is found to be without an identification band: The identity of all infants present in the area must be verified. Only then may a

replacement identification band, which has been checked by two (2) registered midwives/nurses/enrolled nurses (ENs), be placed on the infant, and

A RiskMan incident report should be submitted.

3. For patient identification pertaining to Expressed Breast Milk please refer to the Breastfeeding Clinical Guideline.

4. For some administrative or clerical processes confirming identity with the actual patient is not possible; e.g. preparing and sending correspondence to patients to provide confidential information about their condition or test results. However it is still essential to carefully cross-check a minimum of three patient identifiers (identifiers should include the patient’s address) with all material being provided to ensure the correct patient receives the correct information.


Scope

This procedure is for use by all ACT Health staff in acute, non-acute settings, and community settings including: Clinical Non-clinical, Students and Administrative staff.

It applies where staff, with the participation of the patient, establish or confirm the patient’s identity using a minimum of three patient identifiers, prior to all health care activities, including when: Collecting, registering or updating patient information for the purpose of patient

registration or making bookings, appointments or waiting lists Providing care, therapy, services, advice or information Linking a patient to their clinical record and clinical results, and Transferring responsibility for care.

The processes outlined in this procedure will apply differently in different settings and be informed by the health care activity. For example, patient identification bands are not used in community settings or outpatient clinics. Staff should apply the processes as appropriate to the patient’s needs, setting and the intended health care activity.

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Section 1 – Patient identification and procedure matching in an emergency

Procedure1.1 In an emergency, where any delay in initiating the health care activity might

compromise the safety of the patient or their clinical outcome, the patient identification and procedure matching process should be applied to the extent possible under the circumstances.


Section 2 – When to confirm a patient’s identity

Procedure2.1 Identification of the patient should be performed with the participation of the patient

and prior to all health care activities and at each transfer of care: On presentation or admission to a facility or health care setting When a patient identification band is applied, or an acceptable alternative is

generated (See Section 8: Acceptable alternatives to wearing a patient identification band)

Every time care, therapy, advice, information or service is provided Each time there is a transfer of responsibility or change in location of care On entry to the procedure suite, and Prior to the commencement of anaesthesia, where applicable.


Section 3 – How to confirm a patient’s identity

Procedure3.1 Staff need to explain to patients that they are being asked to confirm their identity as a

measure: For their safety so that they don’t receive the incorrect care, therapy or service,

and So that they are involved in decisions related to their care, in accordance with the

Australian Charter of Healthcare Rights (2008).

3.2 It is important that patients actively participate in patient identification checks and be given opportunities and encouraged to ask questions about the correctness of their care, wherever possible.

3.3 Staff must use a minimum of three patient identifiers every time to establish or confirm a patient’s identity. For inpatients: Full Name



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Date of birth, and Medical Record Number (MRN) allocated by the ACT Patient Administration System

(ACTPAS).

3.4 A patient’s address or identified gender may be used as the third identifier, in addition to their name and date of birth if a patient does not have an existing MRN. For example: If a patient is accessing an ACT Health service for the first time, i.e. registration or

admission, or They are attending a service as an outpatient, e.g. ACT Pathology Is accessing a service that doesn’t use the ACT Patient Administration System

(ACTPAS), or Is accessing ACT Health telephone triage services.

3.5 Patients must always be asked to state aloud their: Full name (family and given names) Date of birth, and Address or identified gender, if this is being used as the third patient identifier.

Note: Parents/Carers responsible for neonatal or paediatric patients will also be asked to confirm a child or young person’s name and date of birth aloud when presenting for services.

Note: For newborns, the three identifiers are confirmed as: Baby of Mother’s family and given names Date of birth and Gender

This is confirmed by the staff member with the mother at the time the patient identification band is applied. This must be completed as soon as possible after birth.

Staff must not state the patient’s name and date of birth and ask for confirmation that this is correct.

3.6 If there is an interruption to the patient identification checking process at any stage staff should start again and repeat the process in entirety.


Section 4 – Patients with communication and/or cognitive difficulties

Procedure4.1 Someone who can confirm the identity of the patient must provide confirmation by

stating aloud the patient’s identification details (as identified in 3.5) for patients who are not able to personally participate in the confirmation process, e.g. patients who are:



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Non-English speaking Hearing and/or speech impaired Visually impaired, Cognitively impaired Sedated or unconscious, or Delusional as a result of a mental health condition, or Children and adolescents who are minors.

The identity of the person who confirmed the patient’s identity needs to be documented in the patient’s clinical record.

4.2 All reasonable attempts should be made to confirm patient identification by checking with other identification, e.g. a driver’s licence, or via an interpreter where appropriate.

4.3 For patients transferred from locations within an ACT Health service or facility who aren’t able to personally participate in the confirmation process and with no designated representative present, a member of staff from the preceding location must act as the patient’s representative for confirmation.


Section 5 – Patients from culturally and linguistically diverse backgrounds and/or with limited English proficiency

Procedure5.1 Some culturally and linguistically diverse (CALD) groups tend to have a high proportion

of similar surnames or construct their names differently than is conventional in Australia. For example: Chinese: In many cases, family names are generally placed before first names.

However some Chinese Australians have adopted the Australian style of naming, placing family names last.

