rm40 patient identification policy - qe gateshead patient... · sponsor director of nursing and...

Policy No: RM40 Version: 4.0

Name of Policy: Patient Identification Policy

Effective From: 11/10/2011

Date Ratified 29/06/2011 Ratified SafeCare Committee Review Date 01/07/2012 Sponsor Director of Nursing and Midwifery Expiry Date 28/06/2014 Withdrawn Date

This policy supersedes all previous issues.

Patient Identification Policy v4 2

Version Control

Version Release Author/Reviewer Ratified by/Authorised

by

Date Changes (Please

identify page no.)

1.0

June 2005 Trust Policy Form

April 2005

2.0

Oct 2006 Trust Policy Form

Oct 2006

3.0

10/06/2009 Transfusion Nurses

Hospital Transfusion Committee

10/06/2009

4.0 11/10/2011

Transfusion Nurses

Hospital Transfusion Committee

10/08/2011


CONTENTS PAGE 1. Introduction ........................................................................................................ 5 2. Policy scope ....................................................................................................... 6 3. Aims of the policy ............................................................................................... 6 4. Duties –roles and responsibilities ....................................................................... 6 5. Definition of terms .............................................................................................. 8 6. Positive patient identification .............................................................................. 9

6.1 What is positive patient identification ....................................................... 9 6.2 How do we positively identify patients ..................................................... 9 6.3 Why are wristbands so important ............................................................ 10

6.4 When to produce wristbands ................................................................... 10 6.5 Printed wristbands ................................................................................... 10 6.6 Handwritten wristbands ........................................................................... 11 6.7 Photo ID .................................................................................................. 12 6.8 Patients who refuse to wear wristbands .................................................. 12 6.9 Allergies and similar risks ........................................................................ 12 6.10 Inpatients ................................................................................................. 12 6.11 Out patients ............................................................................................. 13 6.12 Patients admitted through a GP .............................................................. 13 6.13 Specific groups of patients ...................................................................... 13 6.13.1 Babies born well ......................................................................... 14 6.13.2 Singletons .................................................................................. 14 6.13.3 Multiple births ............................................................................. 14 6.13.4 Babies born unwell ..................................................................... 15 6.13.5 The unknown patient .................................................................. 15 6.13.6 Major incident patients ............................................................... 16 6.13.7 Unconscious patients ................................................................. 17 6.13.8 Anaesthetised and sedated patients .......................................... 17 6.13.9 Patients with communication problems ...................................... 18 6.13.10 Deceased patients ..................................................................... 18 6.13.11 Deceased babies ....................................................................... 19 6.14 Other patient ID issues ............................................................................ 20 6.14.1 Pathology: including requesting and sampling ........................... 20 6.14.2 Sampling .................................................................................... 20 6.14.3 Blood transfusion samples ......................................................... 21 6.14.4 Incorrect/incomplete samples .................................................... 21 6.14.5 Anonymous samples .................................................................. 21 6.14.6 The patient for imaging e.g. x-ray, ultrasound, CT ..................... 21 6.14.7 Requesting collection from blood bank ...................................... 22 6.14.8 Collection of blood from blood bank ........................................... 23 6.14.9 Blood administration .................................................................. 23 6.14.10 Drug administration .................................................................... 23 6.14.11 Collecting prescriptions from pharmacy ..................................... 24 6.14.12 Transferring patient from A&E and ward to ward ....................... 24 6.14.13 Collection of the right patient ...................................................... 24


6.15 Misidentification ....................................................................................... 25 6.15.1 Wrong details in PAS ................................................................. 25 6.15.2 Multiple PAS records ................................................................. 25 6.15.3 Patient has investigation using the wrong details ....................... 25 6.15.4 Patient receives the wrong treatment ......................................... 25 6.15.5 Administrative error .................................................................... 26

7. Training and competency ................................................................................... 26 8. Equality and diversity ......................................................................................... 26 9. Process for monitoring compliance .................................................................... 26 10. Consultation and review of the policy. ................................................................ 26 11. References ......................................................................................................... 27 12. Associated documentation ................................................................................. 27


1. INTRODUCTION Misidentification of a patient is harmful for the patient as well as the trust and can lead to death for the patient and litigation for the trust This policy is in place to improve patient safety by promoting the concept of positive patient identification (PPID) for any patient who attends Gateshead Health NHS Foundation Trust, whether as an inpatient or out patient. The policy will describe effective ways to identify a patient as an individual whilst they attend for investigations, procedures or treatment in the trust. The policy will cover many different kinds of patient issues including: • Patients who can identify themselves • Patient who cannot identify themselves, for example babies. • Unknown and major incident patients • The deceased patient • Wristbands and equivalent means to support PPID • Procedure, department requirements/standards • What to do if a patient is misidentified

THE MAIN PATIENT IDENTIFICATION MESSAGES ARE

1. Whenever possible the patient should be asked to give their full name and date of birth and this should be checked against the details on the ID Wristband to confirm they are correct.

