chl hp-ipsg .01 patient identification-4

CHL/HP/IPSG.01 of 13

THE CENTRAL HOSPITAL, COLOMBO, SRI LANKA

PREPARED BY: NAME: DR. ARUNI MUNASINGHE, DESIGNATION: JCI CHAPTER CHAMPION

SIGNATURE: STAMP: DATE:

REVIEWED BY: NAME: DR. RUWAN SENATILLEKE DESIGNATION: CHAIRPERSON, ASIRI HOSPITALS POLICY REVIEW COMMITTEE


APPROVED BY: NAME: DR. MANJULA KARUNARATNE DESIGNATION: DEPUTY CHIEF EXECUTIVE OFFICE


JCI ACCREDITATION STANDARDS FOR HOSPITALS – 5TH EDITION SECTION II: PATIENT – CENTERED STANDARDS

CHAPTER: INTERNATIONAL PATIENT SAFETY GOALS (IPSG) DOCUMENT IDENTIFICATION NO: CHL/HP/IPSG.01 DOCUMENT TITLE: PATIENT IDENTIFICATION STANDARDS REFERENCE: IPSG.1

REVISION NO: 0 DATE OF REVISION: NA

ISSUE NO: 1 DATE OF ISSUE: 15 DECEMBER 2014

NUMBER OF PAGES: 14


A. PURPOSE

The purpose of this Policy is to reliably identify the patient as the correct person for whom the service or treatment is intended and to match the service or treatment to that individual at all times throughout the hospital in a standardized manner.

B. DEFINITION

Identification Correct patient identification is achieved when all health care workers in the Hospital

(CHL) are able to confirm the identity information provided by the patient, guardian or

patient’s representative, and consistently match those on the patient’s identity band and

other identifiers provided by CHL in all locations throughout the hospital.

In-patients In-patients are those patients who are admitted to the hospital and are expected to stay overnight.

Day patients Day patients are those patients who are admitted to the hospital for a procedure or monitoring, but not expected to stay overnight.

Out-patients (Ambulatory Care) 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 patients Out-patients do not require the in-depth level of care as that of an in-patient.

Cognitively compromised / impaired patients 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.

Unidentified patients This is a patient for whom no identification is known, or whose identification markers are

thought to be unreliable.


C. SCOPE

All Hospital (CHL) Specialists, Medical Officers, Nurses, Allied Health staff and Non-clinical

staff who come in contact with inpatients, outpatients, day patients, ambulatory patients,

cognitively compromised / impaired patients or unidentified patients in the course of

their duties.

D. JCI RELATED STANDARDS

IPSG.1 The hospital develops and implements a process to improve accuracy of patient

identifications

E. RESPONSIBILITY

1. Medical Director

2. Director Of Nursing

3. Chief Nursing Officer / Assistant Chief Nursing Officers

4. Heads Of All Departments Clinical and Non-Clinical

5. All Clinical / Non Clinical staff

6. Quality Head / Quality Assurance Department

F. POLICY

1.1 It is the policy of the Hospital (CHL) to emphasize the responsibility of the health

care worker to reliably identify the patient as the correct person for whom the service or treatment is intended and to match the service or treatment to that individual at all times throughout the hospital.

1.2 It is the policy of Hospital (CHL) that all patients having any medically related

intervention with an CHL health care worker will be identified by the following Two

(2) identifiers:

A. Name; And

B. Date of Birth


1.3 All admitted patients, Emergency room patients and outpatients undergoing procedures will have an identity band displaying the name and date of birth and Unique Hospital Identification Number (UHID), attached to them at the time of admission or first encounter in the case of outpatients.

1.4 It is the policy of CHL to use the two identifiers and UHID together in a 3-Point Verification exercise at each and every medically related encounter to avoid wrong patient errors.