Vietnamese: Very often the family name comes first, then a middle name, and the first (given) name last. Many given names are common to both males and females. Family names such as Nguyễn, Trần and Lê are very common. The Vietnamese language is tonal, resulting in a different pronunciation for a name with the same basic spelling with the addition of a tone marker. The tone marker is usually omitted in Anglicisation which can lead to incorrect assumptions.

India/Sri Lanka: Naming conventions vary across ethnic groups. Many do not use surnames.

Refugee communities: Members of same family may appear to have different surnames in Australia as a result of confusion in transfer of names during immigration.

5.2 This means that identifying individuals using only first name and surname can be problematic and lead to high error rates. The ability to accurately identify patients,



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even when there are complex language challenges, is critical. Although some consumers may have basic or conversational English language skills, in times of stress, this proficiency may significantly decrease.

5.3 The use of a professional, accredited interpreter should be considered. To access an interpreter, ring 131 450, and quote your work area’s client code.


Section 6 – Matching the patient to a health care activity

Equipment Patient identification labels Patient identification bands Patient’s clinical record Records or documents relevant to the intended health care activity Indelible skin marker

Procedure6.1 There are five principles that should be applied; however they will apply differently in

different settings, e.g. acute or non-acute, including community settings. Staff should apply the principles to the extent possible and as appropriate to the patient’s needs, the health care setting and the intended health care activity.

1st Principle:6.2 Confirming identity with the patient:

Verbal information provided by the patient, parent or carer must be cross-checked against patient identifiers documented on: The patient’s clinical record The patient’s identification band, or acceptable alternative patient identification

tool Records or documents relevant to the intended health care activity. This may

include but is not limited to:o Appointment, waiting or consultation/procedure listso Booking request formso Procedure request formso Test resultso X-rays, Imagingo Consent forms.



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6.3 For some administrative or clerical processes confirming identity with the actual patient is not possible. E.g. preparing and sending correspondence to patients to provide confidential information about their condition or test results. However it is still essential to carefully cross-check a minimum of three patient identifiers (in 3.3 and 3.4) (identifiers should included the patient’s address) with all material being provided to ensure the correct patient receives the correct information.

2nd Principle:6.4 Confirmation of consent:

Staff must confirm the patient’s consent to the health care activity. An exception to this rule is in the case of life-threatening emergency treatment. Refer to ACT Health Consent and Treatment Policy and SOPs for further information regarding consent.

6.5 For verbal and written consent, the patient must be asked to state the type of procedure, including the site or side, they have consented to and their understanding of it.

3rd Principle:6.6 Marking the site for surgery or other invasive procedures, if applicable:

Site marking is essential in cases where there is potential for error involving left and right distinction, multiple structures (e.g. fingers or toes, lesions) or levels (e.g. spine). In these cases the site should be marked with an indelible skin marker where practical. Use initials, ‘yes’ or a line representing the proposed incision. Do not use ‘X’, as this may be interpreted incorrectly.

6.7 Marking should take place with the patient involved, awake and aware if possible and should occur before the patient enters the operating/procedure room. Note: an exception may be made for paediatric patients who may be marked under anaesthesia to avoid causing distress. In this instance, the correct site/side must be confirmed verbally by a parent/guardian, where possible.

6.8 The site must be marked, and initialled, by the person performing the procedure (or another senior medical team member who has been fully briefed about the operation or procedure) so that: The intended site of incision/insertion is unambiguous The mark is on or near the incision site, and The mark is visible and sufficiently permanent so as to remain visible following skin

preparation and draping.

6.9 Once appropriate marking has been completed this must be documented in the clinical record. A patient’s refusal to have the site marked must also be documented in the clinical record. Exceptions to marking are: Minor invasive procedures, e.g. Intravenous cannulation, IV/IMI injections If the insertion site is not predetermined, e.g. cardiac catheterisation, epidural or

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If a procedure requires a regional anaesthetic then only the procedure site should be marked to avoid confusion

If the site can’t be marked, e.g. mucous membranes, teeth Premature infants or paediatric patients where marking may cause permanent

tattooing. In this instance, the correct site or side must be confirmed verbally by a parent or guardian where possible

Single organ cases which don’t involve laterality, e.g. caesarean sections If there is trauma at the site, and Where the urgency of the procedure precludes marking.

4th Principle:6.10 Verification that diagnostic images (and/or other relevant test results) are available

and are correct, if applicableRelevant test results or diagnostic images must be viewed and confirmed to be correct by cross-checking the patient’s full name, date of birth and medical record number on the patient identification band, the clinical record and/or documents relevant to the intended clinical activity.

6.11 In the Operating Room and Medical Imaging, the patient’s imaging data (if applicable) must be viewed and confirmed to be correct regarding site and side and correctly labelled, by two or more members of the operative or procedural team. One member must be the proceduralist and the other/s must have appropriate interpretative skills for the image involved.

5th Principle:6.12 Pausing and conducting a final verification check as a ‘team time out’ or ‘time out as

a single operator’:Team time out in the operating theatre and medical imaging is a part of the Surgical Safety Checklist briefing activity.

6.13 All members of the operative team must stop and conduct a final verification together in the operating room, with the participation of the patient where possible, and prior to induction of anaesthesia and starting the procedure.

