Patient Identification Policy

Patient Identification Policy
Reference Number Version Name of responsible (ratifying) committee Date ratified Document Manager (job title) Date issued Review date Electronic location Related Procedural Documents
3.46 5 Patient Safety Working Group 17 February 2010 Lead Nurse: Clinical Standards and Patient Safety 19.04.2011 December 2012 (unless legislation changes) Corporate Policies See section 8 on page 13 of this policy Patients; Wristband identification; Patient identification systems; Health service staff; Patient safety; Blood transfusion; Risk management; Hospital deaths; Wristband identification; Day care; Diagnostic services; Medical treatment; Refuse treatment; Clinical guidelines
Key Words (to aid with searching)
In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the document. For assurance that the most up to date policy is being used, staff should refer to the version held on the intranet
Patient Identification Policy. Issue 5. 19.04.2011 (Review date: December 2012 (unless legislation changes) Page 1 of 20
CONTENTS QUICK REFERENCE GUIDE......................................................................................................3 1. INTRODUCTION............................................................................................................................. 4 2. PURPOSE....................................................................................................................................... 4 3. SCOPE............................................................................................................................................ 4 4. DEFINITIONS.................................................................................................................................. 4 5. DUTIES AND RESPONSIBILITIES..................................................................................................5 6. PROCESS....................................................................................................................................... 7 7. TRAINING REQUIREMENTS .......................................................................................................13 8. REFERENCES AND ASSOCIATED DOCUMENTATION..............................................................13 9. MONITORING COMPLIANCE ......................................................................................................15 Appendices Appendix 1: Patient Identification Policy Audit Tool (adults) Appendix 2: Identification of the Newborn Infant Appendix 3: Neonatal identification guideline
QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need those involved in the process to be aware of and follow the detail of this policy. 1. The National Patient Safety Agency (NPSA) has recognised that failure to correctly identify patients constitutes one of the most serious risks to patient safety and cuts across all sectors of healthcare practice. Correct identification, incorporating the NHS number as directed by the NPSA, will reduce and, where possible, eliminate the risk and consequences of misidentification and as a result improve patient safety. 2. The following patients are to have a single ID band electronically printed and attached by staff immediately on admission or attendance. All patients in the Emergency Department (ED). The patients NHS number may not be immediately available at the time of initial assessment. However, patients must still be fitted with an ID band containing other available information and a new one attached when the NHS number has been confirmed. The attachment of this new ID band must be recorded in the patients records. o o o o Who are placed within the major treatment area; Are non-ambulatory and with Glasgow Coma Score of less than 15 attending the ED; Ambulatory patients attending ED where it is professionally judged to be appropriate, for example patients with cognitive impairment; All patients in ED, where a decision to admit has been made.
3. 4. 5. 6. 7.
All Hospital and Maternity Centre in-patients (excluding the newborn, who have two bands) All day case patients, excluding dialysis out-patients except when they are to receive blood transfusions or any other intravenous therapy or medication, when a patient identity band must be applied. All out-patients undergoing diagnostic or invasive procedures and/or treatment that impair their conscious levels during the appointment excluding dialysis out-patients as above. Any out-patient who is cognitively compromised and/or impaired Patients undergoing a transfusion of blood or blood products. As well as ensuring the correct identification of the patient, the wearing of an ID band for transfusion of blood or blood products is also required for compliance with the current European Union Directive on blood safety, which requires the tracking of all blood products to the point of patient transfusion. All mothers/expectant mothers admitted to Queen Alexandra Hospital (QAH) Site, and Maternity Centres (Blake, Grange and Portsmouth Centres)
All ID bands and specimens/samples must contain a four identity markers (For inpatients, the name of the ward should be included on the ID band) On transfer to a different ward, the original ID band must be removed and replaced with a new one which includes details of the new ward A single red ID band should be applied in the event of allergies/alerts Any damaged / missing ID band must be replaced immediately Patients must be told not to remove the ID band
Separate criteria apply to newborn infants and neonates, who must have two ID bands applied
1. INTRODUCTION
The National Patient Safety Agency (NPSA) has recognised that failure to correctly identify patients constitutes one of the most serious risks to patient safety and cuts across all sectors of healthcare practice. The importance of a standardised procedure across the NHS is the foundation all safe patient identification practices. Correct identification, incorporating the NHS number as directed by the NPSA, will reduce and, where possible, eliminate the risk and consequences of misidentification and as a result improve patient safety.
2. PURPOSE
This policy sets the standard required for the checking and recording patient identification (ID) markers across all areas of documentation including ID bands, clinical notes and specimens It is designed to: Ensure that all aspects of the management of patient identification within the Trust complies with the latest recommendations from the NPSA; Ensure the safety of all patients throughout their hospital journey through correct identification on admission and prior to any assessment, investigation or treatment whilst under the care of Portsmouth Hospitals NHS Trust; Provide clear standards and procedures for staff carrying out their duties involving patient identification.
For the specific standards required when dealing with the newborn infant, please refer to the Identification of the Newborn Infant (Appendix 1) and for neonates refer to the Neonatal Identification Guideline (Appendix 2)
3. SCOPE
This policy applies to all permanent, locum, agency, bank and voluntary staff of Portsmouth Hospitals NHS Trust, the MDHU (Portsmouth) and Carillion who encounter in and outpatients in the course of their duties. It includes, but is not exclusive to: doctors; dentists; pharmacists; phlebotomists; nurses; midwives; operating department practitioners; radiographers; podiatrists; dental nurses; nursery nurses; dialysis assistants; pharmacy technicians/assistant technical officers; healthcare support workers; porters; and drivers. In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety
4. DEFINITIONS
Correct patient identification Correct patient identification is achieved when the healthcare worker is able to confirm that the identity markers given by the patient or the patient's guardian/ representative, match those on the patient's identity band and documents. Misidentification This occurs when the patient identity markers given by the patient, or his/her guardian/representative, do not match exactly, those on the patient's identity band and/or documents. It can also occur when a healthcare worker mistakes one patient for another by not following correct identification policy. In-patients In-patients are those patients who are admitted to the hospital and expected to stay overnight. Day ward attendees
Day ward attendees are those patients who are admitted to the hospital for a procedure or monitoring, but not expected to stay in overnight. Out-patients Out-patients are those patients who attend the Out-Patient Department for a consultation or to undergo a procedure, but who are not admitted as in-patients or day ward attendees. Cognitively compromised/impaired This term refers to those patients who are confused in any way and may be unable to reliably identify themselves and/or the time, date and their location or those patients identified as lacking capacity or with learning disabilities. This also includes children who are unable to communicate due to age or disability. Guardian/representative A guardian or representative is someone who is officially recognised as the person responsible for making decisions on behalf of a patient who is unable to reliably do so himself. This would normally be a parent or legal guardian in the case of a child under the age of 16 years, and the spouse, next of kin or carer of an adult who is unable to communicate for what ever reason, or who is cognitively compromised. Unidentified patient This is a patient for whom no identification is known, or whose identification markers are thought to be unreliable. Treatment Treatment in this context, includes all care, investigations, procedures, therapies and reports relating to in and out-patients. Samples Samples are any physiological samples taken for analysis including tissue, blood and other body fluids. Documentation Any documentation associated with an individual patient including admission documents, specimen request forms, checklists, case-notes, assessment forms, pathway documents, drug charts, observation charts etc. Sunquest ICE An online requesting and result system for specimens which has a derived feed from the Patient Administration System (PAS) and allows for the printing of ID bands
5. DUTIES AND RESPONSIBILITIES