G. PROCEDURE

The procedures by which the various categories of patients are identified by health care

workers at CHL are outlined below and encompass the following:

1. Identification Procedures

2. Identification Band

3. Addressographs

IDENTIFICATION PROCEDURES

1. Positive Patient Identification for Admission & Registration

1.1 Patient identification for Registration at Admission

A. Conscious and / or Mentally Alert patients – self-identification is acceptable

using the National Identity Card (NIC) number. Information required at

Registration is as follows:

Name with initials:

Date of Birth: Date / Month / Year

Address:

NIC / Passport number

UHID

B. Unconscious and/or confused patient may be identified:

- By Guardian / family member / accompanying person providing patients

NIC number

- By demographic data sent with patient from referring facility

- By Police and/or investigating officers

C. Non-English speaking patients


Reasonable and effective efforts must be made to find a translator who

speaks the patients / guardian / family member or accompanying person’s

language to secure the NIC number and/or other identification i.e. Passport

number, Driving / License Number or Postal ID Number in Sri Lanka.

D. Unidentifiable patients

Where the preceding methods of identification have proven unsatisfactory

e.g. where there are unconscious patients or are unaccompanied patients

with questionable identity , the patient may be identified as follows:

i. Unknown Male / will be known as Ranbanda for a male and

Ranmenike for females

ii. A Unique Hospital Identification Number (UHID) is assigned to the

patient in question (11111, 11112 an so forth)

iii. The age of the patient will be estimated by a Physician

iv. A patient’s wristband will be attached to the patients arm containing

Ranbanda / Ranmenike and UHID assigned to the patient e.g.

Ranbanda / 11111 or Ranmenike / 11123.

E. Unidentifiable patients will remain in this state (Ranbanda / 11111 or

Ranmenike / 11123) until Positive Patient Identification is made by a

guardian / family member / accompanying person or Police investigation.

1.2 Where no NIC number is available, a strict period of 48 hours is given to the patient, guardian or patient’s representative to secure the NIC number. The patient registration staff will follow-up and secure the NIC number within 48 hours.

1.3 If not successful after 48 hours, the patient registration staff may utilize any of

the following:

- Passport number

- Driving / License Number

- Postal ID Number

- UHID

1.4 The two mandatory positive identifiers would be the Name and Date of Birth. In

addition the UHID may be used.


1.5 Procedure after Positive Identification Recorded by Hospital

The information must be recorded in the Admission/Patient Registration Form in the Hospital Information System (HIS) at the Admission Counters, Emergency room, Day units and at registration for Endoscopy, Radiology, TMT, Physiotherapy and all other units including counters for Labouratory tests.

The Patient is then registered with a Registration Number and a Patient Medical

Record is created with a system generated UHID number and an Identification Band / Wristband is then attached to the patients arm. An example would be as follows:

Name/DOB/UHID

2. Identification Band / Wristbands

2.1 An Identification Band or Wristband will be placed at the point of initial patient

contact following Positive Identification of the patient and registration or

admission with a UHID to:

a. All in-patients

b. Emergency department patients

c. Out-patients undergoing operative or invasive procedures

o All patients having biopsies

o All patients undergoing Endoscopies

o All patients undergoing CT/MRI/PET scans (may need sedation,

contrast)

o All patients undergoing Hemodialysis

NOTE - All patients receiving a blood transfusion are already admitted according

to hospital policy and therefore have ID bands.

3. Out-Patient identification

Out-Patient’s not undergoing an operative or invasive procedure (such as routine

Labouratory and USG Scan or X-Ray patients who do not receive an identification

band) will be identified through confirmation of their Name and Date of Birth by the

relevant hospital personnel e.g. Radiographer, Radiologist, pharmacist , ECG

technician and in the case of TMT by the technician as well as the medical officer (the

Hospital bill for such Out-Patient services shall contain the Name and Date of Birth of

the patient).


4. Patient Medical Records

4.1 All health information and medical records relating to a patient who is admitted

must bear the patient Registration Number and UHID.

4.2 Patient labels generated by the registration and admission process will be affixed

to each document created for a patient including Addressographs.