6.14 An exception to ‘team time out’ being performed is where it would increase risk/decrease benefit to the patient, e.g. in a life-threatening emergency. This must be documented in the clinical record by a member of the perioperative team performing the surgery. ‘Team time out’ includes, at a minimum, verification of: Patient’s identity Procedure to be performed Correct side and site of procedure Consent



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Imaging data (if applicable), and Availability of appropriate prostheses, implants and/or any specialised equipment

or requirements.

6.15 ‘Time out as a single operator’ requires the person responsible for performing the health care activity to pause and conduct a final check of items listed above, immediately prior to commencing the health care activity or procedure.

6.16 At any time the patient identification and procedure matching process is interrupted staff should start again and repeat the process in entirety.

6.17 If any discrepancy is identified, the intended health care activity must not proceed until the discrepancy has been resolved. Any member of staff is able to stop the health care activity if they or the patient have raised concerns.

6.18 All team members must agree on the resolution of the discrepancy and the resolution must be documented in the clinical record and a RiskMan incident report completed by a member of the perioperative team.

6.19 A wrong patient, wrong site, wrong procedure incident is a mandatory reportable event. Refer to ACT Health Significant Incident SOP for further information.


Section 7 – Use of patient identification bands

Equipment Patient identification labels White and red patient identification bands

Procedure7.1 Patient identification bands that comply with the national specifications in

Attachment 2 must be worn by: All inpatients during their hospital admission Non-admitted patients in the

Emergency Department Outpatients, (with the exception of Canberra Region Cancer Centre (CRCC) patients

– See Section 13) whose care will/may be provided by multiple service providers, undergoing:o Surgery o Blood or blood product transfusiono Invasive medication therapy with significant known risks, potential

complications or adverse health outcomes, oro Invasive and non-invasive procedures with significant known risks, potential

complications or adverse health outcomes.



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7.2 Patient identification bands must be applied as soon as is practicable and the patient information on the band must be checked for accuracy at this time., i.e. patient identity must be confirmed with the patient when the band is applied as per 3.3 – 3.5.

7.3 A red band that complies with the national specifications in Attachment 2 is used to notify staff that an allergy exists.

7.4 The following wristbands must be removed on admission or presentation: Patient identification bands that have been applied by another facility Wristbands other than ACT Health approved patient identification bands. This

includes ‘social message’ wristbands. If the consumer refuses to remove the wristband it should be covered, e.g. with a bandage to avoid confusion.

7.5 Staff must immediately replace a patient identification band if: It is removed in order to perform clinical treatment, or Information isn’t able to be read clearly.


Section 8 – Acceptable alternatives to wearing a patient identification band

Equipment Patient identification labels White and red patient identification bands Waterproof transparent adhesive

Procedure8.1 Where patient identification bands cannot be worn on a limb (as a result of the

patient’s clinical condition or treatment), the patient identification band may be applied to the patient’s shoulder and covered/affixed with waterproof transparent adhesive.

8.2 For infants whose limbs are too small the patient identification band may be applied to the patient’s: Nasogastric/orogastric, or Umbilical catheter/Peripherally Inserted Central Catheter (PICC) line where these

are securely fixed to the patient.

8.3 Alternative patient identification tools may include: Iris scan Photograph, e.g. Adult Mental Health Rehabilitation Unit patients Identification card, e.g. Justice Health detainees.

8.4 These other patient identification tools:



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Must contain a minimum of three patient identifiers as specified in 3.3 and 3.4 with no other information included, and

Are initiated as specified in 7.2.

8.5 Where a photograph is used as a patient identification tool, processes must be put in place to ensure that the photograph provides a good likeness to the patient: Photographs must be a front view close-up of the head and shoulders A new photograph should be taken at least every three years or whenever there is

a significant change to the appearance of the person, whichever comes first Photographs don’t negate the need to ensure the patient identification and

procedure matching processes are applied when care is given.

8.6 There should be a formally risk-assessed alternative implemented for patients where a patient identification band or acceptable alternative patient identification tool (as described above) is not able to be used and this must be documented in the clinical record.


Section 9 – Patient Identification in Mental Health, Justice Health and Alcohol and Drug Services (MHJHADS) Inpatient Units

ProcedureBefore any health care, therapy or services are provided, the patient’s identification must be confirmed using 3 approved identifiers as follows: Full Name Date of birth, and Medical Record Number (MRN) allocated by the ACT Patient Administration System

(ACTPAS).

A patient’s address or identified gender may be used as the third identifier, in addition to their name and date of birth if a patient does not have an existing MRN. For example: If a patient is accessing an ACT Health service for the first time, i.e. registration or

admission, or They are attending a service as an outpatient, e.g. ACT Pathology, or Is accessing a service that doesn’t use the ACT Patient Administration System (ACTPAS).



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Exceptions9.1 Dhulwa Mental Health Unit (DMHU) Photographs will be taken for medication administration ACT Health uses a Biometric Access Control System to provide rightful identity of all

patients, staff and visitors at the DMHU. This is a fingerscan verification access control system that scans the fingerprint as a mathematical algorithm. Please note that ACT Health does not retain any fingerprint records.

9.2 Adult Mental Health Unit (AMHU) and Mental Health Short Stay Unit (MHSSU) Patient identification bands should be offered to all mental health patients in the Emergency Department who will be subsequently admitted to the MHSSU or the AMHU. However it is recognised that not all patients will comply with a request to wear a PatientIdentification band.