Chief Executive The Chief Executive has ultimate accountability for ensuring there are appropriate processes in place to ensuring there are appropriate processes are in place for the effective and reliable identification of patients but delegates this responsibility through the Chief Nurse. The Chief Nurse The Chief Nurse is responsible for there are appropriate processes are in place for the effective and reliable identification of patients Lead Nurse: Clinical Standards and Patient Safety The Lead Nurse is responsible for presenting the outcome of the bi-annual audits to the Patient Safety Working Group Matrons Matrons are responsible for ensuring
An audit of 20 patients (Appendix A) is undertaken bi-annually and for returning the audits to the Clinical Audit Department, within one week of completion. Any required changes or training are implemented, identified as a result of the audit
Note: ensuring the audit of ID bands in the Women and Children Division is undertaken is the responsibility of the CNST lead. Ward, Clinical and Departmental Managers All Managers are responsible for: Adequately disseminating and implementing this policy within their areas of responsibility Adequately training/inducting staff, to ensure they are competent to undertake consistently accurate patient identification requirements Undertaking a bi-annual audit within their areas of responsibility, to monitor ongoing compliance with this policy Implementing any required actions or additional training to address any areas of noncompliance, as identified by the audit Implementing any required action as identified through adverse incidents and near misses
Risk Analyst The Risk Analyst has responsibility for ensuring that all adverse incidents and near misses relating to patient identification are inputted onto the electronic database, to inform the Quality Exception Reports to the Trust Board and reports to other individuals and groups, to support organisational learning and feedback. All Staff All staff are responsible for: Complying with this policy and ensuring that when performing any procedure, investigation or providing care they assume responsibility for checking the identification of a patient, to prevent the occurrence of adverse incidents or near misses arising from misidentification Completing an adverse incident reporting form in accordance with the Trust Policy for the Reporting of Adverse Incidents and Near Misses, for any instances of misidentification or refusal to wear, or loss of, an ID band
Clinical Audit Department The Department is responsible for collating the results of the bi-annual audit and producing a report on that audit, to support onward reporting to the Trust Board, Governance & Quality Committee and the Patient Safety Working Group Trust Board Trust Board has overall responsibility for ensuring appropriate processes are in place for the reliable and safe identification of patients through the receipt of a quarterly Nursing Directorate report Governance & Quality Committee Reporting directly to the Board, the Governance & Quality Committee has responsibility for receiving the results of the bi-annual audit and action taken, to ensure continuous improvement in the quality and safety of the care provided to our patients. Patient Safety Working Group The Patient Safety Working Group will receive the bi-annual audit of compliance with patient identification and ensure that appropriate actions are taken to address any issues of nonPatient Identification Policy. Issue 5. 19.04.2011 (Review date: December 2012 (unless legislation changes) Page 6 of 20
compliance. The Group will also escalate any identified risks to either the Divisional Governance Committees for inclusion in the divisional risk register or to the Risk Assurance Committee for discussion and potential inclusion on the Trust risk register or assurance framework. Risk Assurance Committee (RAC) The purpose of the Risk Assurance Committee is to promote effective risk management and to establish and maintain an assurance framework and a risk register through which the Board can monitor the arrangements in place to achieve a satisfactory level of internal control, safety and quality. Divisional Governance Committees It is the responsibility of Divisional Governance Committees to monitor their divisional risk registers monthly, together with the progress of any action plans associated with noncompliance with patient identification; to ensure any identified risks are addressed in a timely manner.
6. PROCESS
6.1 Identity Bands: what must they contain 6.1.1 ID bands must contain 4 identity markers, together with the name of the ward if the patient is admitted. For example
BOOKMAN Elizabeth 30.JUL.1960 NHS 123456 Q123456 Ward 10
6.1.2 6.1.3 6.1.4
The ID band information will be printed via a thermal printer: black on a white background The NPSA states that only one white wristband must be used per patient, except a newborn infant All newborn infants must have two ID bands attached immediately after birth. Newborn ID bands must be checked in the delivery room, with the parents and against the mothers ID band, to ensure the newborn infants details are correct. The information on the ID band must include: Identification of gender: male infant (M) / female infant (F) Mothers surname Date and time of birth
6.1.5
All neonates must have two ID bands, which will include the same information as for the newborn but additionally the hospital number