2. The wristband should wherever possible be printed and be worn on the

wrist or ankle 3. The wristband must include the Patient’s:

• SURNAME (In Capital Letters) • Forename (In Title Case) • Date of Birth: EG. 01 Jan 2008 • Patient record number • Gender

4. If the patient is known to have a risk/allergy this MUST be clearly

identified by a RED wristband, indicating the exact risk/allergy and this must be recorded on the drug kardex.

5. The patient should be asked about any allergies prior to being given any

medication. 6. If an ID wristband is removed for any reason, it is the responsibility of the

person who removes it to replace it immediately. It is YOUR responsibility to make sure you have the RIGHT patient, first time every time.


2. POLICY SCOPE

The policy for patient identification must be followed by all staff when interacting with patients. Following the policy will reduce the risk of misidentification which can be harmful for the patient, the professional and the organisation

3. AIMS OF THE POLICY

The policy aims to provide staff with information on how to effectively identify all patients as individuals, through positive patient identification. The policy provides clear advice on how to positively identify all types of patients, in different scenarios, from birth to death, whether conscious or unconscious, known or unknown, as part of a major incident, whether clinical or administrative. Patients can have similar names and dates of birth and use of a record number to identify the patient more uniquely will reduce the likelihood of misidentification.

4. DUTIES –ROLES AND RESPONSIBILITIES

The Trust board. Support the Pathology Manager and Transfusion Practitioner in their role in promoting Patient identification strategies for safer patient care. Provide Induction to include Positive Patient Identification (PPID) for all Clinical staff Pathology manager and transfusion practitioner Provide an evidence based policy based on National guidelines. Provide the induction training on PPID to all clinical staff. Monitor the effectiveness of the policy through audit. Health records To produce a unique patient health record for all patients attending the Trust. To maintain accurate, up to date demographic patient details. Administrative staff To ensure they provide the right health record for the right patient. Positively identify all patients as specified in the Patient ID policy. Produce a PPID sticker or Patient ID card, for out patient clinics. Clinical staff All Clinical staff including doctors, nurses, midwives, ODPs MUST positively identify the patients as specified in this policy. Attend induction training, which includes PPID training.


Ensure wristbands are worn by all inpatients in their care, and out patients having invasive procedures or treatments. Ensure all documentation is identified clearly with correct full patient details. Report any errors incidents pertaining to patient identification through the DATIX reporting system (see RM4). Ancillary staff All ancillary for example Phlebotomists, Health Care Assistants (HCAs) and Porters MUST follow the patient ID policy. They must attend induction and mandatory training. See Training Needs Analysis (TNA ). Staff MUST be trained and assessed before carrying out any task specific to transfusion necessary I.E. blood sampling, requesting collection of blood and collection of blood components. Laboratory staff Ensure all specimens received by the laboratory can be easily identified as belonging to a specific patient. Follow the laboratory specimen acceptance criteria for all samples. Promote Zero tolerance for all blood transfusion sample errors. Report all errors on Datix and create a CAPA. Inform the clinician involved, if there is any discrepancy with the specimen/request and ask for a repeat sample Maintain a record of all specimens and any results found. General It is the responsibility of all staff involved in the patient’s care to ensure they are providing the correct care to the correct patient every time by following this patient identification policy. These staff may be: doctors, nurses, midwives, porters, phlebotomists, staff in diagnostic imaging or pharmacy or anyone who carries out any intervention where accurate patient identification is essential. It is the responsibility of the person admitting the patient to provide a wristband for the patient according to the policy. If an ID wristband is removed, it is the responsibility of the person who removes it, to replace it immediately. If an ID wristband comes off or is illegible it is the responsibility of the person who it is reported to, or whoever notices it, to replace it immediately


If there is an incident specifically relating to the patient’s identity, it is the responsibility of the person looking after the patient to report the incident through the Trust’s “DATIX”. incident reporting system,

5. DEFINITION OF TERMS

In Patient. • An inpatient is a patient who is admitted to hospital ward for a procedure e.g.

for surgery, or for treatment of an acute period of illness. • Any day case patient who is admitted to a ward for an overnight stay is

considered to be an inpatient. • All in patients must wear an ID wristband for identification purposes.

Out patient • An out patient is a patient who attends hospital for a clinic appointment under

the care of a consultant or specialist nurse or who attends for a procedure or treatment to a department where it is unlikely they will need to be admitted to a ward.

• Any day case patient who is unlikely to need an overnight stay is considered an out patient.

DATIX: Hospital incident reporting system HCA: Health care assistant PAS: Hospital patient administration system INVASIVE PROCEDURE : For example an operation IMAGING : for example an X Ray SINGLETON: A single baby, not a twin or triplet. WHO CHECKLIST; A world health organisation check list which is checked before an operation to make sure the right patient gets the right operation SOP: standard operational procedure another word for policy SHOT: The serious hazards of transfusion is a voluntary system for reporting blood transfusion incidents and reactions HOSPTIAL TRANSFUSOIN COMMITTEE. This committee is responsible for patient safety in transfusion Hb: the Haemoglobin (Hb) is part of the red blood cell which carried oxygen around the body ICE: the trusts system for requesting pathology tests SPECIAL REQUIREMENTS


CMV: cytomegalovirus is a flu like virus which many of us will have been exposed to. Not all donors are tested for CMV as it isn’t harmful to healthy individuals. Patients who have weak immune systems, for example bone marrow transplant patients, will need to be given CMV negative blood components as the virus may be present in the blood and this may cause harm. IRRADIATED: patient with Hodgkin’s Lymphoma or those who have had specific chemotherapy, for example Fludaribine. CRYOPRECIPITATE: Cryoprecipitate is a blood product which is rich in clotting factors ZERO TOLERANCE: For example blood samples, If any of the sample tube details are wrong or missing , the lab will not accept the sample as this is below standard and will ask for a repeat to be sent.

