Standard Operating Procedure

PATIENT IDENTIFICATION - CORRECT PATIENT, CORRECT SITE, CORRECT

PROCEDURE

Purpose
To establish the identity of ACT Health inpatients and match the correct patient to an
intended clinical activity.

Scope
This standard operating procedure (SOP) provides guidance for use by all ACT Health staff and
applies to establishing patient identity and confirming consent prior to all clinical activities.

Clinical activities improve, maintain or assess the health of a person in a clinical situation and
may include invasive and non-invasive procedures (including those performed in settings
other than the operating room). Some examples are:

• Invasive - taking a specimen of blood

- giving medication via an intravenous, intramuscular or subcutaneous route
- inserting intravenous access, or
- performing a surgical procedure, including a procedure performed in
medical imaging.

• Non-invasive - cognitive interventions such as evaluating, advising, planning

(e.g. dietary education, physiotherapy assessment, crisis intervention,
bereavement counselling, a procedure in medical imaging) and giving
medication.

The processes outlined in the SOP will apply differently in different settings and be informed
by the clinical activity. For example, consultation with a dietician may take place at the
bedside with no specialised equipment; however the patient’s identity and consent to the
consultation must be confirmed with the patient prior to commencement. Staff should apply
the processes as appropriate to the setting and the intended clinical activity.

Responsibility for ensuring the correct patient undergoes the correct clinical activity rests
with all staff and each staff member is individually accountable. However, the person who
will perform the clinical activity carries ultimate responsibility.

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Procedure
Ensuring the correct patient undergoes the correct clinical activity on the correct site requires
achievement of five fundamental goals prior to the clinical activity. These are:

a. Confirming identification with the patient

b. Checking and confirmation of consent by the patient to the clinical activity
c. Marking the site for surgery or other invasive procedures, if applicable
d. Verification that diagnostic images (and/or other relevant test results) are available
and are correct, if applicable, and
e. Time Out - Pausing and conducting a final verification check either as a ‘team time out’
or ‘time out as a single operator’ immediately prior to the activity in the examination
area, treatment area or operating room.

It should be noted that some tasks must be performed in a certain order and at specific times,
whereas other tasks are repeated and/or performed simultaneously. If the checking process is
interrupted staff should start again and repeat the process in entirety.

Patients need to actively participate in patient identification checks, where possible, and be
encouraged to ask questions about the correctness of their care.

If there is any discrepancy noted, the intended clinical activity must not proceed until the
discrepancy has been resolved. Any member of the treating team is able to stop the clinical
activity if they or the patient have raised concerns.

1. In an emergency
1.1 In the event of an emergency, where any delay in initiating the clinical activity might
compromise the safety of the patient or their clinical outcome, the five fundamental goals
should be applied to the extent possible under the circumstances.

2. Confirming identification with the patient

2.1 Identification of the patient should be performed at:
• The time of admission into the facility
• The time the patient identification band is applied
• The time the clinical activity is scheduled
• Each time responsibility for the care of the patient is transferred
• Each time there is change in location of care
• On entry to the procedure suite and prior to the commencement of anaesthesia,
where applicable, and
• During preparation of the patient for the clinical activity and immediately prior to
commencement of the clinical activity.

2.2 Active Communication

The patient needs to participate in confirmation of their identity. They must always be
asked to state aloud their:
• Full name (family and given names), and
• Date of birth.

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

2.3 For patients who are not able to personally participate in the confirmation process, for
example patients who are:

Non-english speaking

Hearing and/or speech impaired

Visually impaired, or

Cognitively impaired,
someone who can confirm identity of the patient must provide confirmation. The identity
of this person needs to be documented. Note: This only relates to identification of the
patient and does not relate to providing consent. Refer to the ACT Health Consent to
Treatment Policy for further information about who can provide consent.

2.4 For patients transferred from locations within the hospital who are incapable of
personally participating 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.

2.5 Verbal information provided by the patient must be cross-checked against

information documented on the patient’s identification band. Patient identification bands
are to be worn by all inpatients of ACT Health (with the exception of Mental Health
patients) as a primary form of identification (Refer to SOP – Patient Identification Bands).