(See Appendix 2: Identification of the Newborn Infant; part of the Newborn Security Policy and Appendix 3: Neonatal Identification Guideline) 6.1.6 6.1.7 Where there is a requirement to indicate an allergy or alert, a RED band must be used with printed black text inside a white box. The details on the ID band must be checked with the patient, relative, carer or guardian and the check recorded in the patients records. The issuer and the patient, relative, carer, guardian or healthcare working confirming the information must sign the check entry in the patients records.
6.1.8
No alterations must be made to the ID band after it has been attached to the patient. If an alteration is required, a new band must be printed and attached by the healthcare worker who made, or recognised, the error. On transfer to the Trust from another organisation, the patients previous ID band must immediately be replaced with a Trust ID band, with the new ward included.
6.1.9 6.2
Identity Bands: who must wear them The following patient groups are to have ID bands electronically printed and attached by nursing staff immediately on admission or attendance: All patients in the Emergency Department (ED). The patients NHS number may not be immediately available at the time of initial assessment. However, patients must still be fitted with an ID band containing other available information and a new one attached when the NHS number has been confirmed. The attachment of this new ID band must be recorded in the patients records. o o o o Who are placed within the major treatment area; Are non-ambulatory and attending the ED; with Glasgow Coma Score of less than 15
Ambulatory patients attending ED where it is professionally judged to be appropriate, for example patients with cognitive impairment; All patients in ED, where a decision to admit has been made.
All Hospital and Maternity Centre in-patients All day case patients, excluding dialysis out-patients except when they are to receive blood transfusions or any other intravenous therapy or medication, when a patient identity band must be applied. All out-patients undergoing diagnostic or invasive procedures and/or treatment that impair their conscious levels during the appointment excluding dialysis outpatients as above. Any out-patient who is cognitively compromised and/or impaired Patients undergoing a transfusion of blood or blood products. As well as ensuring the correct identification of the patient, the wearing of an ID band for transfusion of blood or blood products is also required for compliance with the current European Union Directive on blood safety, which requires the tracking of all blood products to the point of patient transfusion. If an appropriately completed ID band is not attached the transfusion will not be permitted until the patients identification is verified All mothers/expectant mothers admitted to Queen Alexandra Hospital (QAH) Site, and Maternity Centres (Blake, Grange and Portsmouth Centres)
All infants at the time of birth and those admitted up to 6 weeks of age, must wear 2 identity bands at all times whilst an inpatient in: Queen Alexandra Hospital site All Maternity Centres and Childrens units, including neonatal intensive care
6.3
Production and application of the ID band 6.3.1 The ID band is printed on admission, or when presenting to an out-patient area for a procedure, via a derived link from Sunquest ICE results and requesting system 6.3.2 The ID band must, where possible, be applied to the dominant arm, as the band is less likely to be removed when, for example, intravenous lines are inserted. The member of staff applying the wrist-band is required to record in the patients hospital record that the ID band details are correct. Staff printing and issuing ID bands will have undergone training on the printing of the ID band and be deemed competent in issuing and verifying identification markers One white wristband with black test must be used in all cases, unless there is an exception such as in a major incident, allergy/alert or infants (NPSA 2007) If a patient has an allergy/alert, a single red wristband must be used. The healthcare worker will refer to the patient and their documentation for verification of the allergy/alert, as the nature of the alert will not be stated on the wristband For elective/booked admissions, patients and/or guardians will be given an explanation of the ID band and the details checked a the pre-operative assessment On admission, the patient and/or guardian will be advised by the registered nurse or midwife: Not to remove the ID band To inform a member of staff immediately, should the ID band be lost, soiled, damaged or removed and not replaced.
6.3.3
6.3.4 6.3.5
6.3.6
6.3.7
6.4 Refusal to wear an ID band Any patient who refuses to wear an identity band, must be informed that staff will be unable to give any prescribed treatment. This must be documented clearly in the patients notes and a completed Adverse Incident Report submitted to the Risk Management department and escalated to the consultant responsible for the patients care. 6.5 Patients who cannot wear an ID band For patients who cannot wear an identity band, because of their condition or treatment and who are unable to identify themselves, i.e. an unconscious patient suffering severe burns, or major multiple trauma, a risk assessment must be carried out by a registered nurse, and all measures taken to reduce the risk of patient misidentification. Following initial identification by the patients guardian/representative, such risk reduction measures may include: Labeling of the patients bed. Correct patient identity details displayed on the vital signs monitor correlating to the patients bed-space. Reconfirmation of the patients identity with staff at each shift change: this must be recorded in the patients records Cross-referencing of all identifying information. When in theatre, if a limb is not accessible to enable an ID band to be applied; then the band may be fixed temporarily to the patients forehead. The ID band must be reapplied correctly to a limb before leaving the theatre to go to recovery, after being checked by two health care workers.
