Patient Identification Policy
Version
6
Name of responsible (ratifying) committee
Patient Safety Working Group
Date ratified
February 2013
Document Manager (job title)
Head of Patient Safety
Date issued
21.08.2013
Review date
February 2015 (unless legislation changes)
Electronic location
Climical Policies
Related Procedural Documents
See section 8 on page 13 of this policy
Key Words (to aid with searching)
Patients; Wristband identification; Patient identification
systems; Health service staff; Patient safety; Blood
transfusion; Risk management; Hospital deaths;
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 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 1 of 20
CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
QUICK REFERENCE GUIDE....................................................................................................... 3
INTRODUCTION.......................................................................................................................... 4
PURPOSE ................................................................................................................................... 4
SCOPE ........................................................................................................................................ 4
DEFINITIONS .............................................................................................................................. 4
DUTIES AND RESPONSIBILITIES .............................................................................................. 5
PROCESS ................................................................................................................................... 7
TRAINING REQUIREMENTS………………………………………………………………………… 14
REFERENCES AND ASSOCIATED DOCUMENTATION…………………………………………..14
MONITORING COMPLIANCE WITH AND THE EFFFECTIVENESSOF, PROCEDURAL
DOCUMENTS…………………………………………………………………………………………… 16
Appendices
Appendix 1: Patient Identification Policy Audit Tool (adults)
Appendix 2: Identification of the Newborn Infant
Appendix 3: Neonatal identification guideline
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 2 of 20
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. Misidentification of patients now appears on the DoH list of
‘never events’.
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
o
o
o






Who are placed within the ‘major’ treatment area;
Are non-ambulatory and with Glasgow Coma Score of less than 15 attending
the ED;
Ambulatory patients attending ED where it is professionally judged to be
appropriate, for example patients with cognitive impairment;
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 four identity markers i.e. Surname, first name,
date of birth and unique identification number (For inpatients, the name of the ward should be
included on the ID band)
4. On transfer to a different ward, the original ID band must be removed and replaced with a new
one which includes details of the new ward
5. A single red ID band should be applied in the event of allergies/alerts
6. Any damaged / missing ID band must be replaced immediately
7. Patients must be told not to remove the ID band
Separate criteria apply to newborn infants and neonates, who must have two ID bands applied
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 3 of 20
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
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 4 of 20
Day ward attendees are those patients who are admitted to the hospital for a procedure or
monitoring, but not expected to stay in overnight.
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 Director of Nursing
The Director of Nursing is responsible for there are appropriate processes are in place for the
effective and reliable identification of patients
Head of Patient Safety
The Head of Patient safety is responsible for presenting the outcome of the bi-annual audits to
the Patient Safety Working Group
Matrons and Senior Midwifery Managers
Matrons and Senior Midwifery Managers are responsible for ensuring
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 5 of 20


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 Clinical Service Centre is
undertaken is the responsibility of the Matron’s and Senior Midwifery Managers.
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 noncompliance, 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 recorded through 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 online 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
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 annual audit of compliance with patient
identification and ensure that appropriate actions are taken to address any issues of noncompliance. The Group will also escalate any identified risks to either the CSC Governance
Committees for inclusion in the CSC risk register or to the Risk Assurance Committee for
discussion and potential inclusion on the Trust risk register or assurance framework.
CSC Governance Committees
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 6 of 20
It is the responsibility of CSC Governance Committees to monitor their CSC 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:


6.1.5
Identification of gender: male infant (M) / female infant (F)
Mother’s surname, date and time of birth
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)
6.2
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.
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.
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:
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 7 of 20

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
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.
with Glasgow Coma Score of less than 15

