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Patient Identification Policy

By Mildred Henderson,2014-08-07 09:05
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Patient Identification Policy. Issue 5. 19.04.2011 (Review date: December 2012 (unless legislation changes) Page 1 of 19 Patient Identification Policy Reference Number 3.46 Version 5 Name of responsible (ratifying) committee Patient Safety Working Group Date ratified 17 February 2010 ..

    Patient Identification Policy

Reference Number 3.46

    Version 5

    Name of responsible (ratifying) committee Patient Safety Working Group

    Date ratified 17 February 2010

    Document Manager (job title) Lead Nurse: Clinical Standards and Patient Safety

    Date issued 19.04.2011

    Review date December 2012 (unless legislation changes)

    Electronic location Corporate Policies

    Related Procedural Documents 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; Key Words (to aid with searching) Wristband identification; Day care; Diagnostic services;

    Medical treatment; Refuse treatment; Clinical

    guidelines

    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 19

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 WITH, AND THE EFFECTIVENESS OF, PROCEDURAL

    DOCUMENTS ............................................................................................................................ 14

    Appendices

    Appendix 1: Patient Identification Policy Audit Tool (adults)

    Appendix 2: Identification of the Newborn Infant

    Appendix 3: Neonatal identification guideline

    Patient Identification Policy. Issue 5. 19.04.2011 (Review date: December 2012 (unless legislation changes)

    Page 2 of 19

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 patient‟s 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 patient‟s records.

    o Who are placed within the „major‟ treatment area;

    o Are non-ambulatory and with Glasgow Coma Score of less than 15 attending

    the ED;

    o Ambulatory patients attending ED where it is professionally judged to be

    appropriate, for example patients with cognitive impairment;

    o All patients in ED, where a decision to admit has been made.

    ; 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)

    3. 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)

    4. 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

5. A single red ID band should be applied in the event of allergies/alerts

6. Any damaged / missing ID band must be replaced immediately

7. 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

    Patient Identification Policy. Issue 5. 19.04.2011 (Review date: December 2012 (unless legislation changes) Page 3 of 19

    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