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A national standard for patient identification bands.
Enhancing the Ensuring Correct Patient, Correct Site, Correct Procedure Protocol.
Expanding the use of the Ensuring Correct Patient, Correct Site, Correct Procedure Protocol into other therapeutic areas.
Engaging the public and health staff in reducing the risk of misidentification.
Improving learning from sentinel events and root cause analyses (RCAs).
Investigating technological solutions to address patient misidentification.
A national standard for patient identification bands in Australia
Wristbands containing patient information have been the standard method of identifying patients in hospitals for many years. There is evidence, however, that suggests that there are difficulties associated with the use of wristbands.Patient identification bands are a critical tool to prevent errors associated with mismatching patients and their care. Although patient identification bands are present in all Australian hospitals there has not previously been a standard national approach regarding their use.
The Commission has developed ‘specifications for a standard national patient identification band’. The specifications set out standards for the useability, content and colour of patient identification bands in Australia. The specifications are based on design requirements developed by the United Kingdom National Patient Safety Agency.
These specifications have been endorsed by Health Ministers for use in public and private health services.
Enhancing the Ensuring Correct Patient, Correct Site, Correct Procedure Protocol.
The Ensuring Correct Patient, Correct Site, Correct Procedure protocol was developed by the former Australian Council on Safety and Quality in Health Care. It is designed to provide a standard process for checking the identity of a patient and matching that identity to a correct procedure. In 2004 Health Ministers mandated the use of the protocol in all public health facilities. However we know that the success of implementation of the Ensuring correct patient, correct site, correct procedure protocol is variable across the country.The Commission has competed a review of the implementation of the ‘nsuring correct patient, correct site, correct procedure protocol. The review found significant variation in the implementation of and compliance with the protocol at national, jurisdictional, regional and hospital level. A discussion paper presents the results of the review, as well as actions that have been proposed to reduce observed variation in the use of the Protocol. These actions have been informed by preliminary discussions with the Royal Australasian College of Surgeons.
Expanding the use of the Ensuring Correct Patient, Correct Site, Correct Procedure Protocol into other therapeutic areas.
The value of protocol and policy in reducing patient safety risk is well established. The original Ensuring correct patient, correct site, correct procedure protocol was developed specifically for operating theatres. Anecdotal evidence from a number of jurisdictions indicates that take-up of the protocol outside this environment has been limited. Although the protocol has not been widely used outside operating theatres, there is consistent evidence that patient/procedure mismatching also occurs in areas other than surgery.The Commission has developed protocols to support matching of patients to their care in the areas of radiology, nuclear medicine, radiation therapy and oral surgery. These protocols are based on protocols originally developed by NSW Health. The Commission appreciates the assistance of NSW Health in allowing them to be adopted for national use.
Engaging the public and health staff in reducing the risk of misidentification.
Risks associated with patient identification are not well recognised by the public or by a large proportion of healthcare staff, particularly non-clinical staff. The Commission is examining options for increasing awareness of patient identification risks.Improving learning from sentinel events and root cause analyses (RCAs) regarding patient misidentification
Patient misidentification is a national sentinel event that requires mandatory reporting in all jurisdictions, as well as investigation of the contributing factors (usually using the process of root cause analysis). Despite the reporting and investigation of these incidents, patient misidentification continues to occur. This initiative is looking at ways of improving learning from these incidents.Investigating technological solutions to address patient misidentification.
Widespread use of barcodes, radiofrequency identification devices (RFID) and other biometric devices in other industries has resulted in attempts to introduce such approaches in health care. Experience overseas has demonstrated the relatively high cost of introduction, the importance of effective implementation methodologies and the influence of the commercial market.To support the uptake of appropriate technological solutions in Australia, the Commission recently commissioned a review to investigate the current use an potential benefits of technological solutions to patient misidentification in the Australian healthcare setting and its application to safety and quality. The Commission is also looking at ways in which it can support the uptake of appropriate technological solutions in Australia.
