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Patient Identification Policy

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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

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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

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    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.

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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

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    ; 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 non-

    compliance, 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 non-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

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    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 non-compliance 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 The ID band information will be printed via a thermal printer: black on a white

    background

    6.1.3 The NPSA states that only one white wristband must be used per patient, except a

    newborn infant

    6.1.4 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 mother‟s ID band, to ensure the newborn infant‟s details are correct.

    The information on the ID band must include:

    ; Identification of gender: male infant (M) / female infant (F)

    ; Mother‟s 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 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.

    6.1.7 The details on the ID band must be checked with the patient, relative, carer or

    guardian and the check recorded in the patient‟s records. The issuer and the

    patient, relative, carer, guardian or healthcare working confirming the information

    must sign the „check‟ entry in the patient‟s records.

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    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.

    6.1.9 On transfer to the Trust from another organisation, the patient‟s previous ID band

    must immediately be replaced with a Trust ID band, with the new ward included.

    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 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

    ; 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. If an appropriately

    completed ID band is not attached the transfusion will not be permitted until the

    patient‟s 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 Children‟s units, including neonatal intensive care

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    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 patient‟s

    hospital record that the ID band details are correct.

    6.3.3 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

    6.3.4 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)

6.3.5 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

    6.3.6 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

    6.3.7 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.

    6.4 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 patient‟s 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 patient‟s guardian/representative, such risk reduction measures

    may include:

    ; Labeling of the patient‟s bed.

    ; Correct patient identity details displayed on the vital signs monitor correlating

    to the patient‟s bed-space.

    ; Reconfirmation of the patient‟s identity with staff at each shift change: this must

    be recorded in the patient‟s 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.

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    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 6.6.2 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:

    ; 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)

6.6.3 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 12 appropriate investigation, in line with Trust policy3; Inform the patient and relative/carer of the incident and actions taken

    6.7 Ongoing checks throughout the patient’s 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 patient‟s 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.

    6.7.2 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

    entering the transfer on PAS and record the replacement of the ID band in the

    patient‟s records.

     1 Management of Adverse Incidents and Near Misses 2 Management of Serious Untoward Incidents 3 Being Open

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