2.6 The full name, date of birth and medical record number on the patient identification band
should be cross-checked against the clinical record and/or documents relevant to the
intended clinical activity. This may include but is not limited to:
• Consent to treatment form
• Procedure Request form
• Test results, and
• X-Rays/Imaging.

2.7 If a discrepancy related to the patient’s:

• Full name
• Date of birth
• Medical Record number, or
• Clinical record and/or relevant documents occurs
the clinical activity must not proceed to the next checkpoint until the discrepancy has
been resolved. It is not acceptable to note a discrepancy and not take action.

3. Checking and confirmation of consent by the patient for the clinical activity
3.1 Check the completed consent form or procedure request form prior to the
activity. Details must 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)
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 • Left and Right must be written in full
• Name of requesting medical officer printed and signed and dated, and
• Contact details of the requesting medical officer.

To avoid transcription errors, an ACT Health approved patient identification label must be
used to document patient core identifiers (Name, date of birth and medical record
number) where possible.

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.

3.2 The patient must be asked to state the type of clinical activity/procedure, including the
site or side, they have consented to. They must also be asked to state what their
understanding is of the planned clinical activity/procedure.

An exception to this rule is in the case of life-threatening emergency treatment. Refer to

ACT Health Consent to Treatment Policy and Procedure for further information regarding
consent.

3.3 In situations where there is not an actual consent or request form, verbal consent must
be confirmed with the patient and documented in the clinical record.

If there is any discrepancy noted, the intended clinical activity must not proceed until
the discrepancy has been resolved.

4. Marking the site for surgery or other invasive procedures

4.1 Site marking is essential in cases where there is potential for error involving
left/right distinction, multiple structures (e.g. fingers/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.

4.2 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.

4.3 The site must be marked, and initialled, by the person performing the procedure (or
another senior 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.

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 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.

4.4 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/spinal analgesia/anaesthesia
• If a procedure requires a regional anaesthetic then only the procedure site should
be marked to avoid confusion
• If the site cannot be marked, e.g. mucous membranes, teeth
• Premature infants/paediatric patients where marking may cause permanent
Tattooing In this instance, the correct site/side must be confirmed verbally by a
parent/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.

5. Verification that diagnostic images (and/or other relevant test results) are available and
are correct, if applicable
5.1 Relevant 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.

5.2 In the operating room, 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/procedural team. One member must be the proceduralist and
the other/s must have appropriate interpretative skills for the image involved.

6. Pausing and conducting a final verification check as a ‘team time out’ or ‘time out as a
single operator’

6.1 Team time out in the operating theatre is a part of the Surgical Safety Checklist process.
Refer to the SOP - Surgical Safety Checklist for information on this process.

6.2 All members of the operative team must stop and conduct a final verification together,
in the operating room while the patient is present, prior to induction of anaesthesia and
starting the procedure.

6.3 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.

6.4 ‘Team time out’ includes, at a minimum, verification of:

• Patient’s identity
• Procedure to be performed
• Correct side and site of procedure
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 • Consent
• Imaging data (if applicable), and
• Availability of appropriate prostheses, implants and/or any specialised
equipment or requirements.

6.5 ‘Time out as a single operator’ requires the person responsible for performing the clinical
activity to pause and conduct a final check of items listed in 6.4, immediately prior to
commencing the clinical activity/procedure.

If a discrepancy occurs at any point during the ‘time out’ process, the clinical
activity must not commence until the discrepancy is resolved.

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.

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

Evaluation
Outcome Measure
• There will be no reported incidents of patients undergoing an incorrect clinical activity.

Method
• This SOP will be evaluated as part of the annual evaluation of the overarching policy.

• Patient Safety and Quality Unit (PSQU) will monitor and review RiskMan reports relating to
wrong patient, wrong site, wrong procedure incidents.

• PSQU will perform an annual compliance audit for this policy and SOPs.

Related Legislation and Policies

Refer to Section 5 of ACT Health Patient Identification - Correct Patient, Correct Site, Correct
Procedure Policy.

Definitions of Terms
Clinical activity – in this document the term ‘activity’ includes non-invasive and invasive
interventions and procedures.

References
Refer to Section 5 of ACT Health Patient Identification - Correct Patient, Correct Site, Correct
Procedure Policy.

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Disclaimer: This document has been developed by ACT Health, 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 ACT Health
assumes no responsibility

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