6.6 Misidentification 6.6.1 The effect of patient misidentification should not be underestimated, as it can lead to serious or fatal outcomes for patients. The following gives examples of some of the incidents that can occur Administration of wrong drug to the wrong patient Performance of wrong procedure on a patient Patient given the wrong diagnosis Patient receives inappropriate (and potentially harmful) treatment Patient is over-exposed to radiation Wrong patient is brought to theatre Serious delays in commencing treatment on the correct patient Anyone who discovers a patient identification issue should report it immediately to the person in charge: this includes near miss situations where the error was detected before the incident actually took place. Patient identification issues may be: 6.6.3 Wrong addressograph labels in the health records Wrong information on the ID band No ID band on the patient Misidentification of documentation within the health records Misidentification of x-rays Misidentification of investigation results Duplicate registration on the Patient Administration System (PAS)
6.6.2
Ensure patient safety and take remedial action Stop procedures/interventions until details are corrected Inform the person in charge Inform medical staff or other relevant staff, where appropriate Replace ID band Alert other departments, as necessary: this may include the Health Records Library, as further incorrect details may need to be amended. Ensure PAS is checked and updated with correct details, if required Ensure health records and documentation are updated, if required Complete an adverse incident reporting form and set in place an appropriate investigation, in line with Trust policy12 Inform the patient and relative/carer of the incident and actions taken3
6.7 Ongoing checks throughout the patients care episode Correct identification of a patient is paramount throughout the course of their care, to ensure their safety and minimise occurrence of any misidentification. To support this 6.7.1 On admission to a ward/department from the ED, e.g. to the Medical / Surgical Assessment Unit, the patients ED ID band should be replaced by the registered nurse/midwife of the admitting ward, with a band that includes details of the new ward. If a patient is transferred at any other time, the ID must also be replaced immediately by the receiving ward, to ensure the attached details are correct and updated. It is the responsibility of the receiving ward to update the ID band when
6.7.2
1 2 3
Management of Adverse Incidents and Near Misses Management of Serious Untoward Incidents Being Open
entering the transfer on PAS and record the replacement of the ID band in the patients records. 6.7.3 6.7.4 Frontline staff must always verify that the patient they are attending to is the patient for whom the treatment is intended and match the treatment to that patient In normal circumstances, a patients ID band must only be removed on discharge home. As many patients use the discharge lounge, the ID band must not be removed until the patient leaves the hospital premises. Note: ID bands must not be removed if a patient is discharged to another hospital, into social service or private nursing care. ID bands put in place during a major incident and, therefore, containing a Major Incident Number must be left in situ and a second band detailing the patients 4 identity markers applied to the same limb. This is an exception to the policy of the single ID band. If the ID band needs to be removed from the wrist because it interferes with treatment, alternative areas for placement such as the ankle, should be considered. If no alternative area for placement is possible, then the member of staff who removes the ID band must replace it at the earliest possible opportunity. If an ID band is found to be missing, the healthcare worker who discovers the loss is responsible for replacing it immediately and for raising an adverse incident reporting form, in line with the Policy for the Reporting of Adverse Incidents and Near Misses. No alterations must be made to the ID band after it has been attached to the patient. If an alteration is required, a new band must be printed and attached by the healthcare worker who made, or recognised, the error. Except in emergency situations, should the verification process fail at any stage, all activities for the patient must be halted until the patients identity can be accurately determined. In these circumstances, an Adverse Incident Reporting form should be completed and actioned in accordance with the Trust Policy4. Anecdotal evidence suggests that there is a risk of patients or their representatives agreeing to incorrect patient identifiers, due to mishearing or confusion. Verification should, therefore, be active rather than passive: by asking the patient/representative for the patients name, rather than offering a name and by checking the patients details against the ID band and documentation.