Under no circumstances should staff place themselves at unnecessary risk by insisting thatpatients comply with the application of an identification band.

In the event a patient does not comply with a request to wear an identification band, intentionally removes a patient identification band or staff deem that the wearing of an identification band would prove to be an increased risk to the patient, staff or others, staff should: Document this event in the clinical file and add as an alert on the person’s Electronic

Clinical Record (ECR) Report an episode of non compliance through Riskman Report to the treating team at the next multidisciplinary team meeting Adopt the use of alternative patient identifiers:

o Use of at least three of the four approved identifiers including full name, date of birth, address or identified gender

o Use of photo ID such as driver’s licence or personal identification cardso Use of additional health care workers who the patient is known too Use of family, friends or carers

If a patient agrees to wear a patient identification band, it should be applied as soon as is practicable. Ideally the patient identification band should be applied in the ED however if this does not occur, the above listed patient identifiers can be adopted to facilitate transfer of care or clinical treatment until the patient identification band is applied on arrival in the AMHU or the MHSSU.

9.3 Adult Mental Health Rehabilitation Unit (AMHRU) and Extended Care Unit (ECU)Photo identification is adopted as the primary patient identifier in AMHRU and ECU All staff are to be aware of the importance of completing this task on admission to AMHRU and ECU and receive appropriate guidance and training to complete this task safely and competently.



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On admission, the person will be asked to provide photo identification in the form of a head shot only with the head uncovered and the face clearly visible (e.g. Driver’s Licence photo).

Staff will explain to the person the purpose of photo identification and where photos are taken by staff, how these photos will be used, stored and disposed of.

At this time the person is also asked to confirm their personal details, specifically their name, date of birth and any known aliases or other names that they are known by. If the person is unable to identify themselves due to their mental state, an advocate or family member may be asked to confirm their identity.

Where photo identification is available, two colour photocopies are to be taken of the photo identification supplied. Information supplied confirming their personal details are to be documented on the reverse of photocopies and filed in client’s notes.

If the person is unable to supply photographic identification or the photograph provided does not meet with the requirements specified above, staff will take a photo of the client.

Photos will only be taken with the written consent of the person or their guardian. The Consent for Photographs, Videos or Voice Recordings Form which can be found on the Clinical Forms Register must be completed and the original placed in person’s file.

Staff will take a photograph of the person (head shot only with the head uncovered and the face clearly visible). The photo is to be printed in colour and the digital image deleted. The person’s identification is to be written on the back of photograph and the completing nurse to sign the photograph to confirm identity.

One photograph should be attached to the clinical notes and the other to the medication chart, with the use of staples.

If there are any significant changes in the person’s appearance since their original photo identification or during course of admission an updated photograph needs to be taken.

On discharge, photographs attached to existing medication charts and clinical notes are to be filed with person’s medical records. Spare copies of photographs not used prior to discharge should be shredded or confidentially disposed of.

Images captured for clinical care purposes are considered as part of the clinical record and are to be managed in accordance with the Clinical Records Management Policy and any other related operational procedures.

In the event a person does not comply with a request to provide photo identification or have their photo taken, staff should: Document this event in the clinical file as an alert Adopt the use of alternative patient identifiers:Doc Number Version Issued Review Date Area Responsible PageCHHS14/052 1.1 28 November


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Use of at least three identifiers including:o Full name, date of birth, address or identified gendero Use of additional health care workers who the patient may be known too Use of family, friends or carers

Report through Riskman Report to the treating team at the next multidisciplinary team meeting A risk assessment related to not having photo identification available is completed.

This should not preclude further attempts to seek photo identification from the consumer at a later time.

9.4 Alcohol and Drug Services Withdrawal Unit (WU)Identification of the patient should be performed with the participation of the patient prior to all clinician health care procedures. This may include but is not limited to: On admission to the WU Every time care, therapy, advice, information or service is provided Each time there is a transfer of responsibility or change in location of care When a patient identification band is applied

Patient identification bands are a tool which can be used to assist incorrect procedure matching. Patient identification bands are used to cross check verbal information provided by the patient to confirm a patient’s identity during their emergency department or inpatient stay.

Patient identification bands can be offered to all mental health patients in the Emergency Department who will be subsequently admitted to WU. However, it is recognised that not all will comply with a request to wear a Patient identification band.

Under no circumstances should staff place themselves at unnecessary risk by insisting patients comply with the application of an identification band.

In the event a patient does not comply with a request to wear an identification band, purposefully removes a patient identification band or staff deem that the wearing of an identification band would prove to be an increased risk to the patient, staff or others, staff should: Document this event in the clinical file and add as an alert Report an episode of non-compliance through Riskman Report to the treating team at the next multi-disciplinary team meeting Adopt the use of alternative patient identifiers including:

o At least three of the four approved identifiers including full name, date of birth, address or identified gender

o Photo ID such as driver’s licence or personal identification cards, o Additional health care workers who the patient is known too Family, friends or carers



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If a patient agrees to the wearing of a patient identification band, it should be applied as soon as is practicable. Ideally the patient identification band should be applied in the ED. However, if this does not occur, the above listed patient identifiers can be adopted to facilitate transfer of care or clinical treatment until the patient identification band is applied on arrival in the WU.


