Preventing patient identity errors

GS1 Australia

By Catherine Koetz*
Tuesday, 23 October, 2018

Preventing patient identity errors

To provide greater patient safety and deliver better outcomes, today’s healthcare providers need to ‘capture’ the identification of their patients and clinicians at points of care.

Positive patient identification is especially important in busy clinical areas where misidentification could lead to adverse events.

Concerned about increased errors, ACT Health and The Canberra Hospital took action to address this issue. They used GS1 standards to help identify their patients, lab and pathology samples and care providers, ensuring accuracy in patient-care processes throughout each patient’s journey within their hospital.

Unlocking the power of digitisation

While many manual processes are robust, ACT Health found that the risk of error increased with the number of patients needing their services, experiencing possible preventable incidents despite having implemented policies to help avoid them.

To achieve better outcomes for patients, and increase patient safety within their health services, ACT Health invested significantly in creating a digital healthcare infrastructure and digitisation.

They recognised early in this process that successful digitisation required interoperability across their datasets to support clinical processes across, and within, their many services. Bringing together representatives from stakeholder groups across the organisation, they developed a core data standards framework that reflected and supported their needs as they moved from manual processes into the digital world.

Leveraging GS1 standards

The data standards, which include GS1 identifiers, enabled them to accurately identify and capture data in real time, including patient information, the episode of patient care, caregiver’s identity, locations, assets and clinical notes related to the many interactions that take place within the care process.

Importantly, too, the standards were all internationally recognised and scalable — essential for implementing new systems into the future.

Image credit: ©GS1 Australia

Implementing the foundations

In an integrated world, ACT Health recognised that making one change could have flow-on impacts. To contain this, the team started their change journey by focusing on patient identification and by facilitating safety processes that were easy for staff to follow.

The first step in creating an interoperable positive patient identification (PPID) solution was to implement GS1 identifiers for patients and care providers. The team needed to ensure that verifying the patient’s identification in key processes could only occur at the bedside by scanning the patient’s wristband.

To achieve this, the patient wristband was designed with two core elements, including:

  • identifying the patient themselves, and
  • the ‘site’ of the identification and episode of patient care. This second element is key, as it enables a wristband to be electronically distinguishable from a clinical note or other ‘site’ where patient identification may be present within the hospital.

Sample patient ID with GS1 identification in GS1 DataMatrix barcode. Image credit: ©ACT Health

GS1 Australia also introduced the ACT Health team to ISO Technical Standard 18530:2014, which provides detailed workflows that assist with managing pathology samples. The ISO technical specification articulates how GS1 identifiers, specifically the Global Service Reference Number (GSRN) and Service Relation Instance Number (SRIN), could be used for patient identification and for care providers.

Putting positive patient identification (PPID) into action

Today, each patient wristband includes the GSRN and SRIN identifiers encoded in a GS1 DataMatrix barcode to uniquely identify the patient and the episode of patient care.

Labels associated with the clinical notes and specimens for a patient include the same identifiers but with subtle, yet technically significant, differences. These differences ensure that processes that must occur at the patient’s bedside are completed there.

For instance, wrong-blood-in-tube incidents are typically the result of blood collections being taken from the correct patient, only to then be inadvertently switched with another patient’s specimen before being submitted to the lab. This could happen when order handling and labelling is performed away from the patient for a batch of collections. With the new PPID system in the ACT, order handling and labelling are all done at the point of care.

This has provided a logical first place for ACT to implement its PPID solution. The system also prompts the correct action and automatically logs where a near miss has occurred, allowing for analysis to be completed. The implementation of the PPID solution has focused on the need to improve patient safety and outcomes by preventing errors while supporting clinical teams in their work.

Real and scalable benefits

With any change comes challenges, yet the vast majority of caregivers and staff at The Canberra Hospital appreciated the ability to work in a safer and more productive way, enabled by the PPID solution. With the PPID solution in place, a collector can now scan barcodes each step of the way when identifying a patient and the specific pathology lab test to be administered.

The Canberra Hospital has been able to significantly reduce errors related to pathology collections, reduce the number of repeated processes and costs of pathology, and secure better care for patients. The hospital also finds its staff members are finding the easiest way to do their jobs is now the correct way, thus supporting change management and compliance with the policy.

The GS1 standards framework is providing the foundation for many more process improvements where positive patient identification is key. The principles defined in the initial implementation will be used in other areas in the future, such as the tracking of blood products to a patient, expressed breastmilk matching to babies, electronic medications management, administration at bedside and more.

To learn more about this case study and others similar to it, visit the GS1 Healthcare Reference Book 2018–19 here:

For more information about implementing GS1 standards within health care in Australia, contact

*Catherine Koetz is Industry Manager – Healthcare, for GS1 Australia.

Top image: At The Canberra Hospital, Nurse Gladys Kamale uses the PPID system with patient Audrey Vanderburgh. Image credit: ©ACT Health

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