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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 3.1 Safety and quality

Our practice is committed to quality improvement.

Criterion 3.1.4

Patient identification

Our patients are correctly identified at each encounter with our practice team.

Indicators

► A. Our practice has a patient identification process using three approved patient identifiers and the practice team can describe how it is applied.

Explanation

Key points

  • Correct patient identification is vital for patient safety and the maintenance of patient confidentiality
  • Use at least three approved identifiers for each patient encounter or activity such as making appointments, writing prescriptions, writing referrals to other providers, giving results or entering results or correspondence into records
  • Don’t assume you have the correct patient record when treating familiar patients
  • This criterion cross references to Criterion 1.7.1 Patient health records.

Approved patient identifiers

All practice staff should be trained to check for approved patient identifiers as a matter of course.

Approved patient identifiers are those items of information accepted for use in patient identification and include:

  • patient name (family and given names)
  • date of birth
  • gender (as identified by the patient themselves)
  • address
  • patient record number where it exists.

A Medicare number is not an approved identifier.

Why three approved patient identifiers are required

Identifying patients consistently and correctly is a key element in reducing the risk of adverse events and enhancing patient safety.7,8 Studies have confirmed that an adequate level of correct patient identification can be achieved by using at least three approved patient identifiers each time identification is made,9 whether the practice has computer or paper based records. This minimises the risks of misidentification of patients and mismatches when they are undergoing procedures or clinical tests. Studies undertaken in the USA11 using databases of medical records have demonstrated that the risk of false positive matching falls from a two in three chance using last name only to a one in 3500 chance when first and last names, postcode and date of birth are used.

Asking for patient identifier information

When asking for patient identifier information, practice team members should ask the patient to state their name, date of birth and address rather than volunteering the information from the record the staff member has open. It is not appropriate for staff to volunteer patient identifier information and then ask the patient to confirm it – errors will occur if patients who are nervous, over obliging or hearing impaired verify incorrect information. In asking for patient identifier information, staff need to be mindful of privacy and confidentiality issues (see Criterion 5.1.2 Physical conditions conducive to confidentiality and privacy).

When a patient is very familiar to the practice team, it may appear almost nonsensical to check their identity, but most practices have patients with identical names and the mismatching of patients and patient health records is not uncommon. Some practices overcome this by routinely asking patients to verify their address and other particulars each time they attend. This approach has the added benefit of ensuring patient contact details are kept up-to-date.

Telephone and electronic identification

It is important to ensure correct patient identification when a patient telephones for a test result to maintain patient confidentiality and safety as identity checking is more difficult when the patient is not physically present. As before, patients should be asked to provide identifying information rather than asked to confirm information provided by the staff member.

Practices need to exercise caution in the use of text messages or emails to communicate clinical information to patients, since both methods can risk inaccurate patient identification and a breach of patient confidentiality.

It is equally important to ensure correct patient identification when patients ask for a repeat of their medications without attending the practice.

Referral documents

Referral documents to another healthcare provider, such as a specialist, pathology or imaging service or hospital, should also document at least three of the approved patient identifiers of the patient being referred (see Criterion 1.6.2 Referral documents).

Unique patient identifiers

The National E-Health Transition Authority is developing a system of unique patient identifiers for patients, as well as individual healthcare providers and organisations. Unique patient identifiers will support the electronic transfer of information and where available should be used to complement the three required patient identifiers. These identifiers will facilitate the accurate and secure transfer of patient health information between the different areas that provide care to an individual patient.

With the introduction of unique patient health identifiers, the practice’s capacity to collect patient data and utilise this in quality improvement activities will be enhanced.

Errors in patient identification

If errors in patient identification do occur, every member of the practice team is encouraged to report them, so that the event can be analysed and processes introduced to reduce the risk of a recurrence and harm occurring to other patients (see Criterion 3.1.2 Clinical risk management systems).

References

  1. Makeham M et al. Patient safety events reported in general practice: a taxonomy. Qual Saf Health Care 2008;17:53–7.
  2. Makeham M, Bridges-Webb C, Kidd MR. Lessons from the TAPS Study: Errors relating to medical records. Aust Fam Physician 2008;37:243–4.
  3. Australian Commission on Safety and Quality in Health Care. Draft National Safety and Quality Healthcare Standards. Sydney: ACSQHC, 2009.
  4. Mohr J, Batalden P. Improving safety on the frontlines: the role of microsystems. Qual Saf Healthcare 2002;11:45–50.
Standard 3.1 Safety and quality

Our practice is committed to quality improvement.

Criterion 3.1.4

Patient identification

Our patients are correctly identified at each encounter with our practice team.

In a nutshell

Correct patient identification is vital for patient safety and confidentiality. Your health service should routinely check patient identity by the use of three approved patient identifiers for each patient encounter. This minimises the risks of mis-identification and mismatches when patients undergo procedures or clinical tests, or when references are made to medical results.

Key team members

  • Reception staff
  • Clinical staff

Key organisational functions

  • Patient confidentiality and privacy policy
  • Patient health records policy and procedures
  • Patient information management systems and processes
  • Patient communication (including telephone and electronic communications policies)
  • Appointment systems
  • Clinical risk management
  • Referral protocols

Indicators and what they mean

Table 3.4 explains each of the indicators for this criterion. Refer to Criterion 3.1.4 Patient identification of the Standards for general practices for more information and explanations of some of the concepts referred to in this criterion. 

Table 3.4 Criterion 3.1.4 Patient identification
IndicatorWhat this means and handy hints
▶ A. Our practice has a patient identification process using three approved patient identifiers and the practice team can describe how it is applied. Your health service could have a standing policy that at each encounter with the service, patients are required to provide at least three health service-approved identification indicators to staff. It is important that your policy requires staff members to ask patients to state their identifying information rather than to simply confirm the information the staff member provides. These encounters include the following situations:
  • when making appointments
  • at reception
  • in the clinic
  • writing prescriptions, referrals
  • giving or entering results or correspondence into records.
Accepted patient identifiers include:
  • client name (family and given, and/or cultural, skin, clan or bush name)
  • date of birth
  • gender
  • address (may be recorded as community/outstation/homeland)
  • hospital record number or equivalent
  • family relationships
  • for a client who was part of a multiple birth, the order in which the client was born (for example, the second of twins).
Note that Medicare numbers are not approved identifiers.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure that it correctly identifies patients at each encounter. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The service’s patient health files contain at a minimum three approved patient identifiers. The service’s reception staff routinely check that the address and contact details held on file are the current ones for the patient.

A prompt sheet containing approved patient identifiers is kept at reception to remind staff they must ask patients to indicate (not verify) their identity at each encounter with the health service.

A protocol is in place that at each service encounter or activity patients are identified even if they are well known to the service and staff. Staff members routinely ask patients their name, address and date of birth prior to commencing a consultation. The protocol includes instructions that staff ask specific questions such as ‘What is your name? Your address? Your date of birth?’

Clinical staff members check patient identification using three approved patient identifiers before any procedural treatment is provided. Staff members are mindful of privacy and confidentiality issues when asking for patient identifiers.

Staff members are encouraged to report incidents of patient mis-identification if they occur and to record them in the health service’s event register so the event can be reviewed and analysed. In this way, existing processes can be varied or new processes can be implemented to reduce the risk of mis-identification recurring and causing harm to other patients in the future.

Showing how you meet Criterion 3.1.4

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Show that you use health service-approved patient identifiers.
  • Show that you maintain appropriate reception processes.
  • Use patient health files.
  • Keep a prompt sheet at reception.

Related RACGP Standards and criteria

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