5. Patient Identification Reconfirmation Process before Procedures

5.1 The two mandatory identifiers the Name and Date of Birth, and, the UHID

Number will be used to reconfirm patient identification prior to every instance

of:

5.1.1 Administering medications or blood products,

5.1.2 Taking blood samples, and other specimens for clinical testing,

5.1.3 Performing other treatments or procedures (all surgery, Radiographic

procedures, arrhymia, studies, Hemodialysis)

5.1.4 Prior to insertion of an intravenous line

5.1.5 Prior to serving a restricted diet tray

The patient’s Name and Date of Birth and UHID Number on the Identification

Band / Wristband will be verified with the patient / guardian / family member by

verbally stating the Name and D.O.B. at each encounter as well as against the

identifiers on the requisition, medication or specimen collection container label,

or medical record to ensure proper identification (3 point verification) All

requisitions, specimen forms and PMR to contain Addressographs. (Refer to

Attachment C)

5.2 Active rather than passive communication to be used in reconfirmation of

identity. (Active communication is when Patient states Name and D.O.B. Passive

communication - is when caregiver states name and D.O.B. and patient

acknowledges)

5.3 Two persons are required (House physician and Nurse in charge) to match the

blood pack using the two patient identifiers (name, D.O.B.) B.H.T., Blood Group

for compatibility

5.4 All blood and specimen collection containers are to be labeled in the presence of

the patient at the time of collection. (Using Addressographs)


5.5 When drugs or blood products are administered Patient education and

participation is required.

5.6 All surgical patients are to be identified using name, date of birth, surgery with

site and side during scheduling, time of admission, and prior to surgery.

6. Patient Identification Reconfirmation Process before collection of

Specimens

6.1 All registered and admitted patients at CHL having laboratory or blood banks

samples taken must be identified by a properly attached Identification band /

Wristband before specimen collection begins.

6.2 The minimum information required on a specimen label shall be as follows:

a. In-Patients - Patient’s full name / Registration Number & UHID number /

Date and Time of collection of sample / ward & location / Collectors

identification

b. Out-Patient’s - Patient’s full name / Registration Number & UHID number

/ location /Date and Time of collection of sample / Collectors identification

6.3 All specimens must be labelled immediately after collection in the presence of

the patient .

6.4 Errors or omissions in labelling will result in a request for a new sample. Rejected

specimens must be documented in the second request form.

6.5 Specimens of donors drawn should be labeled as follows:

a. the full name and NIC of the Donor (if external)

b. Registration Number/UHID number if the Donor is a registered patient at

CHL

c. the full name and NIC of the Donee (if external)

d. Registration Number/UHID number if the Donee is a registered patient at

CHL

e. the and Date & Time and

f. Collectors identification

7. Irreplaceable Specimens


7.1 Special care must be taken to properly label irreplaceable specimens

7.2 In the event that an irreplaceable specimen arrives in the Laboratory unlabeled or incorrectly labelled, all reasonable attempts must be made to determine positive identification

7.3 Specimens will be processed after positive identification has been made

7.4 If the patients does not have an Identification band / Wristband, routine blood

/specimen collection will not be done until definitive identification can be stablished as per procedure.

8. Patient identification in the Emergency Department

8.1 This shall be similar as outlined for In-Patients above.

9. Identification of Infants / Neonates

9.1 Hospital identification Bands / Wristbands are prepared by the Labour / Delivery

staff with the Mothers Registration Number & UHID Number / Full name /

Infants sex / Birth date and Birth time.

9.2 If the mother is awake the Labour / Delivery Nurse must show her the

Identification Band / Wristbands to verify that the name and sex of the infant is

correct on the Identification Bands.

9.3 Once confirmed the Labour / Delivery Nurse will enter the information into the

baby’s chart at the Mothers bedside.

9.4 The Labour / Delivery Nurse will then place one band on the Mothers arm and

one Band on the Infants arm. A second band will be placed on the Infants leg

after the Infants initial bath.

9.5 If the Mother is unable to check and verify the Identification bands / Wristbands

before the infant is taken to the NNICU, one Senior Nurse and one assisting

Nurse shall verify and check all information. This procedure must be completed

before the Infant is taken away from the delivery area. All identification

information is to be included in all appropriate forms.


10. Procedure if two or more patients in a ward have the same family name

“PATIENT WITH THE SAME NAME IN WARD” cautionary card must be applied to each patient’s Patient Medical Record. Alerts must be applied to all ward bed lists and other documentation while both patients remain in the ward and similar cautions applied during patient handovers. The patient’s given names should be printed on the cards.