6.7.5
6.7.6
6.7.7
6.7.8
6.7.9
6.7.9
Note: In the event of death, the ID band must not be removed from the patients body. 6.8 Unidentified patients 6.8.1 The instances of unidentified patients will invariably occur in the ED. In these circumstances, an ID band must be applied as soon as an ED number has been allocated and must include the patients identity status, gender, approximate age and the ED number. For example
Unknown male Age: approx 30 years 05-123456
Management of Adverse Incidents and Near Misses
6.8.2 6.8.3
For patients who cannot supply the relevant information, the name and date of birth can be verified by the patients family, carer, guardian or other representative Staff must consider the possibility of gender reassignment when identifying patients in this way. Where issues of doubt arise, the staff member must agree appropriate identification with the attending doctor.
6.9 Major Incidents 6.9.1 Patients attending the ED from a Major Incident will arrive with identity information hung around their necks, having had that put in place at the scene of the Incident. Immediately on arrival, ED staff will apply a Major Incident identity label containing a pre-written Major Incident casualty number. 6.9.2 As soon as the identification markers of the casualty name and date of birth have been verified, a second printed ID band detailing this information must be attached to the casualty. To ensure that the patients involvement in the incident can be identified, for any required follow-up purposes, the Major Incident identification label must not be removed until the casualty is discharged from hospital. This is an exception to the policy of single ID bands.
6.10 Allergies/risk Where it is identified from the patients notes that they have a known or suspected allergy, a single red ID band will be used in place of the white band, as a prompt to healthcare workers. Red ID bands must only be used as an alert to the presence of any allergies or drug alerts / reactions and not for notification of a clinical diagnosis. 6.11 Documentation 6.11.2 Addressograph labels Before using the labels and to ensure they are correct, healthcare workers must check the details against those in the patients records It is essential that before newly printed labels are inserted into the patients records, that the person undertaking the filing of the new labels, checks the details on the labels against all the identification information held in those records. It is also their responsibility to check any existing labels and remove them if the details are incorrect. Each page of a patients notes must have an addressograph label
6.11.3 Request / referral forms The minimum of 4 patient identity markers must be on all request / referral forms, and the form signed by the requester / referrer Staff members completing request or referral forms must complete the details themselves and must ensure that the patient information is correct and that the patient identified on the form is the one for which the requested treatment / investigation is intended Prior to commencement of any treatment / investigation, all request or referral forms must be checked against the patients ID band, to ensure the patient due to undergo the treatment / investigation is the one identified on the form. Where possible, the patient should be asked to give their name, date of birth and address to further confirm their identity. 6.11.4 Information to accompany the patient on transfer Prior to transfer, the patients identity must be checked and all associated, relevant information photocopied or scanned, before accompanying the patient. The patients ID band must be in place, to enable other units to confirm the patients identity
6.11.5 Specimens and samples The minimum requirements for the specimen / sample label are the 4 patient identity markers Specimen containers must be labeled, with the patients identification taken from their ID band, not the request form or patient records The container must not be pre-labeled but labeled, by the person taking the specimen, after it is placed into the container. The container must be labeled beside the patient and not removed to another location until the labeling is complete. The label can by handwritten or produced electronically On receipt of a mislabeled specimen or sample, the standard operating procedure for the receiving department must be followed, including informing the originator of the mislabeled specimen / sample and completion of an Adverse Incident Reporting form. If there is any doubt as to the correct identity of the patient, a repeat specimen / sample must be taken.
7. TRAINING REQUIREMENTS
Processes, including this policy, are included in the induction programmes for junior doctors, registered nurses and healthcare support workers Processes, including this policy, are included in local induction in all relevant areas All staff responsible for printing and issuing ID bands undergo training and must be deemed competent by their line manager prior to issuing and verifying identification markers Ward, clinical and departmental managers will ensure that any additional training highlighted as required by the bi-annual audit is implemented
8. REFERENCES AND ASSOCIATED DOCUMENTATION

