Australian Commission on Safety and Quality in Health Care
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Ensuring Correct Patient, Correct Site, Correct Procedure Protocol for Surgery: Review of implementation and proposals for action

Please Note

This publication is only available electronically and is not available in hard copy or to order.

The main aim of this initiative was to gain an understanding of the way in which the Ensuring Correct Patient, Correct Site, Correct Procedure Protocol has been implemented in Australia. The review was focussed on use of the Protocol in a surgical environment.

The review of the implementation of the Protocol involved the following activities:

  • examining the jurisdictional and private hospital policy framework in place regarding the Protocol
  • obtaining information about the level of compliance with the Protocol
  • interviewing individuals who have been involved in the implementation or use of the Protocol about their experiences.
The discussion paper presents the results of the review, as well as actions that were proposed at the time to reduce observed variation in the use of the Protocol. These actions were informed by preliminary discussions with the Royal Australasian College of Surgeons, however in some cases the proposed actions were overtaken by the release and adoption of the WHO Surgical Safety Checklist in 2009. The actions relating to standards for patient identification have been incorporated into the draft National Safety and Quality Service Standards.


Ensuring Correct Patient, Correct Site, Correct Procedure Protocol for Surgery: Review of implementation and proposals for action (PDF 222 KB)


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Updated: 07 December, 2010

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