Correctly identifying and implementing processes to match patients to their intended care is critical to ensuring patient safety. Risks to patient safety occur when there is a mismatch between a patient and components of their care. This includes diagnostic, therapeutic and supportive care.
Patient identification is performed often in all care settings, and can be seen as a relatively unimportant or routine task. The development of safety routines for common tasks (such as patient identification) provides a powerful defence against simple mistakes that may cause harm. Routines allow the workforce to focus their attention on activities that require more cognitive processing and judgement, such as providing clinical care.1 The design and implementation of routines should consider human factors such as human capabilities, limitations and characteristics.2 It is also important to educate and remind the workforce about the use of routines, including who does what, when and how.
Tools such as the WHO Surgical Safety Checklist and the Commission’s Ensuring Correct Patient, Correct Site, Correct Procedure Protocol provide a basis for developing these routines.
Studies using both large and small databases of healthcare records in the United States have demonstrated that the risk of false positive matching decreases from a 2-in-3 chance when using family name only, to a 1-in-3,500 chance when given name, family name, postcode and date of birth are used.3
Regardless of the type of care, therapy or service that is provided, all organisations need to ensure that a comprehensive organisation-wide system is in place to reliably identify patients at each treatment episode, and that there are processes for correct procedure matching.
This criterion is particularly focused on clinical situations in which there may be greater risks to the patient, including procedural areas such as surgery, investigations (for example, radiology) and specific treatments (for example, nuclear medicine). The focus for action is on the use of protocols for matching patients to their intended care.
This criterion does not relate to establishing the legally correct identity of people who may choose to use an alias. The criterion is to ensure that a person’s declared identity can be matched with any care, therapy, medicine or service that is provided within the organisation.
- Karsh BT, Holden RJ, Alper SJ, Or CK. A human factors engineering paradigm for patient safety: designing to support the performance of the healthcare professional. Qual Saf Health Care 2006;15(Suppl 1):i59–65.
- Gosbee J. Human factors engineering and patient safety. Qual Saf Health Care 2002;11(4):352–4.
- Hillestad R, Bigelow JH, Chaudhry B, Dreyer P, Greenberg MD, Meili RC, et al. Identity crisis: an examination of the costs and benefits of a unique patient identifier for the US health care system Santa Monica (CA): RAND; 2008.