Patient Identification

Patient identification incidents refer to incidents involving a mismatch of the patient receiving care, the site care should be provided to (i.e. the body part), the procedure that is to take place, and as applicable, the implant or prosthesis that is to be inserted/attached. The NSW Health Clinical Procedure Safety policy PD2017_032 describes the steps that must be taken to reduce patient identification incidents.

Prior to 10 February 2014, all patient identification incidents were classified as serious incidents (SAC/Harm Score1) in the IIMS, and subsequently underwent RCA investigation. From 2014, incidents not resulting in actual harm were no longer automatically recorded as a SAC/Harm Score1 incident.

Procedures involving the wrong patient or body part, regardless of the outcome, require reporting to the NSW Ministry of Health through a RIB.

There were no SAC/Harm Score1 patient identification incidents during the January – June 2020 reporting period (Table 12). The total number of SAC/Harm Score2-4 patient identification incident reports increased by 16 per cent compared with the July – December 2019 reporting period (Table 13). Most of these incidents involved a failure to perform the procedure on the correct site or side in diagnostic imaging and operating theatres. The majority of these incidents resulted in no actual harm to the patient.

Lower rates of reporting are not a reliable indicator of safer care. NSW Health staff are always encouraged to report all incidents.

Table 12: Location of SAC/Harm Score1 incidents involving patient identification where clinical procedure has occurred, July 2016 – June 2020

Location of SAC/Harm Score1 incidents involving patient identification 20162017201820192020
Jul-DecJan-JunJul-DecJan-JunJul-DecJan-JunJul-DecJan-Jun
Imaging / Nuclear Medicine / Radiotherapy 0 0 0 0 0 0 0 0
Wards and Other areas 0 0 4 0 1 4 0 0
NICU / SCN / Maternity & Paediatrics (EBM incl) 0 0 0 0 0 0 0 0
Operating Theatre (includes Anaesthetics) 2 2 0 1 0 1 1 0
Dental 0 0 0 0 0 0 0 0
Total 2*2*4*1*1*5*1*0

Caveats: Incorrect patient / procedure / site reporting requirements changed 10 February 2014
*Incidents already accounted for in SAC/Harm Score1 table

Table 13: Location of SAC/Harm Score2, SAC/Harm Score3 and SAC/Harm Score4 incidents involving patient identification where clinical procedure has occurred, July 2016 – June 2020

Location of SAC/Harm Score1 incidents involving patient identification20162017201820192020
Jan-JunJul-DecJan-JunJul-DecJan-JunJul-DecJan-JunJul-DecJan-Jun
Imaging / Nuclear Medicine / Radiotherapy 21 19 16 20 22 31 19 23 25
Wards and Other areas 34 21 26 23 20 15 26 9 11
NICU / SCN / Maternity & Paediatrics (includes EBM) 4 6 3 5 5 4 9 3 10
Operating Theatre (includes Anaesthetics) 2 6 4 12 4 8 3 9 5
Dental 5 2 2 0 1 5 1 1 1
Total 665451605263584552

Caveats: Incorrect patient, procedure, site reporting requirements changed 10 February 2014