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 outpatients 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
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 8 of 20
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 online 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 patient’s forehead. The ID band
must be re–applied correctly to a limb before leaving the theatre to go to
recovery, after being checked by two health care workers.
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 9 of 20
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
Administration of the wrong blood component
Taking of samples from the wrong 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)
 Failure of the Healthcare Professional to positively identify their patient
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 online and set in place an
appropriate investigation, in line with Trust policy12
Inform the patient and relative/carer of the incident and actions taken3
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
1
Management of Adverse Incidents and Near Misses
Management of Serious Untoward Incidents
3
Being Open
2
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 10 of 20
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.
6.7.3
Frontline staff must always verify that the patient they are attending to is the
patient for whom the treatment is intended and match the treatment to that patient
6.7.4
In normal circumstances, a patient’s ID band must only be removed on discharge
home. As many patients use the discharge lounge, the ID band must not be
removed until the patient leaves the hospital premises. Note: ID bands must not
be removed if a patient is ‘discharged’ to another hospital, into social service or
private nursing care.
6.7.5
ID bands put in place during a major incident and, therefore, containing a Major
Incident Number must be left in situ and a second band detailing the patient’s 4
identity markers applied to the same limb. This is an exception to the policy of
the single ID band.
6.7.6
If the ID band needs to be removed from the wrist because it interferes with
treatment, alternative areas for placement such as the ankle, should be
considered. If no alternative area for placement is possible, then the member of
staff who removes the ID band must replace it at the earliest possible opportunity.
6.7.7
If an ID band is found to be missing, the healthcare worker who discovers the loss
is responsible for replacing it immediately and for raising an adverse incident
reporting form, in line with the Policy for the Reporting of Adverse Incidents and
Near Misses.
6.7.8
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.
6.7.9
Except in emergency situations, should the verification process fail at any stage,
all activities for the patient must be halted until the patient’s identity can be
accurately determined. In these circumstances, an Adverse Incident Reporting
form should be completed and actioned in accordance with the Trust Policy4.
6.7.9
Anecdotal evidence suggests that there is a risk of patients or their representatives
agreeing to incorrect patient identifiers, due to mishearing or confusion.
Verification should, therefore, be active rather than passive: by asking the
patient/representative for the patient’s name, rather than offering a name and by
checking the patient’s details against the ID band and documentation.
Note: In the event of death, the ID band must not be removed from the patient’s body.
6.8 Unidentified patients
6.8.1 The instances of unidentified patients will invariably occur in the ED. In these
circumstances, an ID band must be applied as soon as an ED number has been
allocated and must include the patient’s identity status, gender, approximate age
and the ED number. For example
4
Management of Adverse Incidents and Near Misses
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 11 of 20
Unknown male
Age:
approx
years
05-123456
30
6.8.2
For patients who cannot supply the relevant information, the name and date of
birth can be verified by the patient’s family, carer, guardian or other representative
6.8.3
Staff must consider the possibility of gender reassignment when identifying
patients in this way. Where issues of doubt arise, the staff member must agree
appropriate identification with the attending doctor.
6.9 Major Incidents
6.9.1 Patients attending the ED from a Major Incident will arrive with identity information
hung around their necks, having had that put in place at the scene of the Incident.
Immediately on arrival, ED staff will apply a Major Incident identity label containing
a pre-written Major Incident casualty number.
6.9.2
As soon as the identification markers of the casualty – name and date of birth have been verified, a second printed ID band detailing this information must be
attached to the casualty. To ensure that the patient’s involvement in the incident
can be identified, for any required follow-up purposes, the Major Incident
identification label must not be removed until the casualty is discharged from
hospital. This is an exception to the policy of single ID bands.
6.10 Allergies/risk
Where it is identified from the patient’s notes that they have a known or suspected allergy,
a single red ID band will be used in place of the white band, as a prompt to healthcare
workers. Red ID bands must only be used as an alert to the presence of any allergies or
drug alerts / reactions and not for notification of a clinical diagnosis.
6.11 Documentation
6.11.2 Addressograph labels
 Before using the labels and to ensure they are correct, healthcare workers
must check the details against those in the patient’s records


