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CLIN 41 Patient Identification Procedure

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CLIN 41 Patient Identification Procedure Powered By Docstoc
					     Patient Identification
     Procedure



 Policy Consistency Group
 Date Approved                                      30/09/2008


 Provider Governance Action Group
 Date Approved                                      02/10/2008




                                                                        Clinical
 Signature                                          Heather Evans




Reference Number      CLIN 41
Version               1
Review Date           October 2010
Responsible Officer   Chair of Professional Leads




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CONTENTS



  1) Introduction ......................................................................................................2

  2) Scope................................................................................................................2

  3) Objectives ........................................................................................................2

  4) Principles of Patient identification................................................................2

  5) Patient identification wristbands ...................................................................3

  6) Application of identification wristbands .......................................................3

  7) Patients unable to wear identity wristband ................................................4

  8) Disposal of Identification wristbands. ..........................................................4

  9) Patient Identification within Prison Health. .................................................4

  10) Requests, Specimen Collection and Handling .........................................6

  11) Imaging ..........................................................................................................6

  12) Risk Management ........................................................................................6

  15) Related PCT Policies...................................................................................6

  14) Training ..........................................................................................................6

  15) Monitoring ......................................................................................................7

  16) References. ...................................................................................................7




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1) Introduction
Patient misidentification is increasingly being recognised as a widespread
problem within healthcare organisations. The National Patient Safety Agency
(NPSA) has recognised patient misidentification as a significant risk within the
NHS.(safer practice notice no 11, 2005) and highlighted within safer practice
notice No 24, that a significant amount of reports relating to patients being
mismatched to their care, were received during February 2006 and January
2007.

Correct patient identification is an essential stage in the care process, with
potential significant consequences arising if an error is made. It poses a
challenge in Hospitals, Prison health and community settings because of the
number of complex interventions that occur to patients, ranging from drug
administration and phlebotomy to invasive procedures. Interventions occur in
a variety of locations and can be provided by large teams of clinical and non-
clinical staff, many of whom work shifts. In addition, patients who have any
kind of barrier to good communication are not always capable of responding
to questions in relation to their identity.

Patient misidentification can lead to serious outcomes for patients. The
following types of incidents are possible:

• Administration of the wrong drug to the wrong patient
• Performance of the wrong procedure on the patient
• Serious delays in commencing treatment on the correct patient e.g.
mislabelling of a sample of abnormal blood or tissue.
• Patient given the wrong diagnosis
• Patient receives inappropriate treatment
• Wrong patient is brought to theatre
• Risk of fatal ABO blood transfusion incompatibility



2) Scope
This procedure applies to all staff working within South Staffordshire PCT who
are treating patients within either the Community Hospitals, a Community
Clinic setting, or a Prison healthcare department



3) Objectives
• To improve patient safety and reduce the risk of misidentification
• To provide assured mechanisms to verify correct patient identification
• To ensure a corporate and standardised approach to patient identification
   and the use and contents of a patient’s identification wristband where
   appropriate.



4) Principles of Patient identification
It is important for all staff, in Hospital, Community, and Prison Health settings
to establish correct patient identification at the first contact with the patient.

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Where possible, verbally check the patient’s identity with the patient by asking
them full name, address and date of birth. It is important to ask the patient to
give YOU the information, rather tha n asking the patient to confirm details
spoken to them.

If the patient does not have the capacity to identify him or herself, then the
information must be checked with a family member or person accompanying
the patient to clinic or Hospital appointments.

Services of an interpreter maybe required for patients who cannot speak
English.

The clinician must ensure that ongoing patient identification takes place prior
to any intervention, treatment, procedure or administration of medication
taking place.



5) Patient identification wristbands
Wristbands must be worn by all patients receiving the following care-

•   Inpatient care.
•   Day case and outpatients undergoing a diagnostic or therapeutic
    procedure.
•   All patients receiving a blood transfusion

Wristbands must comply with the NPSA safer practice notice no 24 –
Standardising wristbands improve patient safety.

The wristband must only state the following information.
   • Surname written in upper case
   • Forename written with first letter uppercase, remainder lower case.
   • Date of birth written dd-Mmm-yyyy e.g. 07-Jun-2005
   • NHS number, with format of numbers 3-3-4 e.g. 124-568-3789 (NPSA
      Safer Practice Notice NPSA/2008/SPN001 - Risk to patient safety of not
      using the NHS Number as the national identifier for all patients)

All information must be written clearly in black indelible ink. The wristband
must be white “write on “ design only, the exception being if the patient has an
allergy when a red band with a white area to record patient information should
be used.

 NB - when a red wristband is used, the above information only is
recorded on the band. The allergy is NOT recorded on the band. The red
wristband prompts the clinician to refer to the patient’s notes to
establish known allergies. (NPSA safer practice notice 24)



6) Application of identification wristbands
It is the responsibility of every Registered Nurse, Healthcare Support worker,
or other member of staff who has been given responsibility to admit a patient,
to ensure that the patient is wearing an identity wristband with the correct
details. It is ward/department Managers responsibility to ensure that
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appropriate staff are competent in the completion and application of patient
wristbands.

Identification wristbands should be written with the patient present, and
applied as part of the admission procedure, ideally within thirty minutes of the
patient arriving within the ward or department.

The wristband should be applied to the patient’s dominant wrist (NPSA notice
No. 11 2005) thus leaving the non dominant wrist free for intravenous access
should this be required.

If the patient has been transferred from another Trust, then a new
identification wristband must be written and applied to the patient, with
removal of the previous wristband.

