Patient Identification Policy

                                                                        Purpose of this document

                To ensure correct identity of patients at all times before undergoing treatment or
                                                                   receiving care in City Hospitals.

                                                All staff who come into contact with patients and all staff
                                                            who deal with samples taken from patients at
                                                        City Hospitals Sunderland NHS Foundation Trust

                 Further copies from
                                                                                         Gary Schuster
                                                                          Clinical Governance Manager
                                                       City Hospitals Sunderland NHS Foundation Trust
                                                                                    Trust Headquarters
                                                                             Sunderland Royal Hospital
                                                                                              SR4 7TP
                                                                           Telephone: 0191 569 42010
                                                                       Also Available on CHS Intranet

                 Document Reference                                                     CGP007-10-2006

                                                                                      Version Control

Version   Release               Author                Update comments

1.0       January 2005          Julie Lane            Planned review
                                                      Revision in response to NPSA Safer Practice
2.0       March 2006            Julie Lane
                                                      Notice 11 (November 2005)
                                                      Review date January 2007

                                                      Revision in light of CNST pilot of general risk
3.0       September 2006        Gary Schuster
                                                      management standards

                                  CLINICAL GOVERNANCE

                             PATIENT IDENTIFICATION POLICY

                                       OCTOBER 2006

1.    Introduction

1.1   Patient identification is increasingly being recognised as a widespread problem within
      healthcare organisations. The National Patient Safety Agency (NPSA) has recognised
      patient identification as a significant risk within the NHS.

1.2   Correct Identification is important from the moment patients are first admitted until they
      are discharged. It is the responsibility of every registered nurse, support worker, or
      other member of staff who has been given responsibility, to check and ensure patients
      are correctly identified throughout their stay in hospital.

1.3   Nurses, in particular, 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.

2.    Patient misidentification

2.1   The extent to which patient misidentification happens is widely underestimated by
      clinical staff, as often they are unaware that a misidentification has occurred. Patient
      misidentification can lead to series or fatal 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 a patient,
         •   Series delays in commencing treatment on the correct patient, e.g mislabeling of
             an abnormal blood sample or tissue sample,
         •   Patient is given wrong diagnosis,
         •   Patient receives inappropriate (and potentially harmful) treatment,
         •   Patient is over-exposed to radiation,
         •   Wrong patient is brought to Theatre,
         •   Cancellation of operation due to mis-filling of results.

3.    Staff responsibility

3.1   It is the responsibility of every registered nurse, midwife, competent support worker,
      student or other member of staff who has been given responsibility, to check and
      ensure that:

         •   A bracelet stating patient’s name, date of birth, hospital number and ward is
             (appropriately) attached,
         •   Where the patient is known to have an allergy, the label must be coloured red,
         •   On transfer of a patient to a new location, the bracelet must be changed to show
             the new location. Do not write over the old one.

4.    Patient identity for Inpatients

4.1   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.

      There are some situations where a patient may not wear an identity bracelet: -

         •   The patient with dermatology/rheumatology conditions where the bracelet
             causes skin irritation
         •   The patient takes medications than can react unfavourably with bracelets.
         •   The patient who refuses to wear an identification band despite a clear
             explanation of the risks of not doing so. This discussion MUST be documented
             in the patient record.

      In these instances a locally agreed policy for identification of patients should be
      developed and adhered to.

4.2   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.

4.3   Any member of staff that discovers a patient does not have a wristband must assume
      responsibility for correctly identifying them.

4.4   The bracelet may be fitted by any member of staff and should then be checked by the
      nurse admitting the patient. A daily check of each patient identity bracelet should be
      made at a convenient time.

4.5   The wristband should be put in the dominant arm, as it is then less likely to be removed
      when for example, intravenous access lines are inserted.

4.6   The bracelet must contain the following minimum information of the patient clearly

         •   Patient’s surname and forenames – no abbreviations or pet names,
         •   Date of birth, ward or department,
         •   Hospital number if known.

4.7   When attaching the bracelet explain the importance of it to the patient and ask them to
      report if it falls to staff, is removed and not replaced or if it becomes illegible.

4.8    The presence and integrity of identity bracelets should be checked at least daily by
       ward staff.

4.9    The information on the bracelet will form the basis of the procedure for checking
       identify before procedures such as administration of medicines.

4.10   If name bands become obscured or difficult to read they must be re-written
       and replaced immediately.

4.11   In the case of patients with the same or similar name – staff must attach alert stickers
       on all patient documentation to ensure correct identity.