Section 10 – Department of Neonatology: Identification bands

Procedure10.1 Two identification bands should be attached, preferably to both infant’s ankles but if

not possible to one ankle and one wrist.For newborns, the three identifiers are confirmed as:

Baby of Mother’s family and given names Date of birth and Gender

This is confirmed by the staff member with the mother at the time the patient identification band is applied. This must be completed as soon as possible after birth. If the neonate is admitted to Neonatology, the patient identification is to be updated with the patient identification label.

10.2 If at any time an infant is found to be without an identification band, the identity of all infants present in the area must be verified. Only then may a replacement identification band, which has been checked by two (2) registered midwives, nurses or enrolled nurses (ENs), be placed on the infant.

10.3 For infants whose limbs are too small the patient identification band, may be applied to the patient’s: Nasogastric/orogastric, or Umbilical catheter/PICC line where these are securely fixed to the patient.

10.4 Once an infant’s ankle is large enough a second identification band must be attached to one ankle or other limb.

10.5 Explain to the parents or carers that the identification bands should not be removed

until the baby is discharged home.


Section 11 – Patient identification in the Peri Operative Unit

Equipment Patient Identification labels



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Red or White Identification Band Patient’s Clinical Records, including the Surgical Safety Checklist Records, documents and imaging relevant to the intended procedure

Procedure11.1 All members of the Peri Operative Team are responsible for identifying their

allocated surgical patient prior to induction of anaesthesia. It is essential that the patient identification band is visually accessible at all times.

11.2 When a patient is transferred within the Peri Operative Unit the patient identification process must be completed as described in Sections 1 – 7 of this clinical procedure.

11.3 Where a patient’s identification band has to be removed for anaesthetic or surgical preparation, a new identification band must be applied immediately prior to the removal of the initial identification band, and:

Confirmed with the patient where they are able or, with two theatre team members (Medical Officer MO, Registered Nurse RN, Enrolled Nurse EN, and

Placed on a different limb of the patient.

11.4 During the Surgical Safety Checklist team briefing, and prior to anaesthetic induction and surgery, the patient’s identity must again be:

Confirmed with the patient (if they are able) Cross checked against the patient’s identification band, and Checked with their Consent To Treatment form.

For further detail please refer to Section 6 of this clinical procedure.

Surgical Positioning and Draping:11.5 When an existing identification band is going to be obstructed due to positioning or

draping, the patient identification band needs to be removed and a new one prepared and placed securely on the patient’s forehead.

11.6 Once the surgical procedure has been completed, the identification band must be moved from the patient’s forehead and secured on an appropriate limb by two theatre team members, following confirmation of patient identifying details (See Section 7 of this clinical procedure).


Section 12 – Patient identification procedures in Medical Imaging

Equipment Patient identification labels White and red patient identification bands



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Patient’s clinical record Records, documents and imaging relevant to the intended procedure Procedure request form

12.1These steps and patient identification moments (ID MOMENT) involved in establishing the correct identification of patients must be performed for patients attending the: Angiography Suite Mammography Suite General X-Ray and Ultrasound Computerised Tomography (CT) and the Magnetic Resonance Imaging (MRI)

modalities Nuclear Medicine Positron Emission Tomography (PET/CT) facility Bone Mineral Density (BMD) of the Medical Imaging Department, and the Medical Imaging Day Ward.Or For those patients receiving bedside imaging procedures e.g. patients in ICU,

NICU.

12.2These steps and patient identification moments (ID MOMENTs) involved in establishing the correct identification of patients must be performed for patients when:

Identifying and importing digital imaging into Picture Archival Communication System (PACS).

Providing copies of digital imaging to patients.

Procedure12.3Check that the procedure request form is correctly completed. Information on the

procedure request form must be clear and legible, and include: Patient’s family and given names Date of birth Medical record number Name of the procedure to be performed Identification of correct site (using precise anatomical location) Left and Right must be written in full Name of requesting medical officer printed and signed, and contact details of

requesting medical officer.

12.4Verification of patient information on arrival - ID MOMENT as per Section 3 – How to confirm a patient’s identity.

12.5Matching information - ID MOMENT as per Section 6: Matching the patient to a health care activity.

Where the patient is able, make sure the patient specifies the site and side for the intended procedure. *Check pregnancy status of female patients (when appropriate).



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Ask yourself – is there any clinical reason I should not perform this procedure right now e.g. patient allergies, clinical condition.

For Nuclear Medicine/PET CT patients: If the female patient is of child bearing age (12-55 years generally) either a signed

questionnaire or standard consent form stating the patient’s pregnancy and breastfeeding status must be completed. This is scanned onto Radiology Information System (RIS) and sent to Medical Records.

If the patient states that they may be pregnant check with the Nuclear Medicine/PET CT Consultant before commencing test. The specialist will decide the suitability for imaging

All female patients must undergo a βHCG test prior to any Nuclear Medicine therapy procedure. If the patient is found to be pregnant, treatment must be postponed.

12.6 Select patient on RIS & conduct Time Out ID MOMENT. In the procedure room with the patient present and immediately before commencing the procedure, the senior clinician conducts a ‘time out’ as a single operator or leads the team in a ‘time out’ and verbally confirms: Correct patient is present Correct procedure to be performed Correct side/site is identified and marked Consent is cross-checked with proposed procedure and where appropriate for the

procedure:o Correct patient details are on the imaging deviceo Correct previous images are displayedo Implant/equipment/medication is available and correct.

