Standard 5

Patient Identification and Procedure Matching

NSQHS Standards Standard 5 - Patient Identification and Procedure Matching


This page contains information about the first edition of the NSQHS standards. This edition has been superseded by the second edition that was endorsed by the Health Ministers in June 2017 and released in November 2017.

This latest edition addresses the gaps that were identified in the first edition, including mental health and cognitive impairment, health literacy, end-of-life care, and Aboriginal and Torres Strait Islander health.

Health service organisations will be assessed to the second edition from January 2019.

To find information and resources for the second edition, visit the Australian Commission on Safety and Quality in Health Care's new NSQHS Standards microsite.

Key message

It is the responsibility of all clinicians to ensure that patients need to be correctly identified and matched to their intended treatment and care at all times.


Ensuring the right care is provided to the right patient is an essential part of providing and receiving safe care. Unfortunately, this does not always happen. The failure to correctly identify patients and match that information to an intended treatment or intervention continues to result in procedures being performed on the wrong person, wrong side or wrong site; medication errors; blood transfusion errors; and errors in diagnostic testing.

Patient identification and the matching of a patient to an intended treatment is an activity that is performed routinely in all care settings, and can often be seen as a relatively unimportant task. The use of tools such as World Health Organisation’s Surgical Safety Checklist and the "Ensuring Correct Patient, Correct Site, Correct Procedure Protocols" provide a basis for the development of safety routines for common tasks, such as patient identification, and provide a powerful defence against simple mistakes that may progress and cause harm to patients.

The aim of this Standard is to ensure that the health workforce correctly identifies all patients whenever care is provided and correctly matches patients to their intended treatment.

Facts and Figures

Mismatches between patients and their care do not often result in harm, but they can have significant consequences. In 2008–09 there were eleven events in Australia with procedures involving the wrong patient or body part resulting in a death or major permanent loss of function. When less serious events from non-surgical areas such as pathology and radiology are included in reporting systems the number of reported events can rise considerably.

Information above is taken directly from the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, October 2012 document published in the Australian Commission on Safety and Quality in Health Care website.

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Responsibilities under Standard 5 include:

  • confirm the identity of the patient by:
    • using three approved identifiers specified by your organisation
    • by asking the patient to state their full name and date of birth and checking this against the patient identification band
    • before any care, therapy or service occurs
    • during the transfer of care from one professional to another, or between health care services
  • ensure patients are wearing one approved identification band
  • ensure all clinical documentation is correctly labelled
  • accurately match patients with their clinical samples and ensure samples are correctly labelled
  • ensure patients and carers understand that they will be repeatedly asked to state their name, date of birth and other details for the purpose of correct identification
  • identify, communicate and document any clinical alerts.

Other eLearning resources

Further information

Below is a full copy of the Patient Identification and Procedure Matching contained in the National Safety and Quality Health Service Standards. It includes the criteria, items and actions required for health services to meet this Standard and is available on the Commission’s website at

  • Download Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, October 2012