Standard 5: Patient Identification and Procedure Matching

1. Standard 5: Patient Identification and Procedure Matching Nicola Dunbar, Accrediting Agencies Surveyor Workshop, 10 July 2012

2. Why have a Standard about patient identification? • Correctly identifying patients and matching them to their treatment is fundamental to safe care • Risks occur when there is a mismatch between a given patient and components of their care – diagnostic, therapeutic, supportive • Patient identification is such a routine process – can be seen as unimportant • Putting systems in place to ensure patients are correctly matched to their care means that more attention can be paid to more complex tasks

3. The Standard • Clinical leaders and senior managers of a health service organisation establish systems to ensure the correct identification of a patients and correct matching of patients with their intended treatment. Clinicians and other members of the workforce use the patients identification and procedure matching system. • Two overarching Standards: • Standard 1: Governance for Safety and Quality • Standard 2: Partnering with Consumers

4. Three criteria • Identification of individual patients • At least approved patients identifiers are used when providing care, therapy or services • Processes to transfer care • A patient’s identity is confirmed using three approved patient identifiers when transferring responsibility for care • Processes to match patients to their care • Health service organisations have explicit processes to correctly match patients with their intended care

5. 1. Identification of individual patients • 5.1 Developing, implementing and regularly reviewing the effectiveness of a patient identification system including the associated policies, procedures and/or protocols that: • define approved patient identifiers • require at least three approved patient identifiers on registration and admission • require at least three approved patient identifiers when care therapy or other services are provided • require at least three approved patient identifiers whenever clinical handover, patient transfer or discharge documentation is generated • Why? • Systematic approach is needed to ensure resources and procedures are organised, integrated, regulated and administered to achieve objective of correctly identifying patients

6. 1. Identification of individual patients • What? • Develop or confirm organisation-wide system for patient identification and describe key requirements for monitoring effectiveness • Agree on strategies for evaluating the patient identification system • Identify where responsibility sits for the patient identification system • Use data from the monitoring system to guide improvements

7. 1. Identification of individual patients • Issues • What is an “organisation-wide patient identification system”? • a system of explicit policies, procedures and protocols that apply across the organisation and cover: • consistent and correct identification of patients • matching identity using at least three identifiers • should include processes for patient identification: • at admission or registration • when matching a patient’s identity to care, therapy or services • whenever clinical handover, patient transfer or discharge documentation is generated • in specific service settings if they are different from those generally used across the organisation

8. 1. Identification of individual patients • Issues • What are “approved patient identifiers”? • patient name (family and given names) • date of birth • gender • address • medical record number • Individual Healthcare Identifier • room and bed number should not be used as they are frequently changed and not intrinsically linked to an individual

9. 1. Identification of individual patients • Issues • Documentation could include: • policy framework and governance (5.1.1): • policies and procedures regarding patient identification and matching of patients to their care that apply across the organisation • policies and procedures for specific clinical areas (eg outpatients) • identification of where responsibility for patient identification sits within the governance framework, eg terms of reference, position descriptions, committee papers etc • evaluation of performance (5.1.1): • plans and audit schedules regarding evaluation and audit of performance of patient identification and procedure matching policies • reports of audits, reviews and evaluation of compliance with and performance of patient identification system • taking action to improve performance (5.1.2): • examples of improvement activities • education and training records

10. 1. Identification of individual patients • 5.2 Implementing a robust organisation-wide system of reporting, investigation and change management to respond to any patient care mismatching events • Why? • Although efforts to eliminate mismatching events have been in place for some time, these types of patient safety incidents continue to occur • When these incidents occur they can provide useful information about how systems can be improved • What? • Establish / confirm incident reporting system that captures data on patient mismatching events and near misses • Use information from the incident reporting system to improve performance

11. 1. Identification of individual patients • Issues • Incident reporting system included in this criterion should be part of the broader system required as part of Criterion 1.14 • Actions to improve performance relevant here and for 5.1

12. 1. Identification of individual patients • 5.3 Ensuring that when a patient identification band is used, it meets the national specifications for patient identification bands • Why? • Specifications for standard patient identification bands are evidence-based and were endorsed by Australian Health Ministers in 2008 • What? • Introduce / confirm that the identification bands used in your organisation meet the national specifications

13. 1. Identification of individual patients • Issues • Specifications for standard patient identification band relate to: • colour • size • comfort • usability • method for recording patient identifiers • information presentation • new technology

14. 1. Identification of individual patients • Issues • Most implementation issues have related to: • colour of the band: • recommend one white band only • if considered necessary to have a coloured alert band – should be red only • information included on the band: • core patient identifiers only – name, date of birth, medical record number • Identification bands may not be needed for all parts of the health service eg outpatients, mental health • these areas should still be included as part of the organisation-wide patient identification system required as part of 5.1 • Documentation: • bands that comply with the specifications • policies / components of policies that include identification bands (5.1)

15. 2. Processes to transfer care • 5.4 Developing, implementing and regularly reviewing the effectiveness of the patient identification and matching system at patient handover, transfer and discharge • Why? • There are significant patient safety risks at transitions of care • Ensuring the identity of the patient is maintained during the transition will reduce this risk • What? • Introduce / confirm structures handover, transfer and discharge processes that include the use of three patient identifiers for each patient

16. 2. Processes to transfer care • Issues • Patient identification and use of three identifiers should be included in structured clinical handover system introduced as part of Standard 6 • Documentation will be based on policies, procedures and protocols required for Standard 6: • need to ensure that these include patient identification and use of three identifiers

17. 3. Processes to match patients and their care • 5.5 Developing and implementing a documented process to match patients to their intended procedure, treatment or investigation and implementing the consistent national guidelines for patient procedure matching protocol or other relevant protocols • Why? • The use of protocols and checklists provide patient safety benefits • These tools can be effectively applied to patient identification processes • What? • Develop / adapt and implement protocols for matching patients to their intended treatment • Monitor compliance with protocols and take action to improve performance

18. 3. Processes to match patients and their care • Issues • Protocols for matching patients and their care: • Ensuring Correct Patient Correct Site Correct Procedure: • originally developed by Australian Council on Safety and Quality in Health Care and RACS (2004) • jurisdictional / regional / hospital policies based on original protocol • additional protocols developed for specific areas outside surgery (2008) – radiology, nuclear medicine, radiation therapy, oral surgery • WHO Surgical Safety Checklist: • adapted by RACS use in Australia • includes patient identification • key steps: • marking site (if necessary) • verification of identity • verification of procedure / site etc • time out • confirmation of all documentation post-procedure

19. 3. Processes to match patients to their care • Issues • Processes to match patient to their care should be included in organisation-wide patient identification system • Evaluation and improvement processes should be linked to overarching system (see 5.1) • Documentation: • protocols / templates for matching patients to their care • may have specific protocols for specific clinical areas (such as surgery, radiology etc) • policies / components of policies that include processes for matching patients to their care (see 5.1)

20. Resources • Safety and Quality Improvement Guide for Standard 5 • Specifications for standard patient identification bands – and FAQs and fact sheets • Patient and procedure matching protocols • Jurisdictional policies and protocols

21. Summary • Patient identification is a basic clinical process and needs to be done properly to ensure safety • Purpose of the Standard is to improve outcomes for patients by setting out basic requirements for patient identification processes • Standard based on a systems approach – rather than what is often ad hoc