REF: PSP 12
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PRINCIPLES OF SAFE PRACTICE IN THE OPERATING DEPARTMENT
PRINICIPLE 12
PATIENT IDENTIFICATION AND CHECKING
Name of author:
Principles of Safe Practice Review Group
Date:
JULY 2013
Approved by (Committee/Group)
Principles of Safe Practice Review Group
Date of approval
JULY 2013
Date issued
JULY 2013
Review date
JULY 2014
Target audience:
Operating Department Staff
WARNING: Always ensure that you are using the most up to date approved procedural document.
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PRINCIPLES OF SAFE PRACTICE IN THE OPERATING DEPARTMENT
PRINCIPLE 12
PATIENT IDENTIFICATION AND CHECKING
Amendment Form
To be completed when reviewing an existing document
Please record brief details of the changes made alongside the next version number.
If the document has been reviewed without change, this information will still need
to be recorded although the version number will remain the same.
Version
Date
5
26th June
2013
4
25th July
2012
3
13/7/11
14th July
2010
2
Brief Summary of Changes
Pg 4 – Reception generate slips for Poswillo list
only.
Pg 6 – Addition of verbalising the intended
procedure to Point 4
Author
CR, ME, L McL,
JS and ST
Generation of collection sheets
CR, ME, LMcL,
JS EA
Koerner sheets removed. Amendments made to
mex.
CR,MBE,L.McL,
ST and SW
Registration number changed to district number.
Addition to end of Principle in relation to WHO
checklist
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PRINCIPLES OF SAFE PRACTICE IN THE OPERATING DEPARTMENT
PRINCIPLE 12
PATIENT IDENTIFICATION AND CHECKING
Contents
Page
Number
Aim
4
Protocol
4
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REF: PSP 12
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PRINCIPLES OF SAFE PRACTICE IN THE OPERATING DEPARTMENT
PRINCIPLE 12
PATIENT IDENTIFICATION AND CHECKING
Aim To ensure that the correct patient undergoes the correct procedure on the correct
side.
This Principle of Safe Practice should be used in conjunction with Trust Policy for
Operative site marking and verification PAT/PS 4 and Patient Identification Policy
PAT/PS7.
Sending for patients.
1
A collection slip must be generated by accessing bluespier system, selecting
correct date/complex and list.
Main Theatre DRI: By the theatre receptionist.
Orthopaedic DRI: Theatre staff.
Womens DRI:
Theatre staff
BDGH:
Theatre receptionist.
Mex
Printed on Rockingham Ward.
The location of the collection sheets.
DRI: Reception generate the slips when the patient is requested for all theatres
apart from Poswillo list, these slips are generated for the full theatre session and
retained in theatre 7.
Mex.
the collection slips are located on the ward
BDGH
The collection slips are generated as each patient is requested..
2
3
4
A team decision is made as to when to send for a patient. A member of staff
working in the team, by using the intercom or relevant communication system for
the department, requests the patient by name.
The first patient is collected from TAU by a member of the theatre team.
Mex the first patient is on the list (not ophthalmic) is collected from the ward by a
theatre team member. Subsequent patients are escorted to theatre by ward escort
staff. All ophthalmic patients are escorted by ward staff.
The requesting member of staff states that a named patient requires collection for
a theatre identified by number.
 Mex For subsequent patients the procedure for sending for patients is as above
in 3.
 Subsequent TAU patients are escorted to theatre by TAU staff.
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5
Where a service assistant or Operating Department Orderly (ODO) is being utilised
then the appropriate collection slip is obtained from:





Main Theatres DRI. At Reception desk.
Orthopaedic Theatres DRI – Collection slip given to the service assistant.
Gynaecology Theatres DRI – Collection slip collected at reception.
Obstetric Theatres DRI – Collection slips given to the ODO.
Mexboro As above
Mexboro Theatres Ophthalmic lists. Theatre staff telephone the ward for the 1st
patient to be brought to theatre. Subsequent patients the escort nurse from the
ward awaits to take the patient back to the ward .
6
When patients are sent for, the service assistant/escort will take the collection slip
sheet to the ward along with the patient trolley (unless the patient is walking to
theatre)
7
If the patient requires their operation site to be marked this should be done by the
surgeon or designated Doctor who should then sign Check 1 of the NPSA/WHO
checklist.
8
On the Ward a qualified nurse must identify the patient by checking the patient’s
identity i.e. name, district number, operative procedure etc, against the information
on the collection slip and on the bluespier operating list. All the patients details
should correspond.
9
The qualified ward nurse with the escort nurse also completes a full check against
the pre-operative patient checklist and ensures that the correct site for surgery is
marked where appropriate. The NPSA/WHO checklist must then be signed by the
nurse checking the patient out for theatre at section No. 2. to show that what is
written is correct and the check is complete. The nurse must also ensure that all
relevant case notes, IPOCs, x-rays, scan results and an appropriate consent form
are sent to theatre with the patient. If it is not appropriate for the site of surgery to
be marked then this must be recorded as not applicable on the NPSA/WHO
checklist.
10
On arrival in theatre, the patient must be asked for their name by the reception
staff/escort nurse or designated person. (The patient is questioned against the
operation list on bluespier, bracelet and verbal information). The escort person
must verbally identify the patients district No. with receptionist. All staff must be
aware of their responsibilities in relation to the Mental Capacity Act (2005) when
checking patients who are unable to confirm details for themselves.
11
The ward nurse/escort/designated person then escorts the patient to the relevant
anaesthetic room.
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Patient Identification and Checking in the Anaesthetic Room.
1
In the anaesthetic room the patient escort and the Operating Department
Practitioner (ODP)/Anaesthetic nurse must question the patient’s identification
asking the patient’s name. The patients date of birth, district number and the ward
should be checked with the escort nurse.
Plus the consent form should be checked for correct information relating to, surgical
procedure, risks, relevant signatures and dates and also where appropriate that the
correct operative site is marked. .
2
Check with the patient the details identified on the ward/theatre checklist e.g.
dentures removed, fasted, allergies etc.
3
When the hand over is complete, the ODP/anaesthetic nurse should sign the
relevant ward/theatre checklist. The NPSA/WHO checklist at No.3. should be
signed by ODP when site of operation is confirmed with the patient.
4
Check 4 –Time Out – In Theatre.
The surgical, anaesthetic and theatre team involved in the intended operative
procedure should pause for a verbal briefing to confirm the correct patient correct
site and identify the operative procedure prior to commencement of surgery in
accordance with the WHO checklist. This should be performed utilising the
bluespier operation list. Where X-rays are to be used in ortho theatres the patients
identification should be checked and side of operation with the relevant x-rays.
5
At all times the patient’s identity must be established, making cross reference with
the identity bracelet, notes, bluespier operating list and consent form.
6.
Check 5 – In Theatre. Should be completed in theatre before patient leaves in
accordance with WHO checklist. This is to confirm swabs, needles, instruments
are carried out. Patients IPOC must be completed.
7.
Check 6 – In Recovery Ward. At handover from theatre and at handover to Ward
Nurse.
All checks to be signed by a Registered Practitioner apart from Check 1 which must be
signed by Surgeon or designated Doctor if applicable.
At all stages of the WHO Checklist the documentation should be signed in real time.
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