Section 3 Patient Management

Patient Identification
Practice Policy Identifying patients correctly and successfully matching that information to an intended clinical activity is a significant patient safety issue. To ensure their safety, patients must be correctly identified and correctly matched to an intended clinical activity by: a. Confirming identification with the patient b. Checking and confirmation of consent by the patient for the clinical activity c. Marking the site for surgery or other invasive procedures, if applicable d. Verification that diagnostic scanning (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. Our specific strategies which support this process are: a. The use of the World Health Organization (WHO) Surgical Safety Checklist (adapted by the Royal Australasian College of Surgeons) in the treatment room.

Purpose
Patient identification has been identified as a key patient safety goal by all of the major international patient safety agencies, including the World Health Organization. To be successful, patients need to actively participate in patient identification checks and be encouraged to ask questions about the correctness of their care. Active patient participation in their health care is essential to achieve best possible outcomes and is in accordance with the Australian Charter of Healthcare Rights (2008). This policy supports staff to ensure this occurs. Patient identification errors can occur in all types of clinical activities, whether they are diagnostic (such as ultrasound), therapeutic (medication administration, surgery) or supportive (such as patient admission processes). Clinical activities that have been performed on the wrong patient or the wrong part of the patients body are significant safety incidents which may cause considerable harm and distress to patients, their families and the health professionals involved in their care.

There is evidence from both the health system and other high risk industries that suggest that standardised procedures help prevent activities causing harm. This policy has been developed to: 1) Outline the process to correctly establish the identity of patients and match them to the correct clinical activity 2) Help staff understand and meet their responsibilities in the identification of patients in accordance with: a. Relevant policy b. Legislation, and c. Quality and safety standards 3) Provide evidence for ongoing evaluation and audit of processes and actions.

Scope
This policy provides information for use by all staff and applies to establishing patient identity prior to all clinical activities (including those performed in settings other than the treatment room) that have the potential to cause unintended harm to the patient. 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 treatment 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 diagnostic scanning. Non-invasive - interventions such as evaluating, advising, planning (e.g. prostate surgery, physiotherapy assessment, a procedure in diagnostic scanning) and giving medication.

Roles & Responsibilities

All staff involved in patient identification are responsible for becoming familiar with this policy. The Director must ensure staff are able to access, interpret and apply this document and are provided with education related to this policy. 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.

Evaluation
Outcome Measures There will be no reported incidents of patients undergoing an incorrect clinical activity. Method The Director will monitor and review RiskMan reports relating to wrong patient, wrong site, wrong procedure incidents and will perform an annual compliance audit for this policy.