4.12   Patients without bracelets MUST NOT be moved from the ward until a bracelet has
       been supplied and fitted.

4.13   When collecting an inpatient from a ward, portering staff must ask the ward staff to
       identify the patient. Details of the patient to be collected are then checked against the
       patient’s identification bracelet.

4.14   If an inpatient arrives in another department for treatment or investigation, i.e for a
       radiological examination, without a bracelet, an accompanying nurse may confirm the
       patient’s identity.

5.     Patient identity for Outpatients

5.1.1 Ask the patient to state their full name, address and date of birth. Ask the patient to
      declare their details rather than asking them to agree to the details read out to them.

5.1.2 Check these details against those given on the request form. If the details match,
      proceed with the test/ procedure/exposure.

5.3    Patients receiving any kind of interventional investigation or treatment who are unable
       to clearly confirm identity verbally or who are receiving sedation must have an identity
       bracelet attached.

6.     Patient identify for the ‘uncomprehending’ or unknown patient

6.1    In the case of young children, unconscious or confused patients, and those with
       language difficulties (i.e first language is not English) the details should be checked
       and agreed with an accompanying capable adult (the parent/carer/ relative).

6.2    An interpreter must be used if there is a language problem.

6.3    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.”

7.     Patient identity in deceased patients

7.1    All deceased patients MUST be properly identified with 2 identification bracelets one
       on the wrist and one on the ankle before leaving the ward or department.

7.2    Should a patient not have an identity bracelet it is the responsibility of the nursing staff
       from the transferring ward or department to go to the mortuary to affix the bracelet.

7.3    In the event of the patient’s name not been known, then the identification bracelet must
       state: UNKNOWN MALE / FEMALE

7.4    Patient brought in by funeral director / police: accompanying funeral director or police
       officer to apply identification bracelet.

7.5    Notification of death: one copy of the notification of death card must be taped securely
       to the shroud. The second notification of death card must b taped securely to the
       outside of the sheet or body bag.

8.     Patient identity in the Operating Departments, DCU, Endoscopy and MADCU

8.1    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.

8.2    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.

9.     Patient identity in relation to the Maternity Unit

9.1    On admission to the Maternity Unit, an identity bracelet will be placed on the patient’s

10.    Patient identity in the Delivery Suite

10.1   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.

10.2   Before the transfer to another area i.e. ward/hospital/NNU, the identification bracelets
       should be checked by the midwife.

10.3   Where more that one baby is born, the order of the birth must be indicated on the
       bracelet e.g. twin 1, twin 2.

10.4   The mother should be told that the bracelets must not be removed until they arrive
       home with the baby.

11.    Patient identity in Obstetric Theatre

11.1   If the mother has an epidural/spinal anaesthetic then the procedure in 4. Is followed to
       ensure accurate identification of the baby.

11.2   If the mother has a general anaesthetic to ensure accurate information is obtained, the
       two nurses present will check the details.

11.3   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.

12.    Patient identity when transferring to the Postnatal Ward

12.1   With reference to the baby notes, the identification bracelets are checked by ward and
       delivery suite nurses for accuracy.

12.2   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.

12.3   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.

13.    Patient identity in the Neonatal Intensive Care Unit

13.1   Every morning and on admission of a baby you should check the name bracelets. The
       bracelets should be located on the babies’ ankles; if for any reason they need to be
       removed (for the siting of I.V.’s, excoriation etc) the bracelets should be re-located to
       the wrists or firmly adhered to the baby’s incubator/cot if this is not possible.

13.2   Indicate on the baby’s care chart that this procedure has been carried out; this is for
       audit purposes.

13.3   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.
13.5   Action to be followed when the Neonate’s Identification Bracelet(s) is
       lost : 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.
       (b) Relevant documentation is obtained for the baby that has lost it’s
           bracelets, and in the presence of the mother, the following are
                       (i) Mother’s identification bracelet
                       (ii) Details in the mother and baby notes.
       (c) In the Neonatal Unit, the baby notes only are checked
       (d) Make out new identification bracelets and place them on the baby’s
       (e) 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).

14.    Patient identity (special arrangements)

14.1   Blood transfusion collection and administration (including blood products): Please refer
       to Blood Product Users Policy (September 2005).

