# Patient identification and pre-treatment time-out in radiotherapy

Source: https://onco.cc/protocols/radiotherapy-patient-identification-and-time-out/  
OnCo record `radiotherapy-patient-identification-and-time-out` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Every time you come for radiotherapy, even on the last day and even when the staff know you well, they will ask you to say your full name, date of birth and often your address, rather than asking you to confirm them. They also check that the plan on the machine is yours and that the right side is being treated. This is one of the most important safety checks in radiotherapy.

## Summary

In the UK the check is a legal requirement: IR(ME)R 2017 Schedule 2 requires the employer's written procedures to include procedures to identify correctly the individual to be exposed. Towards Safer Radiotherapy (RCR, SCoR, IPEM, NPSA, BIR, 2008) sets the method: open questions that elicit an active response (full name, date of birth, address), never closed yes/no questions; formal identification for every procedure even when the patient is well known, because mistakes are more likely later in treatment than at the beginning; a specified procedure for patients who cannot identify themselves; and confirmation of the correct side at set-up for each fraction. It recommends exploring technology such as bar codes, photographs in the record and verify system and biometrics. The WHO Radiotherapy Risk Profile (2008) rates incorrect patient identification as a high-impact risk at every stage and lists open questions with an active response, a minimum of three points of identification, photo identification and a unique identifier as solutions.

The time-out is less settled. AAPM TG-100 (2016) includes two forms of identification and a time-out in its example day-1 checklist, notes that the Joint Commission requires a time-out for procedures, and says there is no specific guidance requiring one at every treatment session, though it is a good idea; at day 1, it suggests the radiation oncologist take part. ASTRO's Safety is No Accident (2019) could not be read.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: radiotherapy ID check; patient ID check at the linac; radiotherapy time-out; pause and check radiotherapy; wrong patient radiotherapy; wrong site radiotherapy; correct side check radiotherapy; positive patient identification

## Connected records

- protocols: [Consent for radiotherapy: who takes it, when, and what it must cover](https://onco.cc/protocols/radiotherapy-consent/), [HDR brachytherapy: treatment-room safety and the stuck-source emergency](https://onco.cc/protocols/hdr-brachytherapy-room-safety-and-stuck-source-emergency/), [Immobilisation mask for head and neck and brain radiotherapy, including mask anxiety](https://onco.cc/protocols/head-and-neck-radiotherapy-immobilisation-mask/), [Linear accelerator quality assurance: daily, weekly, monthly and annual machine checks](https://onco.cc/protocols/linear-accelerator-quality-assurance/), [Pregnancy and breastfeeding checks before radiotherapy](https://onco.cc/protocols/radiotherapy-pregnancy-and-breastfeeding-enquiry/), [Radiotherapy planning scan (CT simulation): positioning, skin marks and what the patient does](https://onco.cc/protocols/radiotherapy-planning-ct-simulation/), [Radiotherapy with a pacemaker or implanted defibrillator](https://onco.cc/protocols/radiotherapy-with-pacemaker-or-defibrillator/), [Risk-based quality management of the radiotherapy process (TG-100 failure mode and effects analysis)](https://onco.cc/protocols/radiotherapy-risk-analysis-fmea/), [Stereotactic radiosurgery and SBRT: planning and delivery safeguards](https://onco.cc/protocols/stereotactic-radiosurgery-and-sbrt-delivery-safeguards/)
- technologies: [IMRT / IGRT (modern external beam)](https://onco.cc/technologies/imrt-igrt/)
- terms: [Radiotherapy](https://onco.cc/terms/radiotherapy/)

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