6. PATIENT IDENTIFICATION

6.1 What is positive patient identification? Positive patient identification (PPID) is a process which, when followed, will promote good patient identification practice and reduce the risk of misidentification from occurring. N.B. Different cultures, nationalities and faiths have different naming systems, which can sometimes lead to confusion This process should be an integral part of patient care. Checking the patient’s identity should not only take place at the beginning of a care episode but continue at each patient intervention throughout the patient’s entire admission to maintain the patient’s safety. Misidentification of the patient, results in wrong: diagnosis, treatment, procedure, medication, blood transfusion etc. all of which can result in minor or major morbidity and even death. PPID ensures the right patient gets the right diagnostic test, treatment, procedure or medication etc, first time every time. It will also save time on repeated tests, incident reporting and investigation etc.

6.2 How do we positively identify patients? Generally speaking, the patient knows better than anyone who they are, so we should ask the patient to confirm their identity for us wherever this is possible. You MUST: ASK the patient for their full name and date of birth.


NEVER ask the patient, “are you Mr/Mrs Jones” as the patient may have misheard what was said and mistakenly agrees. ALWAYS check this against the patient’s ID wristband, which must say exactly the same. NEVER assume the patient is in the right bed as the name above it suggests. The patient may have sat by the wrong bed or have just been admitted without the board being changed. N.B. Never assume a minor difference is not important. Patients have very similar names and dates of birth. SEE APPENDIX 1 “Do s and Don’ts”

6.3 ID Wristbands - Why are wristbands so important? Frequently we do things to patients which prevents them from being able to communicate or care for themselves eg, during anaesthetic, sedation etc. We have a responsibility to ensure they are safe during this time. We must be able to identify anyone who cannot do this for themselves. ID wristbands facilitate this process. Part of the PPID process is the use of ID wristbands or an equivalent for example, photo ID cards. The Trust has introduced printed ID wristbands which are produced using the PAS system as the source of patient information and it is important that only printed wristbands are used wherever possible. The only exceptions are new born babies who still have handwritten wristbands and this will change when a printed alternative is available.

6.4 When to produce a wristband A wristband MUST be produced for the patient as soon as they are admitted and it is the responsibility of the person admitting the patient to provide an ID wristband. Emergency admissions are no exception. The patient is already at risk in an emergency without the added potential problem of being misidentified.

6.5 Printed wristbands.

The printed ID wristband contains the patient’s details in eye readable and barcode format including: Surname TESTING Forename Robert


Date of birth 06-Jun-1966 Record number 0777777 Gender M If there is a problem with the printer it must be reported immediately and an attempt must be made to get a wristband from another printer. Wristband printers are now available to all wards. Knowledge on use of the PAS system is not essential; however the record number must be used to create a wristband. This can be accessed from PAS or through Admissions / A&E reception. It is vitally important that the patient is positively identified before the wristband is produced. They should be asked for: A full name Date of birth Address Telephone number GP name and surgery address. If these details match the health record exactly, a wristband can be produced using the record number. If any of the details are incorrect, a further check must be made to find the correct health record OR amend PAS. Once the wristband is produced a final check of the patient details MUST be done to confirm the right wristband is going onto the right patient wrist. SEE APPENDIX 2 “How to produce a printed wristband”

6.6 Handwritten wristbands. If a printed wristband is not available a handwritten wristband is acceptable but it must contain the same patient details as a printed wristband. Addressograph labels are no substitute for a printed band and must not be used for ID wristbands.

CAUTION!! Shortened versions of names eg. Tom instead of Thomas is NOT acceptable. Only the patient’s full name must be used.

Dates of birth are not significant in all cultures. Some patients may not be clear about a date of birth so may “choose” a date instead.

APPENDIX 3 “How to access health records”


6.7 Photo ID card. Patients, who are regularly transfused, I.E. more than every three months, are eligible for a photo ID card, which includes full patient details including a barcode and a recent photograph of the patient. These can be used in the out patient setting and community. Ask the transfusion nurse about Photo ID.

6.8 Patients who refuse to wear wristbands There are some situations where a patient may not wear an ID wristband: The patient refuses to wear the ID wristband. The ID wristband causes skin irritation The patient removes ID wristband. The patient MUST be informed of the potential risks of not wearing an ID wristband and whether an acceptable alternative could be used, however the patient does have the right to refuse.