The person writing the details on the identity bracelet is responsible for
ensuring the details are correct. Where possible, the information recorded on
the wristband must be checked with the patient and against the medical notes
before application. If the patient is unable to check the details, a relative or
friend should be asked to check the details on their behalf.

If the identity wristband is removed, faded, damaged or unreadable then the
staff member who noted the absence or damaged wristband, must apply a
new replacement identity wristband immediately.



7) Patients unable to wear identity wristband
There are some situations where a patient may not wear an identity
Wristband .

§ The patient refuses to wear the identity wristband
§ The wristband causes skin irritation
§ The patient removes the identity wristband

A risk assessment must be formally documented and the patient MUST be
informed of the potential risks of not wearing an identity wristband. This
discussion and the reason for the patient not wearing the identity wristband
MUST be clearly documented in the patient record, along with the risk
assessment.



8) Disposal of Identification wristbands.
Identification wristbands should be removed at the point of discharge and
disposed of within confidential waste bag due to containing patient
information.



9) Patient Identification within Prison Health.
Patients/prisoners fall into the category of patients who do not wear
wristbands therefore they pose a significant risk where patients
misidentification is concerned. Health Care staff must ensure the following is
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clarified with the patient/prisoner at their initial reception and when carrying
out any treatment/procedure, to ensure patient safety at all times.

Initial Reception

•   Nursing staff should identify the prisoner from either the court warrant or
    prison F2050 for new receptions or from the inmate medical record if
    transferring from another prison.
•   A photograph of the prisoner should be placed on the outer cover of the
    inmate Medical record.
•   Date of Birth, prison number and name should be recorded on the inmate
    medical record and the establishment at which they are to reside.
•   Date of Birth, name and prison number should be checked with the
    prisoner on reception interview.
•   It is the responsibility of the reception screening nurse to ensure prisoner’s
    photograph, prisoner’s number, name and date of birth are displayed on
    the inmate medical record and drug administration chart at the time of
    initial reception to the establishment.

Identification of a prisoner prior to drug administration.

It is the responsibility of the registered nurse to ensure that they have correctly
identified a prisoner prior to the administration of any drug or treatment. In
order to do this safely they must ensure that they have clarified:

    1. Prisoner/Patients full name
    2. Prisoner/Patients prison number
    3. Prisoner/Patients date of birth.
    4. Checks the photograph on the treatment card and ensure they are
       satisfied the prisoner is who he states he is.
    5. Ensure consent is given where relevant for any treatment (refer to
       South Staffordshire Primary Care Trust consent to treatment policy for
       further clarification.)
    6. Where a patient is unable to identify themselves by the above
       questions being asked medical staff should ensure:
       • They have verbal clarification from prison staff as to who the
           patient/prisoner is.
       • Check name and prison number against cell card
       • Check inmate medical record and match photograph to
           patient/prisoner.

Identification of a prisoner/patient prior to dental treatment or invasive
procedure.

To ensure patient safety for dental treatment or any invasive procedure the
practitioner must ensure they obtain the following prior to treatment.
   1. Patient/prisoners full name
   2. Patient/prisoners DOB
   3. Patient/prisoners number
   4. Check photograph on inmate medical record is a true likeness of the
        patient/prisoner to be treated.



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10) Requests, Specimen Collection and Handling
It is essential that all staff involved in medical laboratory requests, specimen
Collection and handling of such specimens are familiar and follow the
Standards for Medical Laboratories (CPA 2004) relating to patient
identification.
This will ensure that request forms are completed correctly, which are
essential for the performance of the correct laboratory test to the benefit of the
patient and the satisfaction of the requesting physician. It will also ensure the
correct preparation of the patient, correct specimen collection and handling
which are essential for the production of valid results by the Laboratory.



11) Imaging
It is the ultimate responsibility of the operator to ensure that the correct patient
is being examined according to the request that has been made. The expose
must not be performed until the patient identification has been verified. All
operators must adhere to local Trust procedures and guidance from IRMER
(2000).



12) Risk Management
Any member of staff discovering any variance or deviation from this policy
must complete an incident form immediately in line with the PCT Adverse
Incident Risk Reporting Policy.

If an error occurs (e g the wrong patient receives treatment or investigations
or consultation) then immediate action must be taken to remedy the error and
ensure the patient’s safety. The error must be recorded in the patient’ notes.
Details of actions taken to rectify the error must also be recorded. The patient
must also be fully informed of the incident and explanation of actions taken
given.



13) Related PCT Policies
This procedure must be read in conjunction with relevant Trust policies
Including the:

•    Corp 11 Consent Policy
•    Corp 27 Adverse Incident Reporting Policy
•    Clin 02 Clinical Record Keeping Policy
•    Clin 03 Blood Transfusion Guidelines
•    Corp 33Risk Assessment Policy



14) Training
Staff will receive ward or departmental training in relation to this procedure as
part of team induction.



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15) Monitoring
It is the responsibility of the Ward Manager/Team leader to ensure members
of the team adhere to this procedure. Audit maybe used to monitor
compliance.



16) References.
Ionising Radiation (Medical exposure) Regulations 2000

NPSA Safer practice notice no 11,-. Wristbands for Hospital inpatients
improves safety. (2005).

NPSA Safer practice notice no 24- Standardising wristbands improves patient
safety (2007)

Standards for the Medical Laboratory (CPA 2007)

National Patient Safety Agency Safer Practice Notice SPN 001 - Risk to
patient safety of not using the NHS Number as the national identifier for all
patients




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Description: CLIN 41 Patient Identification Procedure