For Nuclear Medicine blood products must be correctly labelled and cross-checked with patient ID prior to re-injection by a Nuclear Medicine Scientist or Technologist. With multi-step imaging (patient already injected) a check of patient ID is required with each step.

Post procedure12.7Prior to releasing/sending the image to a clinician or any networked device that can be

used for display or interpretation, e.g. PACS, make sure that: Patient details and the side marker attached to the post-processed image are

correct and documented, and All patient identification documentation is completed.

Escalation Process



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12.8If, at any step in the identification process, the patient’s identity cannot be established or verified then the staff member should immediately seek more information from the referrer or referring team before proceeding.

12.9If an error in identification has been detected then the staff member should immediately contact the RIS-PACS Administrator and referring team, if the images have been sent to PACS. Identification errors must also be reported via Riskman.




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Section 13 – Patient identification procedures for patients receiving cytotoxic medications in Outpatient Day Therapy Units

PurposeTo describe the process undertaken for patients receiving Cytotoxic Medications in Outpatient Day Therapy Units to establish or confirm their identity and match them to the correct intended health care activity using three (3) patient identifiers. A Photo ID will be used if a fourth identifier is required.

This procedure is consistent with Section 8 - Acceptable Alternatives to Wearing a Patient Identification Band.

ScopeThis procedure is for use by all Cancer, Ambulatory and Community Health Support staff providing services to patients receiving Cytotoxic Medications in Outpatient Day Therapy Units.

Procedure13.1 How to confirm a patient’s identity: Refer to Attachment 3 for Flow Chart for Patient ID Process. Patients attending the Cancer Outpatients Day Therapy Unit to receive cytotoxic medications will have their identity recorded on their clinical record in CHARM (electronic medical record system), including:

Full name Date of birth (DOB) Address.

Staff must use these three patient identifiers (name, DOB, address) every time there is a need to establish or confirm a patient’s identity, or match the patient to the procedure or medication. Patients will be asked to state aloud the abovementioned 3 patient identifiers.

This information is cross-checked with the information in the medical record in CHARM or on the relevant documentation e.g. medication chart.

For a small number of patients, a fourth identifier may be necessary. In these cases, the patient will be asked to provide a photo ID if they have one. It will be used to support confirmation of the patient’s identity during booking in or treatment if the patient is unable to state their name, DOB and address due to communication or cognitive difficulties, or limited English proficiency.

If there is an interruption to the patient identification checking process at any stage staff should start again and repeat the process in entirety.

Staff must not state the patient’s name and date of birth and ask for confirmation that this is correct. Refer to Attachment 3 for Flow Chart for Patient ID ProcessDoc Number Version Issued Review Date Area Responsible PageCHHS14/052 1.1 28 November


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13.2 Matching the patient to a health care activityConfirming identity with the patientVerbal information provided by the patient, parent or carer must be cross-checked against patient identifiers documented on the patient’s clinical record to ensure the correct patient before any procedure, medication administration or other health intervention, and when handing over care to other health professionals.

If the patient or carer is unable to provide the information verbally, staff will check the photo ID to verify the patient’s identity.

Verification that relevant test results are available and are correct, if applicableRelevant test results must be viewed and confirmed to be correct by cross-checking the patient’s full name, date of birth and address with the clinical record and/or documents relevant to the intended clinical activity.

A wrong patient, wrong site, wrong procedure incident is a mandatory reportable event. Refer to ACT Health Significant Incident SOP for further information.

13.3 Patients with communication and/or cognitive difficultiesFor additional information see Section 4.

13.4 Patients from culturally and linguistically diverse backgrounds and/or with limited English proficiencyFor additional see Section 5.

13.5 Non-compliance with patient identification safety systemsSee Section 11.

13.6 Risk Assessment of Use of Photographs for Outpatients receiving Cytotoxic MedicationsID Bands are not used in this patient group due to the need for intravenous access, the frequency of attendance at the Unit and the holistic approach to care in this outpatient setting. The photo ID provides an additional patient identifier if the three verbal identifiers (name, DOB and address) are unable to be provided or if there is any doubt about the information or identify of the patient.

The use of the three patient identifiers (name, address and DOB) and the photo ID as a fourth identifier instead of the ID band has been risk assessed. See Table 1 below.



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Table 1 - Risk Assessment of use of ID Photo Card

Potential Risk Current Status Mitigating Strategies Required

Use of agency or relief staff

The Cancer Outpatients Service does not use any agency staff or staff from other hospital departments. Staff shortages are managed within the existing staff cohort.

Nil

Lack of clear procedure leading to mismatch incidents

The Cancer Outpatients Service staff will be guided by this procedure, and are required to be compliant with it. There have been no incidents of mismatches in the period July 2014 – February 2015.

Audits to monitor compliance with this procedure

Patient’s identity cannot be established

The staff member should immediately seek more information from carer, or referrer before proceeding.

Use the ID Photo to verify the patient ID if available

Patient’s refuse to provide a photo ID

Process will be monitored over period May 15 – Oct 15.