6.9 Allergies and similar risks

Patient identification also includes any allergy or risk the patient may have. Patients who have a known allergy/risk should wear a white patient ID wristband + a RED allergy/risk wristband on the same wrist. The allergy/risk must be clearly stated on the red allergy/risk wristband. The positive patient identification process should include asking the patient if they have any allergies that staff need to be aware of. This is particularly important before giving the patient any medication. Any allergies must also be documented in the patient’s health record, and on the drug kardex.

6.10 Inpatients

ALL inpatients must wear an ID wristband for identification purposes. This includes ALL outpatients and day attenders who are attending for any treatment or invasive procedure, including, patients in the Emergency Department who have been through Triage and are receiving treatment. Patients who are undergoing an invasive procedure including imaging and patients having specimens/samples taken. Patients having medicines including chemotherapy.


Patients having a blood transfusion. Patients being transferred between wards/departments. Any treatment which could result in the patient being unable to identify themselves.

6.11 Out patients

On presentation at clinic reception. On arrival at the out patient department the patient MUST be positively identified, by asking for a full name and date of birth. They must then be asked for their address, phone number, GP and GP surgery address. NEVER ask the patient, “are you John Smith” as the may have misheard you but still answered yes. These details should be checked in PAS. If correct, a patient ID sticker will be produced and stuck to the patient’s letter or appointment card or diagnostic test card if available. The card can then be used to positively identify the patient before requesting blood tests and radiology requests on ICE.

6.12 Patients admitted through a GP

During normal hours, it is the responsibility of the person taking the call from the GP, to take as many patient details as possible. These details must be given to the ward clerk who must then locate and retrieve the relevant patient records. Out of hours it is the responsibility of the person taking the call from the GP to take as many patient details as possible. Admissions (A&E reception after 22.00hrs) must be contacted and the medical records requested. Even if there are no patient records available, admissions will be able to provide a record number and front sheet. You will need the patient’s record number to create an ID wristband.

6.13 Specific problem groups of patients In the majority of cases the patient will be able to identify themselves, however there will always be patients who cannot do this.


It is especially important that these patients are wearing an ID wristband to assist in the identification process. 6.13.1 Babies born in the QEH who are well on delivery

Care needs to be taken with all new babies as they will have similar dates of birth as the rest of the babies in the ward and it is not unusual to have two mothers with the same surname deliver at the same time. Currently babies must be registered on the PROTOS system which will issue a “birth number” and an NHS number. A copy of this should be sent to maternity reception so all babies can be registered on PAS as soon as possible. EVOLUTION will replace PROTOS and this will provide an NHS and birth number for the baby, but will also automatically register the baby in the hospital PAS system. As soon as a baby is born two wristbands should be produced and attached to two different limbs (often the ankles). Currently these are hand written wristbands.

6.13.2 Singletons should be identified as: Forename, OR where the baby has not yet been given a name, Boy/Girl Mother’s Surname MUST be used Date of Birth Time of Birth Mother’s record number. N.B. However if the baby requires any investigations, they must be registered on PAS and only their own record number used. The mother’s number must not be used for investigations.

6.13.3 Multiple births.

Care needs to be taken with multiple births to ensure the babies can be identified as a twin for example, the order of birth and gender. The safest way to identify those babies who have not yet been given a name is; o Twinoneboy or girl o Twintwogirl or boy o Tripletoneboy or girl o Triplettwogirl or boy o Tripletthreeboy or girl o Etc.


6.13.4 Babies who are born unwell and are admitted to SCBU

If a baby is ill and requires admission to SCBU, they must be registered through maternity reception (or A&E reception out of hours) as soon as possible as the baby will need a record number if tests and treatment are to be given. Two ID wristbands must be produced using the baby’s own details which must include: Name OR Boy OR girl (see information on multiple births) • Mother’s surname must be used • Date of Birth • Baby’s hospital record number • Gender

CAUTION!!

Babies are likely to have similar dates of birth. It is important that babies are identified as individuals. Mother’s and babies cannot share hospital numbers so it is important to use the baby’s number wherever possible. All babies in SCBU must have a record number on their wristband. All babies will be registered on PAS and will be given a record number

6.13.5 The unknown patient

There will be occasions when a patient is admitted to hospital unconscious and without any means of identification. Even without knowing the patient details, PPID is achievable to reduce the risk for the patient. Unknown/unconscious patients (or those incapable of identifying themselves) must be registered in PAS and identified as: Unknown Male/Female Adults DOB: 08.08.1988 Children DOB: 01.01.2009 PAS generated record number. These details should be used to generate a printed ID wristband for the patient. All documentation, requests and results should use these details at all times to minimise misidentification errors.


CAUTION!! Great care is needed in deciding to revert to the patients own details. Only change to the patient’s own details when it is safe to do so and remember to inform the laboratory of the updated information. If the patient is having active treatment, i.e. surgery, blood or blood component transfusion, changing the patient details too early could lead to confusion and put the patient at risk. A new updated wristband must be produced See Blood Transfusion Policy RM36

6.13.6 Major incident patient

In a major incident there are likely to be multiple patients requiring attention as soon as they arrive. In this situation, patients will be allocated a major incident plan (MIP) identity. Patients will be identified using the MIP ID when they initially present to the hospital and will keep this identity until they are safe to revert back to their own identity. The system will initially be a paper system. All MIP records have already been prepared in advance. The files are colour coded to identify patients as being, male (blue), female (pink) or child (green).