11. Monitoring compliance and Audits

The Medical Director / Chief Nursing Officer / Assistant Chief Nursing Officers on daily rounds will perform random checks to ensure the adherence to this policy. All cases of non-identification (patients with missing ID Bands) / misidentification, must be written on the Incident Report forms and investigated with a report given to the Medical Director.

All data of misidentification is to be reviewed for progress every 3 weeks / monthly by the QA Department or a committee appointed by the Medical Director

IDENTIFICATION BAND

Pre-admission all patients are to be informed through the admission brochure the

importance of wearing the ID band throughout the hospital stay until discharge. ID

bands are to be issued in duplicate at Admission. One ID band is to be worn by the

patient, and the second to be in the PMR to be used in case of replacement.

1. ID bands should be worn during transfer of patients to other hospitals. In the

case of patient transferred to the hospital, ID to be verified at initial contact, ID

band to be placed at admission to the hospital.

2. The preferred placement of the patient ID band is the wrist of the dominant

hand unless physical condition or procedure precludes this (in which case

another extremity is used).

3. ID bands should contain Patients Name, Date of Birth (D.O.B.), and PMR. In the

case of neonate’s mother’s full name, Gender, Date and time of birth will also be

included.

4. Patient Name, Date of Birth and UHID are to be used as mandatory patient

identifiers.

5. ID bands are not to be altered, if alteration is necessary, a fresh ID band shall be

applied for.


6. All patients to wear single ID bands other than neonates who will wear two ID

bands.

7. All ID bands to have white background with black print.

8. ID bands to contain in addition to patient identifiers Red stickers for patients

with allergies, and Blue stickers to for patients with High Falls Risk and Yellow

stickers for infectious patients.

9. Where the details of the ID band do not match patient details all procedures and

treatment should be halted until fresh identification is established and a correct

ID band attached.

10. If a patient is unable to wear a wristband due to their clinical condition, an

alternative method of identification must be sought (ID tag on patient’s bed).

11. If an ID band must be removed for procedural access or other clinical

circumstance, duplicate ID band on PMR obtained, the information is verified by

comparing the patient identifiers on the new band with that of the band to be

removed, and ID band is replaced at an alternate site.

12. If at any time, the patient is found to not have an ID band, the initial

identification process must be performed and an ID band applied after reporting

it as an adverse incident by the personnel who first observed the lack of an ID

band.

ADDRESSOGRAPHS

All patients to be issued Addressographs with the Patient Medical Record (PMR) on

admission.

Addressographs to be issued in two sizes. Standard for PMR and other documents (listed

below) and small, for specimen labelling.

The Large to contain Patient name with initials.

D.O. B. Age,

PMR No. UHID

Physician:

On all Pages of the PMR and all attached documents:

Temperature charts

Fluid Balance Charts


Diet charts

Nursing notes

Drug charts

Flow charts

Requests for investigations

Falls assessment, Pain assessment

Neuro observation/Weight charts

Small Addressographs on all specimens.

Patient name with initials;

D.O.B. SEX. P.M.R.

In the event that initial Addressographs are inadequate or contain errors Admissions

counter to be notified for further supplies and corrections.

H. IMPLEMENTATION

1. Accurate and timely identification of all patients is the responsibility of the

following:

b) Medical Director

c) Nursing Director

d) Chief Nursing Officer / Assistant Chief Nursing Officers

e) All Consultants

f) All Physicians / Medical Officers

g) All Nursing Supervisors / Nurses / Staff in all departments

h) Admission Counter staff

i) Outpatient Department staff

j) Blood Bank / Radiology / Labouratory staff

k) Medical Records Dept. staff

2. Training needs and modules have been developed and all those that require training

have been identified in collabouration with the Human Resource department who

will coordinate and track all training requirements

I. REFERENCES


JCI ACCREDITATION STANDARDS FOR HOSPITALS – 5TH EDITION (EFFECTIVE 1ST APRIL

2014)

J. POLICIES CROSS-LINKAGES

1. AOP 5.7 ME2 – linked to Section 6 of this Policy – collection of Sample specimens

J. ATTACHMENTS

ATTACHMENT A – SAMPLE PATIENT REGISTRATION FORM

ATTACHMENT B – ID BAND IMAGE

ATTACHMENT C – SAMPLE ADDRESOGRAPHS

chl hp-ipsg .01 patient identification-4

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