Where a patient refuses to provide a photo ID, 3 patient identifiers only (name, DOB and address will be used)


Section 14 – Patient identification procedures for providing correct meal to correct patient - Food Services

Equipment Patient white board (listing patient name and diet) DIETPAS system patient patient meal ordering fields: patient name, location and

dietary request Patient Tray Card Ward List. (Generated by DietPAS 10 minutes prior to the meal trolley leaving Food

Services)

ProcedureThese steps and patient identification involved in establishing the correct identification of patients must be performed when distributing meals to patients. Refer to Attachment 4 for Food Service Patient Meal Tray Delivery Ward Patient ID and Process Matching flowchart.

14.1Identification of the patient should be performed with the participation of the patient and prior to distributing the patient meal. Refer to Sections 2, 3, 4, and 5 of Patient



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Identification and Procedure Matching (this document) for Patient identity confirmation requirements.

14.2 All members of the Food Services Team in conjunction with the clinical staff are responsible for providing the correct meal to the correct patient at each patient meal service.

14.3 Menu Monitor is responsible for providing patient meal tray cards. Patient meal tray cards stating patient name, diet and location are generated based on the current DietPAS / My Meal information and used for patient meal assembly.

14.4 Patient Services is responsible for assembling each meal correctly, placing the assembled meal in the meal trolley for Patient Services Assistant to distribute at ward level.

14.5 Patient Services are responsible for awaiting meal returns requiring transfers, and removing all meals not required due to patient discharges based on the ward list. If the diet has changed, the clinical staff must update DietPAS and phone Food Services for a meal to be sent.

14.6 Patient Services Assistant is responsible for delivering the correct meal tray to the correct patient’s room. The Wards List is the most recent patient status record and is printed 5 – 10 minutes prior to the meal trolley leaving the kitchen and captures recent ward changes. The ward list notes the patient’s name and dietary information.

14.7 The Patient Services Assistant compares the patient meal tray card with the patient white board and diet listed on the ward list. If the information on each is identical, the meal can be delivered to the patient. Refer to Attachment 5 for quick reference patient identification steps.

14.8 If the tray card does not match the patient white board sign name and diet listed, the meal is to be withheld, with a notation placed on the wards list.

The Patient Services Assistant is responsible for checking with the Clinical Staff that the patient white board is correct when the patient meal tray card does not match. The patient white board needs to be correct before a meal tray can be delivered. If the patient white board is not updated, the meal remains in the trolley.

The clinical staff are to be advised if the patient did not receive a meal or if the diet listed on the tray is different to the patient white board and ward list.

Clinical staff are required to update the patient diet in DietPAS and on the patient white board before a meal will be provided at each meal service. Patient Service Assistant is responsible for returning the Wards list with any notes to the Menu



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Monitor for filing. Any (concerns) should be communicated to the Patient Service Supervisor to follow-up as required with the ward CMC.

14.9 If a patient is listed as NBM (Nil by Mouth) under no circumstances should a meal be left for a patient. The patient diet is required to be updated on the patient white board and DietPAS by the clinical staff before a patient meal can be left.

Section 15 – Patient identification processes for unknown patients

As a tertiary trauma centre, Canberra Hospital Emergency Department/Intensive Care/Operating Theatres occasionally receive patients whose identity is not known, but who require treatment and care in the interim. The procedure below describes the process for managing these ‘unknown’ patients, and the process for transitioning them safely, and all their clinical information to a ‘known’ identity.

Unknown patients, by their feature of being unknown, are at greater risk and a higher level of vigilance is required. Unknown patients are managed using only 2 unique identifiers in CHHS.

Procedure Patients who arrive at Canberra Hospital and are designated as ‘Unknown’ will be

managed using the ‘Unknown Patient Pack’ in Canberra Hospital Emergency Department.

o The surname labelled as ‘UNKNOWN’o The given name in the format of ‘MALE 123’ or ‘FEMALE 123’ where 123

is a unique number, also reserved for unidentified patients, and which is never reused. This number is allocated by the Emergency Department.

o Date of birth recorded as 01/01/1900, ando Address recorded as ‘UNKNOWN’ (applies to the request form only).

This unique identifier Unknown Patient Number is entered as the patient identifier in the EDIS and ACTPAS information systems. This forms the main identifying feature for this patient and will be entered on all clinical records and investigation requests.

On entering this information, a temporary Medical Record Number (MRN) is generated in EDIS – this forms the Second identifier for this patient.

An arm band is created with both these identifiers and attached to the patient. All procedure matching and identity checks are based on these 2 unique

identifiers (unknown patient number and MRN).

Transition arrangements for Unknown Patient to Known Patient:Where patients who have been designated as ‘unknown’ become ‘known’ the following process applies.

Patient information is entered in EDIS and ACTPAS. Doc Number Version Issued Review Date Area Responsible PageCHHS14/052 1.1 28 November


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For new presentations, the MRN issued at admission is maintained. For patients who have presented previously, their unique MRN is reactivated and

they are admitted to the system. A new patient arm band with the patient’s details is created. This arm band is attached to a different limb (either arm or leg) from the

‘Unknown’ Patient arm band. The patient will now be identified by using either or both of these arm bands for

all procedure matching and identity checks. Patient records will have both the unknown patient label and the known patient

label affixed to ensure that the patients clinical record transitions to their known identity.

Merging of Unknown/Known patient identity is an automatic process via the EDIS /ACTPAS /RISPACs interface.