When the patient’s true identity is known, if the patient is a current Gateshead patient, the records may be requested for information only. Any relevant information should be copied and placed into the MIP record. The Gateshead record number must be displayed in the front of the MIP record to aid patient identification The Gateshead record should then be returned to the health records library.

Child One 01.03.2009 0743617

Adam One 08.08.1988 0743271

Eve One 08.08.1988 0743248


Only when it is safe to do so, the patient can revert back to their own identity. All subsequent documentation must be stored in the MIP file even though it will contain the patient’s actual details.

6.13.7 The unconscious patient

Patients can be unconscious for a number of reasons. Sometimes it is the treatment they are having eg, anaesthetic/sedation, but it may be due to the influence of drugs or alcohol. These patients are incapable of identifying themselves and maintaining their own safety. It is the responsibility of the staff looking after the patient to ensure they can be identified properly. All unconscious patients must wear an ID wristband for identification purposes. A reliable adult (eg relative) may be asked for the patient’s full name and date of birth. NB. Care is needed in choosing this person.

6.13.8 Anaesthetised and sedated patients

6.13.8a Theatre reception

Wherever possible the patient must be positively identified by theatre reception staff, by asking for a full name and date of birth which must be checked against the ID wristband. All details must be checked against the theatre list, patient notes, X rays etc before proceeding (see also Correct Site Surgery Policy, RM 43).

CAUTION!! N.B. For Medical Legal reasons it is important to keep all documentation relating to the major incident in one place. This is why only the physical MIP record should be used to keep all incident/ treatment activity together. Returning Gateshead records to the library will avoid information being missed from MIP record.


6.13.8b Prior to induction of anaesthesia/sedation The WHO Checklist must be carried out by the team looking after the patient and this must include a patient identity check prior to induction of anaesthetic wherever possible. All patient details must be checked against the theatre list, patient notes, X rays etc before proceeding.

6.13.9 Patients with communication problems i.e. children,

confused, non English speaking

If the patient be unable to communicate for themselves, as they are too young, confused, or don’t have English as a first language etc it is especially important these patients have an ID wristband to assist identification. An accompanying reliable adult eg Parent or relative, may be asked to confirm the patient’s details. Where there is a language barrier an interpreter MUST be used. (see Interpreter policy OP 32). However members of staff may be able to communicate with patients with learning disabilities, or who are hearing impaired. Members of staff should refer to the Mental Capacity Policy RM 74 when dealing with patients who may lack capacity.

6.13.10 The deceased patient.

It is vitally important that the deceased patient is identified properly to prevent a mix up later on in the mortuary. Mix ups will cause a great deal of upset for the family and can also lead to litigation. All deceased patients MUST be properly identified with a printed ID Wristband. This MUST include the patient’s: Forename. Surname. Date of birth. NHS/hospital record number. Gender. A mortuary label MUST be attached to the patient’s wrist. It is permissible to use an addressograph on the reverse of the label, however the rest of the information MUST be completed as well. All of this information is essential and must to include: Full name. Age. Date of death Ward.


Religion. Hospital Record Number In the event of the patient’s name not being known, they should be identified as any other unknown patient which includes a unique hospital record number. A second identical label should be taped to the outside of the sheet for transfer to the mortuary. This “clean” label is used to record the patient in the mortuary register.

6.13.11 Deceased babies.

PLEASE NOTE. It is vitally important that all stillborn babies going to the mortuary can be identified properly and it is sensible to include the mother and father’s details on the paperwork if they have different surnames. If the baby is identified in the mortuary using the mother’s name and is then registered with the father’s, the death certificate will differ from the details attached to the baby. Including both parent’s names will reduce the risk of mix up and help to clarify which baby is being collected. Foetuses less than 24 weeks gestation. For post mortem or Cytogentics testing. The foetus, complete with placenta, must be sent to the mortuary in a dry pot with a foetal loss form and cytogentics consent form if appropriate. No post mortem or Cytogentics required The foetus should be sent to Pathology, in 10% formalin with an Histology request form. Foetuses over 24 weeks gestation. For post mortem or Cytogentics testing. Any cytogenetic samples must be taken first, placed in saline and sent to Histology with the relevant paperwork. The foetus should be placed in a Moses basket with a foetal loss form clearly stating not for post mortem. The placenta should be placed in a pot with 10% formalin and sent to Pathology with an Histology form No post mortem or Cytogentics required Cytogenetics samples should be taken and placed in a pot with saline. This should be sent to Histology with a Cytogenetics consent form.


The baby should be placed and a Moses basket and taken to the mortuary with a foetal loss form clearly stating not for post mortem. The placenta should be placed in a pot with 10% formalin and sent to Histology.

6.14 Other patient identification issues - general

The basic principles in PPID are the same regardless of the task, procedure, test, or substance to be given. There are a number of tasks which depend upon good patient identification processes. PPID is essential in every aspect of patient care to ensure the right patient has the right care, treatment, investigation, test etc. the following are just a few of those tasks. 6.14.1 Pathology specimens. - ICE requesting.

