Patient identification and procedure matching in diagnostic imaging

Guideline number: QH-GDL-957:2022

Effective date: 28 June 2022

Review date: 28 June 2025

Supersedes: Version 2

On this page:

1. Statement
2. Scope
3. Requirements
4. Supporting documents
5. Definitions
6. Version control

1. Statement

This guideline provides recommendations regarding best practice to support the correct identification and procedure matching of diagnostic imaging patients.

Following this guideline will contribute to the prevention of patient harm by reducing clinical incidents associated with the incidence of ‘procedures involving wrong patient or body part’ (wrong patient, wrong site, wrong side and wrong procedure).

2. Scope

This guideline provides information for Queensland public health system employees (permanent, temporary and casual) and all organisations and individuals acting as its agents (including Visiting Medical Officers and other partners, contractors, consultants, students and volunteers) in the delivery of diagnostic imaging services.

3. Requirements

3.1 Verification of patient information on arrival

The patient needs to be identified with at least three identifiers e.g. full name, date of birth and address. If the patient is unable to answer the questions, their representative should answer on their behalf:

• What is your name?
• What is your date of birth?
• What is your address?

Verification of the patient identity should be obtained at patient presentation and at each point when care is transferred to or shared with another healthcare worker. Ensure you ask open questions e.g. “What is your name?” instead of closed questions e.g. “Are you Peter Smith?”

Where the patient is a child or unable to confirm these details, the details must be confirmed with the patient’s designated representative. If no representative is available, then the patient’s identification band or a staff member accompanying the patient must be used to verify the patient’s identity.

3.2 Verification of patient procedure

The intended procedure including the site and side requested must be confirmed before the examination commences.

• What are you here for?

Where appropriate, to confirm the correct side:

• Please point to the area(s) you’re having imaged today.

Where multiple sides and sites are to be imaged, you should ensure you have the correct site and side for each specific examination and that each examination has been confirmed by the patient.

If there is a discrepancy between the planned examination/procedure and the understanding of the patient, this should prompt a double check of the patient’s identity and the procedure that has been requested.

3.3 Matching information

Check the request form is clear and legible and contains the following information:

• patient’s first name and family name, date of birth, address and medical record number/URN
• procedure requested including site and side
• relevant clinical notes, including allergies and medical conditions / infectious risks
• reason for procedure
• referring clinician’s name and signature (written or electronic).

Responses to the verification questions should be matched to the request form (or completed consent form) and, if present, the patient’s identification band.

If a mismatch is discovered, the examination/procedure must not commence until the mismatch is resolved.

3.4 Time out

1. For single-operator procedures, the operator must stop and verify the listed requirements immediately before commencing the examination.
2. For team procedures, with the patient awake and present, the senior clinician involved in the procedure will call a “time out”.
   All members of the team are involved in this process and will verbally confirm the listed requirements prior to the procedure commencing:

For all modalities:

• correct patient is present
• correct procedure is being performed
• clinical history corresponds to the requested examination(s) / procedure(s)
• consent has been obtained and written consent (if applicable), cross checked with proposed correct procedure
• correct patient details are on the imaging device
• correct previous imaging is viewed and/or displayed, if applicable.

For general x-ray and ultrasound:

• correct side is identified and marked if, applicable
• if applicable, right or left side markers are being used and are correct to the side/extremity.

For CT and MRI:

• correct side is identified and marked, if applicable
• MRI safety checklist, if applicable
• contrast checks, if contrast being used.

For fluoroscopic procedures (including interventional radiology and cardiac catheter procedures):

• correct side is identified and marked, if applicable
• implant/equipment/medication are available and correct
• contrast checks, if contrast being used.

For nuclear medicine:

• correct radioisotope and activity are being used
• correct patient radio-labelled blood products are about to be injected (if applicable)
• for therapeutic administrations, at least 2 members of the team have performed the check.

3.5 Post procedure

Prior to release of images from the imaging modality to any networked device used for display or interpretation, the radiographer (or medical radiation professional or x-ray operator) must ensure:

• patient details (e.g. name, date of birth, URN, accession number) and side marker (if applicable) attached to the image(s) are correct
• both the radiology final check and time out have been recorded on the request form or RIS to demonstrate patient identification and procedure matching has been completed
• correct exam documentation (e.g. request, consent form, sonographer report, MRI safety checklist etc.) has been uploaded to the patient record.

3.6 Training

Online training in patient identification and procedure matching in diagnostic imaging is available through the Queensland Health learning management system. All staff members working within a department that performs diagnostic imaging examinations will undertake training on patient identification and procedure matching upon commencement of employment and every year thereafter. Students will undertake training on patient identification and procedure matching during their orientation to a diagnostic imaging department.

3.7 Incident reporting

Any discrepancies or mismatches identified during the patient identification and procedure matching process must be dealt with according to the Queensland Health Best practice guide to clinical incident management, or its local equivalent.

3.8 Review and audits

A department performing diagnostic imaging examinations will perform:

• 6 monthly retrospective audits to determine compliance with the guideline for patient identification and procedure matching in diagnostic imaging. Audits require a review of request forms and the RIS/PACS to ensure all sections of the radiology final check were completed and patient information fields, sidemarkers and examination performed were all correct.

Audits will be completed for each modality within a department.

Audit outcomes will be documented and reported to the Director of Medical Imaging (or equivalent) and discussed at staff meetings. Action plans will be developed, implemented and reviewed where areas of non-compliance or suggestions for improvements are reported.

4. Supporting documents

Australian Commission on Safety and Quality in Health Care factsheets and protocols for patient identification and procedure matching

5. Definitions

6. Version control