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CITY HOSPITALS SUNDERLAND NHS TRUST DEPARTMENT OF NURSING & QUALITY NURSING/ MIDWIFERY POLICY No 5 PATIENT IDENTIFICATION Introduction Identification of patients is important from the moment a patient is admitted until they are discharged. Nurses should ensure they are familiar with the policy relating to Administration and Prescribing of Medicines and also the Nursing and Midwifery Council (NMC) Standards for Administration of Medicines (10.1) together with the NMC Code of Professional Conduct, Part. 2. 1. 1.1 Essential Requirements All inpatients should be identified by means of an identification bracelet attached to the wrist (or appropriate limb in the case of amputation). Where this is not desirable, it should be agreed by the Named Nurse and the Ward Manager and recorded in the care plan. Examples of areas where the wearing of identification bracelet may be seen as undesirable are: • Dermatology/Rheumatology: some conditions or medications can react unfavourably with bracelets. • Day hospitals • Neo Natal Unit In these instances a locally agreed policy for identification of patients should be developed and adhered to. 1.2 It is the responsibility of the Ward Manager to ensure that all patients in his/her areas are identified and to ensure that staff are familiar with the policy. The bracelet may be fitted by any member of staff and should then be checked by the nurse admitting the patient. The bracelet will bear the patient’s surname and forenames, along with the date of birth, ward and the hospital number if known. This will be printed clearly. The information on the bracelet will form the basis of the procedure for checking identify before procedures such as administration of medicines. If name bands become obscured or difficult to read they must be re-written and replaced immediately. 1.3 1.4 1.5 1.6 1 1.7 In the case of patients with the same or similar name – staff must attach alert stickers on all patient documentation to ensure correct identity. General principles in relation to patients with Special Needs In the case of children, unconscious or confused patients, the details should be checked and agreed with the parent/carer/relative. In the case of an unidentified patient in Accident and Emergency, an identification bracelet should be placed on the wrist and ankle stating: “Unidentified patient – male/female – A &E No.” 2. 2.1 2.2 2.3 In the case of deceased patients an identification bracelet is placed on the wrist and ankle before moving to the Mortuary. General principles in relation to Operating Departments, DCU, Endoscopy and MADCU In the operating department theatre personnel will confirm the identity of the Patient using the theatre checklist and identity bracelets in line with theatre Protocols No 1. 2 and 3. Should it prove necessary, in exceptional circumstances, prior to or during the course of the operation/procedure, to remove the patient’s identity bracelet, this should be carried out by the named nurse in theatre. It will remain her/his responsibility for immediately re- attaching the bracelet to the patient or arranging for the fitting of a new bracelet on return to the ward. The bracelet that has been removed should be attached to the front of the patients notes and a record of the event documented in the theatre profile. 3. 3.1 3.2 4. 4.1 General Principles in relation to the Maternity Unit On admission to the Maternity Unit, an identity bracelet will be placed on the patient’s wrist. Delivery Suite Following birth, two identification bracelets should be made out bearing the name, sex, date and time of birth of the baby and the mothers unit number and surname and shown to the mother and a birth companion if present. A bracelet is then placed around each of the baby’s ankles as soon as possible after the birth. 5. 5.1 5.2 Before the transfer to another area i.e. ward/hospital/NNU, the identification bracelets should be checked by the midwife. Where more that one baby is born, the order of the birth must be indicated 2 5.3 on the bracelet e.g. twin 1, twin 2. 5.4 The mother should be told that the bracelets must not be removed until they arrive home with the baby. Obstetric Theatre If the mother has an epidural/spinal anaesthetic then the procedure in 4. followed to ensure accurate identification of the baby. 6.2 If the mother has a general anaesthetic to ensure accurate information is obtained, the two nurses present will check the details. Should it prove necessary, in exceptional circumstances, prior to or during the course of the operation, to remove the patient’s identity bracelet, this should be carried out by the named nurse in theatre. It will remain her/his responsibility for immediately re- attaching the bracelet to the patient or arranging for the fitting of a new bracelet on return to the ward. The bracelet that has been removed should be attached to the front of the patients notes and a record of the event documented in the theatre profile. 7. 7.1 Transfer to the Postnatal Ward With reference to the baby notes, the identification bracelets are checked by ward and delivery suite nurses for accuracy. The baby’s identification bracelets are checked daily to ensure that they are still in situ. This is then recorded in the mother’s postnatal notes. 6. 6.1 is 6.3 7.2 7.2.1 In the case of a baby admitted from the community to the ward or the neonatal unit, two identify bracelets are applied immediately one to each ankle. Two nurses check details with the parent/carer where appropriate. 8. Action to be followed when the Neonate’s Identification Bracelet(s) is lost One bracelet missing: Obtain all relevant documentation and in the presence of the mother and another Nurse, a duplicate bracelet is then completed and placed around the baby’s ankle and action recorded. 8.2 Both bracelets missing: (a) The identification bracelets of all the other babies in the ward are checked by the Midwifery co-ordinator and the Ward /Neonatal Nurse. 8.1 3 (b) Relevant documentation is obtained for the baby that has lost it’s bracelets, and in the presence of the mother, the following are checked: (i) (ii) Mother’s identification bracelet Details in the mother and baby notes. (c) (d) (e) In the Neonatal Unit, the baby notes only are checked Make out new identification bracelets and place them on the baby’s ankles. Record in the relevant documentation, the date and time of reapplication of the identification bracelets with the signature of the Ward Midwife after checking the details with the mother and partner (if present). Effective date Review date January 2005 January 2007 4
"CITY HOSPITALS SUNDERLAND NHS TRUST DEPARTMENT OF NURSING "