External NPSA: Framework for Action: http://www.saferhealthcare.org.uk/IHI/Products/Publications/rightpatientrightcare.htm NPSA/2005/11 Safer Practice Notice: Wristbands for hospital inpatients improves safety: http://www.npsa.nhs.uk/site/media/documents/1440_Safer_Patient_Identification_SPN.pdf NPSA (2007) Your Guide to Implementing Wristbands NPSA (2007) Standardising wristbands improves patient safety: Guidance on implementing the Safer Practice Notice IR (ME) R 2000: Regulations 4(5), and 5(1) and Schedule 1, 15.3: http://www.dh.gov.uk/assetRoot/04/05/78/38/04057838.pdf HRC supplement A. Risk Analysis: Patient Identification: http://www.ecri.org/Patient_Information/Patient_Safety/RiskQual16.pdf Quality & Safety in Healthcare http://qhc.bmjjournals.com/cgi/content/full/13/5/329 Beyea SC Patient identification-A crucial aspect of patient safety. Association of operating room nurses. 7. AORN Journal; Sept 2003, 78; ProQuest Medical Library p 478. Henderson J & Embry D. Unpublished paper. Mismatching between planned and act treatments in medicine- Manual checking approaches to prevention. Final Report March 2004.
Sevdalis,N. (2007) Design and specification of patient wristbands: Evidence from existing literature, NPSA-facilitated workshops, and a NHS Trusts survey. N.sevdalis@npsa.nhs.uk;n.sevdalis@imperial.ac.uk
Department of Health: Better Blood Transfusion. www.dh.gov.uk BSCH Guidelines - Administration of blood and blood components and the management of transfused patients, 1990
NMC (2002) Code of Conduct, Nursing & Midwifery Council, London: http://www.nmcuk.org/nmc/main/about/docs/Members_code.pdf
Internal Identification of the Newborn Infant Neonatal Identification Guideline Policy for the Management of Adverse Incidents and Near Misses Policy for the Management of Serious Untoward Incidents Blood Transfusion Policy Major Incident Plan
9. MONITORING COMPLIANCE
This document will be monitored to ensure it is effective and to assurance compliance. Key Performance Indicator
100% compliance with the requirements of patient identification
Lead Responsible for Audit