It is essential that before newly printed labels are inserted into the patient’s
records, that the person undertaking the filing of the new labels, checks the
details on the labels against all the identification information held in those
records. It is also their responsibility to check any existing labels and
remove them if the details are incorrect.
Each page of a patient’s notes must have an addressograph label
6.11.3 Request / referral forms
 The minimum of 4 patient identity markers must be on all request / referral
forms, and the form signed by the requester / referrer and must correspond
to the patients’ identity band
 Staff members completing request or referral forms must complete the
details themselves and must ensure that the patient information is correct
and that the patient identified on the form is the one for which the
requested treatment / investigation is intended
 Prior to commencement of any treatment / investigation, all request or
referral forms must be checked against the patient’s ID band, to ensure the
patient due to undergo the treatment / investigation is the one identified on
the form. Where possible, the patient should be asked to give their name,
date of birth and address to further confirm their identity.
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 12 of 20
6.11.4 Information to accompany the patient on transfer
 Prior to transfer, the patient’s identity must be checked and all associated,
relevant information photocopied or scanned, before accompanying the
patient. The patient’s ID band must be in place, to enable other units to
confirm the patient’s identity
6.11.5 Specimens and samples
 The minimum requirements for the specimen / sample label are the 4
patient identity markers ( surname, first name, date of birth and unique
identification number.
 Specimen containers must be labeled, with the patient’s identification taken
from their ID band, not the request form or patient records
 The container must not be pre-labeled but labeled, by the person taking the
specimen, after it is placed into the container. The container must be
labeled beside the patient and not removed to another location until the
labeling is complete.
 The label can by handwritten or produced electronically
 On receipt of a mislabeled specimen or sample, the standard operating
procedure for the receiving department must be followed, including
informing the originator of the mislabeled specimen / sample and
completion of an Adverse Incident Reporting form.
 If there is any doubt as to the correct identity of the patient, a repeat
specimen / sample must be taken.
7. TRAINING REQUIREMENTS




Processes, including this policy, are included in the induction programmes for junior
doctors, registered nurses and healthcare support workers
Processes, including this policy, are included in local induction in all relevant areas
All staff responsible for printing and issuing ID bands undergo training and must be
deemed competent by their line manager prior to issuing and verifying identification
markers
Ward, clinical and departmental managers will ensure that any additional training
highlighted as required by the bi-annual audit is implemented
8. REFERENCES AND ASSOCIATED DOCUMENTATION
External
 NPSA: Framework for Action:
http://www.saferhealthcare.org.uk/IHI/Products/Publications/rightpatientrightcare.htm
 NPSA/2005/11 – Safer Practice Notice: Wristbands for hospital inpatients improves
safety:
http://www.npsa.nhs.uk/site/media/documents/1440_Safer_Patient_Identification_SPN.pdf
 NPSA (2007) Your Guide to Implementing Wristbands
 NPSA (2007) Standardising wristbands improves patient safety: Guidance on
implementing the Safer Practice Notice
 IR (ME) R 2000: Regulations 4(5), and 5(1) and Schedule 1, 15.3:
http://www.dh.gov.uk/assetRoot/04/05/78/38/04057838.pdf
 HRC supplement A. Risk Analysis: Patient Identification:
http://www.ecri.org/Patient_Information/Patient_Safety/RiskQual16.pdf
 Quality & Safety in Healthcare http://qhc.bmjjournals.com/cgi/content/full/13/5/329
 Beyea SC Patient identification-A crucial aspect of patient safety. Association of operating
room nurses. 7. AORN Journal; Sept 2003, 78; ProQuest Medical Library p 478.
 Henderson J & Embry D. Unpublished paper. Mismatching between planned and act
treatments in medicine- Manual checking approaches to prevention. Final Report March
2004.
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 13 of 20

Sevdalis,N. (2007) Design and specification of patient wristbands: Evidence from
existing literature, NPSA-facilitated workshops, and a NHS Trusts survey.
N.sevdalis@npsa.nhs.uk;n.sevdalis@imperial.ac.uk


Department of Health: Better Blood Transfusion. www.dh.gov.uk
BSCH Guidelines - Administration of blood and blood components and the management
of transfused patients, 1990
NMC (2002) Code of Conduct, Nursing & Midwifery Council, London: http://www.nmcuk.org/nmc/main/about/docs/Members_code.pdf

Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 14 of 20
Internal
 Identification of the Newborn Infant
 Neonatal Identification Guideline
 Policy for the Management of Adverse Incidents and Near Misses
 Policy for the Management of Serious Untoward Incidents
 Blood Transfusion Policy
 Major Incident Plan
9. MONITORING COMPLIANCE
This document will be monitored to ensure it is effective and to assurance compliance.
Key Performance
Indicator
Lead
Responsible
for Audit
Evidence
Reviewed by /
Frequency
Lead Responsible
for any Required
Actions
100% compliance with the
requirements of patient
identification
Ward, clinical,
departmental
managers
Report of audit
of 10 patients in
each area
Patient Safety
Working Group
annually
Heads of Nursing
coordinated by Head
of Patient Safety

Duties are addressed through:
o Annual appraisals and personal development plans
o Annual review of attendance at key committees. Any required action will be taken by
the Chair of the committee, as set down in the standard Terms of Reference
Template.

