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Grand Round - Patient Identification, Communicating for Safety

August 02, 2021


This QRG outlines the staff responsibilities in performing correct patient identification to provide safe and timely clinical care.


Alignment to Western Health Best Care Framework

Right Care, Safe Care

To take a look at the Western Health Best Care Framework, please click here.


Why is this Important?

Accurate and consistent patient identification at every point of care is essential to patient safety.


What does this look like in practice?

Patients are identified at point of triage by self-identification or from family/friends accompanying the patient. Identification should also be validated using another legally documented form of identification (Medicare card, health care card, drivers licence etc.)

All patients must be identified using three of the following approved identifiers:

  • Full name
  • Date of birth
  • Age
  • Gender
  • Address
  • UR Number
  • Medicare Number
  • DVA number


Key Points

  1. At the point of triage, patients are issued a unique WH UR number.
  2. Clerical staff will confirm details on the hospital wristband with the patient.
  3. The ID band will be applied at triage and must remain on the patient throughout their hospital stay.
  4. If the ID band is removed at any point, a new band must be reapplied immediately.
  5. ‘RESUS UNKNOWN’ is to be given to any patient who is unable to identify themselves, has no one present to provide the patients identity and has no supporting documentation on their persons to identify them.
  6. ‘Resus unknown’ patients will be assigned a pre-generated UR number and efforts should be made to identify the patient as soon as possible.
  7. Patients must be identified at the commencement of any care or treatment:
    1. When commencing any treatment including observations
    2. When collecting a patient from the waiting room or AV triage
    3. When taking a pathology sample
    4. When ordering radiology
    5. When giving or receiving handover of a patient
    6. When giving medications or IV fluids
    7. Inter-ward transfers (includes transfer to radiology and theatre)
  8. Patient identification is performed by asking patients open-ended questions such as “What is your name?” and “What is your date of birth?” as well as checking the patients unique WH UR number on their identification band.
  9. If a patient is unable to communicate, a family member or carer should be consulted to formally identify the patient where possible
  10. A patient ID label must be attached to all patient documentation including blood prescription forms, procedure forms and all other paper based documentation in the patient’s medical record.
  11. A patient ID label (or bradma) must contain the following information
  • Patient UR number
  • Family name
  • Given name
  • Address
  • Date of birth
  • Gender
  • Episode barcode





Policies, Procedures and Guidelines

OP-GC1 Patient Identification

OP-CM5 Management of Patient Clinical Records

OP-GC8 Consent, Prescribing and Administration of Blood and Blood Products



Alert & Allergy surveillance in the Emergency Department

Clinical Handover

Electronic Medical Records (EMR) Documentation

Risk Screening in the Emergency Departments

Transfer of Patient within the Hospital