Ward, clinical, departmental managers
Evidence
Report of audit of 20 patients in each area
Reviewed by / Frequency
Patient Safety Working Group Bi-annually
Lead Responsible for any Required Actions

Lead Nurse: Clinical Practice and Patient Safety
o o
Duties are addressed through: Annual appraisals and personal development plans Annual review of attendance at key committees. Any required action will be taken by the Chair of the committee, as set down in the standard Terms of Reference Template.
The results of the bi-annual audit will be presented to the Patient Safety Working Group together with any actions and implementation plans, identified as a result of the audits. The Divisional Governance Leads, as members of the Patient Safety Working Group, are responsible for: o o o o Cascading the results of the audits through the divisional structure: to ensure organisational learning Placing any identified risks onto Divisional Risk Register and ensure the Risk Register is discussed and monitored at the monthly Divisional Governance Committee meetings Escalating any high level (16+) risks to the Risk Assurance Committee, for potential transfer to the Trust Risk Register or Assurance Framework Ensuring any adverse incidents or near misses are discussed at the monthly Divisional Governance Committee meetings, to foster a culture of Divisional including any required changes in practice.
It is the responsibility of the CNST lead in the Women and Children Division to ensure the results of the audits undertaken in that division are cascaded appropriately and any required actions implemented
Appendix 1 Patient Identification Policy Audit tool (adults)