The results of the bi-annual audit will be presented to the Patient Safety Working Group
together with any actions and implementation plans, identified as a result of the audits.

The CSC Governance Leads, as members of the Patient Safety Working Group, are
responsible for:
o
o
o
o

Cascading the results of the audits through the CSC structure: to ensure
organisational learning
Placing any identified risks onto CSC Risk Register and ensure the Risk Register is
discussed and monitored at the monthly Divisional Governance Committee meetings
Escalating any high level (16+) risks to the Risk Assurance Committee, for potential
transfer to the Trust Risk Register or Assurance Framework
Ensuring any adverse incidents or near misses are discussed at the monthly CSC
Governance Committee meetings, to foster a culture of learning including any required
changes in practice.
It is the responsibility of the CNST lead in the Women and Children Division to ensure the
results of the audits undertaken in that CSC are cascaded appropriately and any required
actions implemented
Patient Identification Policy. Issue 6. 21 August 2013 (Review date: February 2015 (unless legislation changes)
Page 15 of 20
Appendix 1
Patient Identification Policy Audit tool (adults)
Compliance Score
Patient ID Audit Item
1
2
3
4
5
6
7
8
9
10
11
12
Patient had an appropriate ID band in
place or approved form of alternative
identification as outlined in policy
The required information is present on
the ID band:
 SURNAME
 Forename
 DOB (DD:Mmm:YYYY)
 NHS Number
 Hospital/ED Number
There is one band only – either white or
red
The ID band is black writing on a white
background (except for allergy red band
as below)
The ID band is legible and easy to read
There is a record, in the patient records,
of when / where the ID band has been
applied
The entry of when / where the ID band
has been applied is signed
Patients wearing a red alert band have
the allergy/alert clearly documented on
the drug chart / in their records (N/A if
not applicable)
All inpatients have the ward name also
included on the ID band (N/A if not
applicable)
Staff caring for, or treating, the patient
and are responsible for issuing or
verifying the wristband/ patient ID have
read the Patient ID policy and are able
to demonstrate understanding
The patient has been informed that the
ID band should not be removed
The patient has been informed that they
must notify a member of staff if the ID
band is removed or damaged
Patient Identification Policy. Issue 4v2. 10.03.2010 (Review date: December 2012 (unless legislation changes)
12/02/2016
Page 16 of 20
(100%)
Appendix 2
Identification of the Newborn Infant
IDENTIFICATION OF THE NEWBORN INFANT
Introduction

Infant identification is crucial within all areas of Maternity Services to ensure and maintain infant
security. The parents need to be informed of the importance of labeling and their baby’s security.

All newborn infants must have two identification bracelets attached after birth.

All bracelets must contain the following information:



Infant’s first name or F/I or M/I if undecided.
Mother’s surname
Date and time of birth

The labels should be checked with the parents and with the mother’s own identity bracelet to
ensure the information is correct. This should be undertaken in the birthing room or theatre.

Parents should be informed of the security measures available in the locality and advised not to
leave their baby unattended.

The parents should be encouraged to check that their infant has two identification bracelets and
that the information is correct every time they handle him or her, or after a period of separation
Checking of identification during hospital stay
 On transfer to a different ward i.e. from labour ward to postnatal ward the identification labels
should be checked by the healthcare professional on the receiving ward.

Following a period of separation of the mother and her infant.

Infant identification bracelets should be checked to ensure present at daily midwifery checks.

Prior to transfer out of hospital.