Merging of Unknown/Known patient record through the Kestral pathology system is a manual process with a number of quality assurance (QA) processes attached and is carried out by specialist personnel in business hours.

To ensure continuity of care and reduce any delays to treatment based on dual identities - Use of the Unknown patient labels, and Unknown Patient Arm Band will only cease on formal notification by Pathology that the patient records have been merged. Patients will have BOTH armbands in place until this notification is received.

On receipt of this notification, all unknown labels and the unknown patient arm band are removed and destroyed.

At completion of this patient episode this Unknown Patient number is permanently retired.


Section 16 – Non-compliance with patient identification safety systems

Procedure16.1If a patient does not comply with:

Wearing either a patient identification band An acceptable alternative patient identification tool, or Identifying themselves, it must be explained to them that this may compromise

their safety. This issue must be:o Documented in the patient’s clinical recordo Escalated through line management, ando Reported on RiskMan.


Section 17 – Patient identification labels on ACT Health clinical records

Equipment ACTPAS patient identification labels



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Procedure

17.1 To avoid transcription errors, an ACT Health approved patient identification label must be used to document patient identifiers, where possible.

17.2 Patient identification labels from facilities outside of ACT Health must not be used. If found the labels must be removed and replaced with an ACT Health approved patient identification label.


Implementation

All staff email Article on the HealthHUB (including Information for Staff Fact Sheet) ‘Information for Staff Fact’ Sheet Distribution of information through QSOs A Patient Identification eLearning currently exists. It will be reviewed to align with the

policy documents Current Patient Identification Band audit and other current clinical audits include patient

identification questions, e.g. clinical handover, medication administration, blood and blood products – contributes to awareness raising and education.


Related Policies, Procedures, Guidelines and Legislation

PoliciesClinical Handover PolicyMedication Management PolicyClinical Records Management PolicyConsent and Treatment PolicyIncident Management Policy

ProceduresPatient Identification and Procedure Matching SOPPatient Identification: Pathology Specimen Labelling SOPPatient Identification: Medical Imaging SOPClinical Record Documentation SOPConsent and Treatment SOPConsent and Treatment: Capacity and Substitute Decision Maker SOPConsent for a Child or Young Person SOPIncident Management Policy and SOPSignificant Incident SOP



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


References

Australian Commission on Safety and Quality in Health Care National Health Service Standards, (September 2011)

Specifications for a standard patient identification band – Specifications, Fact Sheet and FAQs, Australian Commission on Safety and Quality in Health Care 2009

Protocol ‘Ensuring Correct Patient, Correct Site, Correct Procedure’, Australian Council on Safety and Quality, 2004

WHO Surgical Safety Checklist 2009 Australia and New Zealand Surgical Safety Checklist 2009 Patient Identification Policy and Guideline, Version 3.0 Government of South Australia,

Department of Health and Ageing, Public Health and Clinical Systems, 2013 Surgical Team Safety Checklist Policy Directive, Version 2.0 Government of South

Australia, Department of Health and Ageing, Public Health and Clinical Coordination, 2012

Australian Charter of Healthcare Rights 2008 Towards Culturally Appropriate and Inclusive Services; A Co-ordinating Framework for

ACT Health 2014-2018, ACT Government Health National Standards for Mental Health Services 2010 Diagnostic Imaging Accreditation Scheme (DIAS) Stage 11 Standards – Part 2, Standard

2.3 Patient Identification and Procedure Matching Standard, Commonwealth of Australia, 2010


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



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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 workero to a patient, client, consumer

Complaint, loss or damage:o to property and services (including infrastructure)o to the environmento regarding financial managemento regarding information managemento regarding the reputation of the organisation

Deviationso 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.


Search Terms

Patient identificationPatient identification bandID bandPatient armbandsAlert bandsCorrect patientCorrect siteCorrect procedurePatient identification tool


Attachments

Attachment 1 – Examples of Health Care Activities



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Attachment 2 – National Patient Identification Band SpecificationsAttachment 3 – Flow Chart for Patient ID ProcessAttachment 4 – Chemotherapy Education ChecklistAttachment 5 – Process Evaluation PlanAttachment 6 – Food Service -Quick Reference Patient Identification Attachment 7 – Food Service Patient Meal Tray Delivery - Ward Patient ID and Process Matching

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services, 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.

Date Amended Section Amended Approved By28 Nov 2016 MHJHADS Inpatient Units

information addedCHHS Policy Committee

19 Apr 2018 Section 13 – information relating to patients with no photo id and the use of a fourth identifier removed

CHHS PC Chair and Exec Leads for Standards 5 & 6

11 July 2018 Inclusions throughout document to update name change for AMHRU and ECU

MHJHADS Executive Director

22 Aug 2018 Section 9 updated to reflect MHJHADS specific requirements for Patient Identification

Standard 5 – Patient Identification and Procedure Matching Committee



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Attachment 1: 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 educationo Physiotherapy assessmento Crisis interventiono 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



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Attachment 2: National Patient Identification Band Specifications



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Attachment 3 – Flow Chart for Patient ID Process for patients receiving cytotoxic medications in Outpatient Day Therapy Units



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Attachment 4 – Food Service Patient Meal Tray Delivery - Ward Patient ID and Process Matching



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Attachment 5: Food Service -Quick Reference Patient Identification



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