Requests should be made using the patient record number to access the correct patient record in ICE. This can be achieved by scanning the patient’s wristband or equivalent, for example an ID card in the out patient setting, or typing the patient’s record number into the system. If the patient is present at the time of requesting, they should be positively identified by asking for their name and date of birth and this information should be checked in the ICE system to make sure the correct record has been accessed.

6.14.2 Sampling. If no wristband is present it is up to the ward staff to provide one so that samples can be taken safely. The specimen/sample label MUST be completed at the bedside, by the person who took the sample regardless of the sample type. The specimen/sample details must be checked against the wristband or equivalent, where ICE or addressograph labels are used. ICE and addressograph labels cannot be used for blood transfusion. These details should include the patient’s full name, date of birth and hospital record number. Any ICE/addressograph label must be checked against the wristband before attaching it to the sample container.


6.14.3 Blood transfusion samples The transfusion laboratory has a zero tolerance policy for all samples. All blood transfusion samples must be labelled correctly. The patient’s full name, date of birth, record number and gender must be complete and correct. The sample must also be signed and dated by the person who took the sample. N.B. Samples can no longer be amended, therefore any unlabelled, mislabelled, addressograph labelled, inappropriately labelled or unsigned or undated samples will be discarded and will need to be repeated.

6.14.4 Incorrect/incomplete samples (other than blood

transfusion).

Any specimen which does not fit the laboratory acceptance criteria will be dealt with in accordance with the laboratory Standard Operational Procedure (SOP). This may result in the specimen being processed but no result being made available on the system

CAUTION!! The requesting clinician should note any comments made by laboratory personnel, regarding specimens, which are inadequately labelled, mislabelled or unlabelled and treat the results with caution where there is any doubt about the true patient identity.

6.14.5 Anonymous samples

Occasionally Occupational Health may need to send anonymous specimens for screening of staff. These specimens will be labeled with a unique identifier known only to the Occupational Health department, taken in accordance with their local protocol. SEE APPENDIX 4

6.14.6 The patient for imaging eg Xray, Ultrasound, CT, MRI, Medical physics.

It is the responsibility of the Operator to ensure that the correct patient is being examined according to the request that has been made.


If the patient details stated on the request form are incomplete or incorrect, further information must be obtained before an exposure is performed. The operator must correctly identify the patient prior to performing any exposure by: Asking the patient to state their full name, date of birth and address. Do not offer details for confirmation by the patient. Check all details given against those on the request RIS/ICE system or request form if appropriate. The name, date of birth and address and GP should all match. If the details match, proceed with the investigation/treatment. If the patient is an inpatient they MUST have an ID wristband and this should be checked against the details given by the patient. If an inpatient does attend without an ID wristband, the ward must be informed. If the patient is an out patient the should have a wristband equivalent as a means for identification. NB. Be especially vigilant if there is more than one patient with the same name in the system

6.14.7 Requesting collection from blood bank N.B. Anyone carrying out this task should be trained and competency assessed see TNA The “porter trac” system should be used whenever it is available usually 08.00-20.00hrs. The patient’s full name, date of birth and record number are essential for the safe collection of blood. Which component and the quantity is also essential otherwise a single unit will be collected. “Bleeder” should only be used if massive transfusion is expected. This will result in a porter being allocated as a runner for blood. Inadequate information causes delay and can lead to errors Delays can harm patients Taking the time to check details will save having to repeating the process


SEE APPENDIX 5 “To order blood component collection by the porters”.

6.14.8 Collection of blood from blood bank N.B. Anyone carrying out this task should be trained and competency assessed see TNA Information on the patient’s full name, date of birth, record number, what is to be collected, how much and where it is to be delivered, is essential for collection of blood. 08.00-20.00 this will be printed in blood bank from the “Porter trac” system and out of hours a green collection slip must be used. The patient’s details must be checked against the collection slip. Collection slips must not be written out in blood bank from the blood bags. This defeats the object of taking information to select the correct blood.

6.14.9 Blood administration

N.B. Anyone carrying out this task should be trained and competency assessed. See TNA The bedside check is the last opportunity to discover an error prior to administration (SHOT). The blood must be checked at the bedside and this process must include the patient. The patient must wear an ID wristband regardless of whether the transfusion is given as an in patient or out patient day case. The patient MUST be positively identified, by asking them to give their full name and date of birth. This must be checked against the ID wristband. If anything is different or you are unsure – DO NOT give the blood and seek advice. See the Blood Transfusion Policy RM 36

6.14.10 Drug administration

All patients receiving any drug in this Trust MUST wear an ID wristband or equivalent. The patient MUST be positively identified, by asking them to give their full name and date of birth.


This must be checked against the ID wristband. The patient MUST be asked if they have any allergies which need to be known about, and a check should be made to see if the patient is wearing a red allergy wristband and any allergies noted on the Kardex, and The patient details must be checked against the prescription and the drug given in accordance with the appropriate drug policy. If unsure do not give the drug and seek advice.