Compliance Score (100%)
Patient ID Audit Item
3 4 5 6 7 8 9
10 11 12
Patient had an appropriate ID band in place or approved form of alternative identification as outlined in policy The required information is present on the ID band: SURNAME Forename DOB (DD:Mmm:YYYY) NHS Number Hospital/ED Number There is one band only either white or red The ID band is black writing on a white background (except for allergy red band as below) The ID band is legible and easy to read There is a record, in the patient records, of when / where the ID band has been applied The entry of when / where the ID band has been applied is signed Patients wearing a red alert band have the allergy/alert clearly documented on the drug chart / in their records (N/A if not applicable) All inpatients have the ward name also included on the ID band (N/A if not applicable) Staff caring for, or treating, the patient and are responsible for issuing or verifying the wristband/ patient ID have read the Patient ID policy and are able to demonstrate understanding The patient has been informed that the ID band should not be removed The patient has been informed that they must notify a member of staff if the ID band is removed or damaged
Patient Identification Policy. Issue 4v2. 10.03.2010 (Review date: December 2012 (unless legislation changes) 12/05/2013 Page 16 of 20
Appendix 2
Identification of the Newborn Infant
IDENTIFICATION OF THE NEWBORN INFANT
Introduction
Infant identification is crucial within all areas of Maternity Services to ensure and maintain infant security. The parents need to be informed of the importance of labeling and their babys security. All newborn infants must have two identification bracelets attached after birth. All bracelets must contain the following information: Infants first name or F/I or M/I if undecided. Mothers surname Date and time of birth
The labels should be checked with the parents and with the mothers own identity bracelet to ensure the information is correct. This should be undertaken in the birthing room or theatre. Parents should be informed of the security measures available in the locality and advised not to leave their baby unattended. The parents should be encouraged to check that their infant has two identification bracelets and that the information is correct every time they handle him or her, or after a period of separation
Checking of identification during hospital stay On transfer to a different ward i.e. from labour ward to postnatal ward the identification labels should be checked by the healthcare professional on the receiving ward. Following a period of separation of the mother and her infant. Infant identification bracelets should be checked to ensure present at daily midwifery checks. Prior to transfer out of hospital. Parents should be made aware that if an identification bracelet becomes unattached they must inform a member of the ward staff immediately.
If one of the infants identification bracelets is missing 1. The information on the remaining identification bracelet must be checked with the mother using her identification label. 2. If correct a second label can be rewritten and double-checked with the parents before being attached to the infant. 3. The event should be recorded in the care plan.
If an infant is found with no identification bracelets 1. The identification labels of all other infants on the ward must be checked and counted by two Midwives 2. After this check has been completed and all other infant labels are found to be present and correct the infant can be re-labeled. 3. This event must be recorded in the infants care plan. 4. The unit coordinator must be informed. An Adverse Incident reporting form must be completed immediately. AUDIT ASPECT OF CARE/OUTCOMES Two bracelets applied at birth Has a bracelet been reapplied at any time during the postnatal stay in hospital Has a bracelet been reapplied at any time during the postnatal stay in a birth Centre Have both bracelets been reapplied Was an Adverse event form completed Has the number of the Adverse incident form been recorded in the infants notes? EXPECTED STANDARD/ TARGET 100% 100% SOURCE OF DATA COLLECTION Health record Health record
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Health record Health record Health record Health record
Appendix 3 Neonatal Identification Guideline 1. Introduction The National Patient Safety Agency (NPSA) has recognized that failure to correctly identify patients constitutes one of the most serious risks to patient safety and cuts across all sectors of healthcare practice. The importance of safe checking procedures is the foundation of all safe patient identification practices. This guideline sets out the standards required for correct patient identification with the aim of reducing and where possible, eliminating, the risk and consequences of misidentification. 2. Purpose The purpose of this guideline is to Ensure all babies on the Newborn Intensive Care Unit are clearly identified at all times. Ensure that all aspects of the management of patient identification within the NICU complies with the latest recommendations from the NPSA, (Ref 2); Ensure the safety of all patients throughout their hospital stay; Provide clear standards and procedures for staff carrying out their duties involving patient identification using identity bands. 3. Scope This guideline applies to all health care professionals who are employed by Portsmouth Hospitals NHS Trust, including temporary, bank or agency staff. There will be exceptional circumstances where this policy may not be strictly adhered to, however this should only be in individual cases and negotiated on each cases merit. Any deviation should be agreed with senior staff only and clearly documented in patient notes. 4. Definitions At delivery All newborns must have two patient identification labels (wristbands) attached immediately after birth. This should include: Identification of gender: male infant (M/I) / female infant (F/I) Mothers surname, underlined and written in CAPITALS. Date and time of birth, with the year in full For example:
Elizabeth BOOKMAN F/I 30.JUL.2007 2100hrs
The label should be checked with the parents and with the mothers identity label to ensure correct. This should be done in the birthing room or theatre. One finger should be able to be placed under the band to ensure correct fit.
Parents Parents should be informed of the importance of labeling and security. They must be told to: Check that their infant has two correct labels every time they handle him/her or after a period of separation. Inform a member of staff if either of the labels becomes detached
On admission to NICU 1 cot card surname, first name, male/female, date & time of birth, type of delivery. Patient identification board Q number, name, consultant, family nurse, associate nurse and nurse today. When the babys NHS number is available the name bands should be renewed using the ICE system. The Q number, NHS number, NICU and Rank Identification e.g. Single (singleton), Twin 1, Twin 2 Triplet 1, 2 or 3 should be added to the previous information when printing new labels. These should be checked with parents or another member of staff using patients notes before putting on the baby One finger should be able to be placed under the band to ensure correct fit If the baby is under 28 weeks or if there are concerns regarding skin integrity then name bands may be placed on the hat and saturation probe. Once the skin is mature bands can be placed in the usual manner. Checking of identification during hospital stay. Infant identification bracelets should be checked checked each shift to ensure two wristbands are in place with correct information recorded. On handover and during care the nurse should check and record two wristbands in place with correct information present. If one of the infants identification labels is missing. The information on the remaining wristband must be checked with the mother, , if still inpatient using her ID band If correct a second wristband must be printed and checked with the parents or another member of staff before being attached to infant. The event should be recorded in the health records. If an infant is found with no identification labels. Two nurses must check the wristbands of all other infants on the NICU. After this check is completed and all other infant labels are found to be present and correct new wristbands can be attached. The incident should be recorded in the infant care plan. Nurse in charge must be informed An adverse incident reporting form should be completed in accordance with Trust Policy 5 and the incident number recorded in patient notes.
Management of Adverse Incidents and Near Misses

Patient Identification Policy

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QUICK REFERENCE GUIDE

5. DUTIES AND RESPONSIBILITIES

6.1.2 6.1.3 6.1.4

Management of Adverse Incidents and Near Misses

8. REFERENCES AND ASSOCIATED DOCUMENTATION

Lead Responsible for Audit

Lead Responsible for any Required Actions

Appendix 1 Patient Identification Policy Audit tool (adults)

Patient ID Audit Item

Identification of the Newborn Infant

IDENTIFICATION OF THE NEWBORN INFANT

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Management of Adverse Incidents and Near Misses

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