14.2   Identity related to Pathology samples: Please refer to:

       a) Protocol for patient identification and sample labeling (January 2005)
       b) Protocol for patient identification and sample labeling in G.P practices and the
          community (January 2005)

15.    Patient identity and Radiology

15.1   Pre-procedure ID checks: reception of patients to the Imaging Department

On arrival at reception areas the following will be checked:

a)     Routine work - patients will be asked to GIVE their name and DOB

b)     Patients unable to communicate verbally, including babies and small children, should
       be identified by either their identification band or attending nurse/carer. If a positive
       identification can not be confirmed the examination should not proceed.

c)     Emergency procedures - if a patient is of unknown identity as much information as
       possible should be recorded including A&E number.

d)     All relevant documentation will be made available, i.e, examination request card, film
       packet and previous films and case notes where applicable. These must be accurately
       matched to the correct patient.

e)     Patient information and Imaging procedure/s must be accurately recorded on HISS and
       any previously entered incorrect details corrected.

15.2   Pre-procedure ID checks: Assisting with patient preparation prior to Imaging

On collecting patient from a waiting area the following will be checked:

a)     Patients will be asked to STATE their name and DOB where competent to do so.
       Where the patient is not considered responsible formal identification must be made by
       the identification band, carer or chaperone.

b)     All relevant documentation will be matched to patient and made available to the

c)     Where appropriate ensure that patient information is accurately recorded on the
       Imaging system

15.3   Pre-procedure ID checks: Identification of patients undergoing Imaging

Before each patient is examined the following procedure must be carried out:

a)     The responsible professional (operator) for the procedure, must ask the patient to
       STATE their name and DOB. If the patient is not considered responsible, then this
       information must be verified by a relative or carer. Only when this is confirmed can the
       examination be performed.

b)     The operator must ascertain that all documentation, i.e., requisition and any previous
       films and case notes apply to that patient. This must include justification of

c)     Where relevant, pre –procedural check lists are completed.

d)     Where relevant, pregnancy checks are completed

e)     Each image to be correctly marked with correct side legends and maximum possible
       patient identification. The images should then be placed with the correct

f)     In areas where digital image acquisition is made e.g., CT/MRI/US/CR Fluoroscopy,
       all patient details are accurately recorded on work -stations prior to procedures

g)     Information should then be input into the HISS against the correct patient and account
       number. This is the responsibility of the person carrying out the procedure or a
       specifically designated other.

h)     In an emergency situation only, when a patient’s identification can not be confirmed,
       e.g., in a major accident situation, as much information as is known should be marked
       on the images. This should include the A&E number. In all situations the examinations
       must be justified.

i)     To avoid inappropriate examinations, the examination requested must be verified
       against clinical history and referral guidelines e.g., RCR guidelines.

j)     If a patient is transferred between radiologist/radiographer or modalities the patient
       identification must be reconfirmed.

15.4   Pre-procedure ID checks: Discharging patients from the Imaging Department

In order to accurately discharge a patient from the Imaging Department

a)     Patients will be accurately identified by checking their name/DOB before discharge
       from Imaging department.

b)     Where relevant, transportation slips will be checked against the patient prior to posting
       on transport board.

c)     Where relevant patient’s case notes will be returned to ward areas with the patient
       when it has been confirmed that the correct notes have been given to the patient.

15.5   Post-procedure ID checks: Image /data collation after procedure

a)     All relevant staff will check patient identification on all Images for accuracy and match
       with all documentation/film packets

15.6   Post-procedure ID checks: Image preparation prior to reporting

Identify Images and documentation by:

a)     Patient name/hospital number

b)     Check that patient details on film envelope match those on the requisition and images

15.7   Post-procedure ID checks: Image reporting

a)     Check patient details are correct on images and documentation. Check that all images
       for reporting are available

b)     Check that all annotation on images is correct

15.8   Post-procedure ID checks: Report input onto HISS

Prior to inputting report:

a) Check patient name and DOB against account number and procedure.
16     Reporting patient identification errors

16.1   If you discover a patient identification error please report it as soon as possible to the
       ward/department person in charge. Complete an incident report form. This would
       include an incident that has occurred as a result of misidentification and also ‘near
       miss’ situations where the error has been detected before an incident has taken place.
       Examples may include:

            •   Wrong addressograph labels in the case notes
            •   Wrong information on identity bracelet
            •   No identity bracelet on patient
            •   Misidentification of documentation within the case notes
            •   Misidentification of X-rays
            •   Misidentification of investigation requests
            •   Misidentification appointments
            •   Duplicate registration on HISS

       Please refer to Trust Policy on incident reporting.

17.    Monitoring and review

17.1   Clinical audit will include ongoing audit of procedures checking:

           •    The number and percentage of patients wearing ID bracelets,
           •    The accuracy and reliability of the information included on them,
           •    The reasons why patients may not be wearing bracelets,
           •    The efficacy of alternative arrangements,
           •    Safety incidents related to misidentification

Effective date:      October 2006
Review date:         October 2008


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