6.14.11 Collecting prescriptions from pharmacy Patients collecting prescriptions from pharmacy must be positively identified by asking for a name and date of birth. this should be checked against the appointment card patient ID sticker which should have been given in the out patient department.

6.14.12 Transferring patients from A&E.

Patients who are transferred to a ward from the A &E department, MUST be registered on PAS and already have an ID wristband provided.

It is the responsibility of the person receiving the patient onto the ward to check the ID wristband for accuracy. If the patient is at risk of wandering off the ward the ward number can be added to the wristband If the ID Wristband is in poor condition or inaccurate, it should be replaced immediately with a new one.

6.14.13 Collection of the right patient.

When collecting an inpatient from a ward, portering staff must ask the ward staff to identify the patient. Details of the patient to be collected are then checked against the patient’s ID Wristband involving the ward staff, porter and patient. Patients without ID wristbands MUST NOT be removed from the ward until an ID Wristband has been supplied and fitted. It is the responsibility of the ward staff to provide an ID wristband


6.15 Misidentification of a patient. Not following the process of positive patient identification is a common reason why patients are misidentified. Lack of ID checks, pre-labelled samples, poor record keeping and inappropriate use of addressograph labels can all contribute to misidentification of the patient.

6.15.1 Wrong details on PAS

As soon as it is realised that the wrong patient details are on PAS the entry MUST be updated. If the patient is an inpatient and the error involves the name DOB or record number, the wristband must be changed. All departments involved in the patient’s care, for example the laboratories, must also be notified.

6.15.2 Patient has multiple records in PAS

Health records must be informed. The earliest record should be used for all requests, investigations and treatments, however if treatment has already started using the newer records this should continue until discharge to prevent confusion. Once the patient is discharged all notes must be sent to health records for merging.

6.15.3 The patient has an investigation using the wrong detail

As soon as the error is discovered, the laboratory / radiology / medical physics must be informed. The incident must be reported. The incident must be investigated using root cause analysis if necessary. The investigation must be repeated wherever possible. If this is not possible all results must be interpreted with caution. An apology must be made to the patient.

6.15.4 The patient receives the wrong treatment The treatment must be stopped immediately and remedial action taken if necessary.


The incident must be investigated using root cause analysis if necessary. If this is not possible all results must be interpreted with caution. An apology must be made to the patient.

6.15.5 Administrative error where the wrong patient details are used for example, to book an appointment, admission, letter etc. The request should be withdrawn if possible. The error must be reported and investigated if appropriate The patient involved should be contacted and advised of the error and an apology made if appropriate

7. Training and competency

See the TNA 8. Equality and diversity

The Trust is committed to ensuring that ,as far a reasonably practicable, the way we provide services to the public, staff and visitors reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic. Whilst the policy does not aim to promote disability equality, it does enable the Trust to make reasonable adjustments to ensure that the different needs of patients are met. Members of staff are expected to be mindful that different cultures, nationalities and faiths have different naming systems, which can sometimes lead to confusion. Further information is available by contacting the Chaplaincy ( on extn 2072) or by reference to information on the Chaplaincy page on the intranet site. This policy has been assessed.

9. Process for monitoring compliance with this policy

An annual audit of wristband compliance must be carried out. This will include an audit of red allergy wristbands the result of which is given to the pharmacy department.

10. Implementation of the policy.

Patient identification is included in Induction for all clinical staff, including, nurses, midwives, doctors, HCAs, porters, ODPs, ward clerks etc. All admin staff must have patient identification as part of their local induction.


Policy RM 40 is available on the intranet

11. Consultation and review of the policy.

The policy will be reviewed using the most up to date information available. The policy will be guided by any national recommendations as appropriate. The process will include consultation with various departments to ensure that the information is accurate and relevant. This policy has been approved by the Hospital transfusion committee and the Safe care council.

12. References

National Patient Safety Agency, safer practice notice 28 (2007), Standardising wristbands improves patient safety. British committee for standards in haematology (2009). Guideline on the administration of blood components. Gateshead hospital policies. • RM 4 Incident reporting • RM43 correct site surgery • OP32 Interpreter policy • RM 36 Transfusion policy • SOP for sample acceptance (available through pathology) • SOP for receiving bodies to the mortuary (available through pathology)


How do we prevent patient misidentification? DOs • DO read policy RM40 • DO indentify the patient as soon as they are admitted by asking for a full name and date of birth as well as confirming all other demographic details • DO place a wristband on the patient’s wrist as soon as you have established their identity • DO ensure the ID wristband is worn throughout the whole admission whether that be a day or weeks • DO explain the need to wear a wristband to the patient • DO ask the patient for their full name and date of birth at every intervention • DO remember that no one should take specimens from patients who are not wearing a correctly completed ID wristband • DO check the details against the wristband before carrying out any procedure or administration of medicines or blood • DO make sure the details on prescriptions and request cards are exactly the same as those on the wristband • DO label any specimens after they have been taken before leaving the bedside, with the details from the ID wristband • DO regularly check the wristband details are legible. If not, replace it • DO take care in clinics as patients may admit to being someone else to jump the queue. Always ask the patient to give you their details and not just confirm what you say to them • DO be aware that different cultures, nationalities and faiths have different naming systems. DON’TS • DON’T read the patient details and ask them to confirm them • DON’T accept a patient pointing to a name above the bed • DON’T take specimens without identifying the patient first • DON’T label sample tubes and bottles before taking the specimen • DON’T take samples from more than one person at a time. Concentrate on one patient, one sample, one request • DON’T label samples of check medication or blood away from the bedside. Remember the patient’s identity is the most important part of the checking procedure, as any treatment is no good for the wrong patient • DON’T print off more addressographs labels or use them for patient identification as they can be misfiled and have been proven to lead to wrong blood transfusions • DON’T label samples for someone else