Parents should be made aware that if an identification bracelet becomes unattached they
must inform a member of the ward staff immediately.
If one of the infant’s identification bracelets is missing
1. The information on the remaining identification bracelet must be checked with the mother using
her identification label.
2. If correct a second label can be reprinted and double-checked with the parents before being
attached to the infant.
3. The event should be recorded in the hand held notes.
If an infant is found with no identification bracelets
Patient Identification Policy. Issue 5v1. Nov 2012 (Review date: December 2014 (unless legislation changes)
12/02/2016
Page 17 of 20
1. The identification labels of all other infants on the ward must be checked and counted by two
midwives
2. After this check has been completed and all other infant labels are found to be present and
correct the infant can be re-labeled.
3. This event must be recorded in the infant section of the hand held notes.
4. The Maternity bleep holder must be informed.
An Adverse Incident reporting form must be completed immediately.
AUDIT
ASPECT OF
CARE/OUTCOMES
Two bracelets applied at birth
Has a bracelet been reapplied
at any time during the
postnatal stay in hospital
Have both bracelets been
reapplied
Was an Adverse event form
completed
Has the number of the
Adverse incident form been
recorded in the infants notes?
EXPECTED
STANDARD/
TARGET
100%
SOURCE OF DATA
COLLECTION
Health record
100%
Health record
100%
Health record
100%
Health record
100%
Health record
Appendix 3
Neonatal Identification Guideline
Patient Identification Policy. Issue 5v1. Nov 2012 (Review date: December 2014 (unless legislation changes)
12/02/2016
Page 18 of 20
1. Introduction
The National Patient Safety Agency (NPSA) has recognized 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 safe checking procedures is the foundation of all safe
patient identification practices. This guideline sets out the standards required for correct patient
identification with the aim of reducing and where possible, eliminating, the risk and
consequences of misidentification.
2. Purpose
The purpose of this guideline is to
 Ensure all babies on the Newborn Intensive Care Unit are clearly identified at all times.
 Ensure that all aspects of the management of patient identification within the NICU
complies with the latest recommendations from the NPSA, (Ref 2);
 Ensure the safety of all patients throughout their hospital stay;
 Provide clear standards and procedures for staff carrying out their duties involving
patient identification using identity bands.
3. Scope
This guideline applies to all health care professionals who are employed by Portsmouth
Hospitals NHS Trust, including temporary, bank or agency staff. There will be exceptional
circumstances where this policy may not be strictly adhered to, however this should only be in
individual cases and negotiated on each cases merit. Any deviation should be agreed with
senior staff only and clearly documented in patient notes.
4. Definitions

At delivery
All newborns must have two patient identification labels (wristbands) attached immediately
after birth. This should include:
 Identification of gender: male infant (M/I) / female infant (F/I)
 Mother’s surname, underlined and written in CAPITALS.
 Date and time of birth, with the year in full
For example:
Elizabeth BOOKMAN
F/I 30.JUL.2007 2100hrs


The label should be checked with the parents and with the mother’s identity label to ensure
correct. This should be done in the birthing room or theatre.
One finger should be able to be placed under the band to ensure correct fit.
Parents
Parents should be informed of the importance of labeling and security. They must be told to:


Check that their infant has two correct labels every time they handle him/her or after a period of
separation.
Inform a member of staff if either of the labels becomes detached
On admission to NICU



1 cot card – surname, first name, male/female, date & time of birth, type of delivery.
Patient identification board – Q number, name, consultant, family nurse, associate nurse and
nurse today.
When the baby’s NHS number is available the name bands should be renewed using the ICE
Patient Identification Policy. Issue 5v1. Nov 2012 (Review date: December 2014 (unless legislation changes)
12/02/2016
Page 19 of 20


system. The Q number, NHS number, NICU and Rank Identification e.g. Single (singleton),
Twin 1, Twin 2 Triplet 1, 2 or 3 should be added to the previous information when printing new
labels. These should be checked with parents or another member of staff using patient’s notes
before putting on the baby
One finger should be able to be placed under the band to ensure correct fit
If the baby is under 28 weeks or if there are concerns regarding skin integrity then name bands
may be placed on the hat and saturation probe. Once the skin is mature bands can be placed
in the usual manner.
Checking of identification during hospital stay.
 Infant identification bracelets should be checked checked each shift to ensure two wristbands
are in place with correct information recorded.
 On handover and during care the nurse should check and record two wristbands in place with
correct information present.
If one of the infant’s identification labels is missing.
 The information on the remaining wristband must be checked with the mother, , if still inpatient
using her ID band
 If correct a second wristband must be printed and checked with the parents or another member
of staff before being attached to infant.
 The event should be recorded in the health records.
If an infant is found with no identification labels.
 Two nurses must check the wristbands of all other infants on the NICU.
 After this check is completed and all other infant labels are found to be present and correct new
wristbands can be attached.
 The incident should be recorded in the infant care plan.
 Nurse in charge must be informed
 An adverse incident reporting form should be completed in accordance with Trust Policy5 and
the incident number recorded in patient notes.
5
Management of Adverse Incidents and Near Misses
Patient Identification Policy. Issue 5v1. Nov 2012 (Review date: December 2014 (unless legislation changes)
12/02/2016
Page 20 of 20