Standard 5


Standard 5: Patient identification and procedure matching


To provide excellent care to our patients it is important that we have explicit processes to correctly match patients with their intended care. We encourage our staff to report all circumstances were this might be an issue so that we can implement improvement processes.

Hospital Standards

Epworth is accredited under the National Safety and Quality Health Service Standards. These national standards apply to all health services organisations and state the minimum level of care – the national benchmark – that consumers can expect. Hospitals must report their performance against the standards on a regular basis and are also subject to periodic reviews and assessments.

For further information, refer to the National Safety and Quality Health Service Standards Guide (PDF).


Epworth Standards

At Epworth we want to provide excellent patient care. For this reason, we set our own, stricter benchmarks against each of the standards, and we measure our performance against these. The table below provides details of the national benchmark, the Epworth internal benchmark and our average result against each of the items.

​Standard 5: Patient identification and procedure matching
​National Benchmark
​Epworth HealthCare Internal Benchmark
​Epworth HealthCare Average 2014
​Epworth HealthCare Average 2015 Average FY
2015-16 †
​Consent related incident rate ​n/a* ​0.10 ​0.18 0.20 #​ 0.27 #​
​Patient Identification incident rate ​n/a* 4.00 ​5.40 4.80 #​ 5.00 #​
Patient Identification process as contributing factors rate
​4.20 4.50 #​ 4.90 #​

Rate=per 1,000 bed days.​

* n/a denotes that no national benchmark has been defined, so Epworth has set its own.

# A lower number is better.
† Figures for year ending 30/6/2016.

We are working on

  • Reducing our rate of patient identification incidents by:
    • implementing a standard identification band across all Epworth hospitals
    • introducing processes to eliminate the risk of misidentifying a person when carrying out diagnostic procedures, medication prescriptions or blood transfusions.
  • Reporting of incidents related to patient identification and procedure matching is a self-reporting system. At Epworth, we encourage our staff to report incidents and near misses so that we can improve our safety. Increased reporting reflects our positive culture of self-reporting and continuous improvement.

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