• • DON’T expect phlebotomists to take samples when there is no wristband on the patient

APPENDIX 1


Easy Step Guide

Step 1 Double click on icon from your desktop.

Step 2 Enter 7 digit unit number and press enter.

Step 3 Check patient’s demographics, and press enter to

print wristband.

To close this box, click on the x in the top right corner.

Trouble Shooting

If printer doesn’t print

● Check that the printer is turned on, the green light should be on. ● Check the wristband roll is inserted correctly. ● If a new roll is needed for the printer, replace and try again. ● If the printer still won' print, contact the The IT service desk on extension 2397.

Notes: When consumables (wristbands and clips) are running low, please contact pathology stores.

APPENDIX 2


How to access health records.

Patients can be admitted through A&E, medical admissions and surgical admissions. GP admissions are not always admitted through A&E. The patient WILL need a wristband so you will require a record number in advance of their arrival As soon as a ward has been contacted to say a patient is to be admitted, the health records need to be accessed to ensure there is a record number available to create a printed wristband. A few minutes invested in letting admissions know the patient is coming in can help to prepare for the arrival and save time trying to catch up once the patient is admitted.

APPENDIX 3

Check PAS to see if the patient is already registered.

YES Complete an admissions form, including the patient’s full details as registered on PAS. Send this via the chute system to admissions asap.

NO Complete an admissions form including as much information as you can I.E. the patient’s full name, date of birth, address and GP information. Send this via the chute to admissions asap.

Out of Hours admissions are dealt with by A&E reception staff.


SAMPLING, REQUESTING, AND CHECKING PATIENT ID Patient identification, sampling and requesting group and save /

crossmatch specimens, and checking blood. All patients for transfusion must wear an ID wristband containing their full name, date

of birth, record number and gender. NO WRISTBAND, NO TRANSFUSION.

No ID Wristband STOP NO TRANSFUSION

ID Wristband present. CONTINUE

Check ID wristband for: Surname Forename Date of birth Record number Gender

Details differ to what patient says.

STOP +

APPENDIX 4

POSITIVELY IDENTIFY THE PATIENT BY ASKING FOR A FULL NAME AND DATE OF BIRTH.

SAMPLE If YOU take a sample YOU must label it at patient’s side with:

Surname Forename Date of birth Record number Gender Date Signature DO NOT pre label tubes. Transfusion must be hand written, complete and signed and dated unless order-communication labels are used. All incorrect samples will be discarded

REQUEST FORM information required:

Surname Forename Date of birth Record number Gender Full clinical details eg current treatment and reason for request Ward/Dept Consultant. Requesting doctor’s bleep/contact number and Signature/name in case of problems For Transfusion Recent Hb if known State component and quantity required Special requirements, eg. Irradiated CMV etc.

BEDSIDE CHECK. All of the following must be exactly the same on the ID wristband, prescription, blood bag/drug label Surname. Forename Date of birth Record number Gender In transfusion check Blood group. Rh D group (+ve OR-ve) Donation number Component type Expiry and use by date

Only when all of the details above are given should the sample be sent to the laboratory with the request form Only if all of the above are

exactly the same can the treatment commence. For URGENT requests ring the laboratory

Haematology 2277 Transfusion 2281 Biochem 2288

Details same as patient says: CONTINUE


TO ORDER BLOOD COMPONENTS THROUGH THE PORTERS.

APPENDIX 5

When ordering blood components using the porter track system you MUST provide the following information.

• The Patient’s: Name, Date of Birth and Record number, MUST be typed into the “PATIENT” box.

• You MUST select “Pathology” if the blood is to be collected from

blood bank OR your ward if the blood is being returned to blood bank

• You MUST select which blood product you need, Blood, FFP,

Platelets or Cryo, Beriplex or Novoseven and how much you require

“BLEEDER” should only be used in a dire emergency and you

must remember to state what needs to be collected in the t b

Out of hours you must telephone the request to the porters. You MUST provide:

• Patient’s full name • Date of birth • Record number • Which blood component you want

collected and how much. • Where it is to be delivered.

• Porter track has been introduced to improve patient safety and efficiency.

• All blood requests are a priority. • Failure to provide essential information will delay the transfusion as

porters are not allowed to collect blood without it. • It is not the porter’s fault when transfusions are delayed due to lack of

information. They are not being difficult, they are keeping your patient safe!


Wristband audit tool. Only collect missing information + any additional information ward band patient

aware name DOB number gender condition

of band allergy or risk

Additional information present

APPENDIX 6

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