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Patient Identification Policy

Responsible Directorate:

Provider Services

Responsible Director:

Robert Flack

Date Approved:

8 August 2008


Governance Committee

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Version Control.

Document Title Document number Author Contributors Version Date of Production Review date Postholder responsible revision Primary Circulation List Web address Restrictions

Patient Identification Policy 1 Gwen Ruddlesdin Staff and Managers, Provider Services 2 June 2008 August 2009 for Head of Governance, Provider Services Provider Services staff

Standard for Better Health Map.



Core Standard Reference Performance Indicators

C1a 1. All clinical staff will be trained in patient identification procedures on induction 2. All adverse incidents resulting from patient identification errors 3. Outcome of annual auditing processes

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Section 1 2 3 4 5 6 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 7 7.1 8 9 10

Introduction Associated policies and procedures Aims and objectives Scope of policy Accountabilities and responsibilities Positive patient identification within in-patient settings Identification on admission Identification during admission Patients who refuse / do not wear armbands Information to be provided on name band Location of identity band Patients unable to wear a name band Removal of identification bands confidentiality Positive patient identification within community settings Identification of children Training needs analysis Monitoring compliance with this policy References

Appendices A Stakeholder Consultation B Equality impact statement

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Policy Statement.

Kirklees PCT Provider Services will have a systematic approach to the identification of patients receiving care from its staff. This will ensure that patient safety is maintained within the care environment.



This policy for the identification of patients fully supports recommendations from the National Patient Safety Agency (NPSA) and World Health Organisation Collaborating Centre for Patient Safety Solutions. It has been written for all staff within Kirklees PCT Provider Services as significant consequences could follow if an error is made. Between February 2006 and January 2007 the NPSA received 2,900 reports of patients being misidentified and subsequently receiving inappropriate treatment.

Associated Policies and Procedures.


This Policy / procedure should be read in accordance with the following PCT policies, procedures and guidance. • • •

Risk Management Policies Intravenous Therapy Policy Incident Reporting Policy

Aims and Objectives.


This policy has been written: •

To ensure patient safety at all times

To provide and ensure mechanisms to verify correct identification

To ensure a consistent approach to identification throughout Kirklees PCT Provider Services

To promote the use of patient identification procedures to reduce the risk of medicine and treatment errors

To ensure that, in all cases, the staff member providing care of any form is certain that the patient’s identity has been established beyond question.

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Scope of the Policy / Procedure

This policy must be followed by all Kirklees PCT Provider Services employees and staff on temporary or honorary contracts as well as bank staff and students. All staff must familiarise themselves with its content and adhere to the guidance given. Although the policy refers to ‘patient’ identification, it is intended to concern all users of the organisation’s services.


Accountabilities & Responsibilities

Managers in clinical area are responsible for ensuring and monitoring the implementation of this policy. All staff are responsible for ensuring that patients are identified using accurate personal details. The staff member entering the patient details on records or name bands is responsible for ensuring their accuracy. However, the use of name bands in a number of clinical areas does not remove the clinician’s responsibilities for checking patient identity prior to the administration of medication or treatment, in line with other Trust policies. This policy is intended to support the professional responsibilities of all clinically qualified staff.


Positive Patient Identification within in-patient settings

Positive patient identification is essential in all aspects of healthcare and must be adopted by staff as best practice. Staff must check, as a minimum, the patient’s name, date of birth and address. This should be achieved by open questioning that requires more than a ‘yes’ or ‘no response ie ‘What is your name?’ rather than ‘Are you Mrs Smith?’ If the patient is unable to state their name, any identity band generated must be checked by two members of staff with the health records available to ensure all details match. It may be necessary to use an interpreter or language line service. Where possible, the possession of a name band should not be the only confirmation of identity. Verbal identification given by the patient should always be checked against the information on the name band prior to any procedure, administration of any prescribed medication, instigation of an examination, investigation or treatment. Patients with the same or similar names can present additional risks. To reduce the risk of misidentification, additional confirmation of identity must be sought from the patient, relative and/or other healthcare professional by asking them for details of name, date of birth and address. Stickers alerting staff to the problem must be placed on the communication boards, medication charges and case notes. Where possible, these patients should not be nursed in the same bays and the patients themselves should also be alerted to the situation.

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Identification on admission

Patients should verify identification details on admission to the unit and these should be checked with those on their health records. If this is not appropriate, the carer/partner should provide and check them. Whenever a patient is transferred from an in-patient area, staff must positively identify them prior to the transfer taking place. This check must include the name band and any patient records and medication accompanying the patient. 6.2

Identification during admission

All patients’ identities should be checked before any treatment or medication is given. All patients within the ward environment should have identity name bands checked regularly (at least weekly) and replaced immediately if found to be faded, damaged, missing or unreadable. Any member of staff responsible for removing a name band is responsible for ensuring it is replaced immediately. 6.3

Patients who refuse / do not wear name bands

Some patients may refuse to wear a name band and it must be recognised that this is their right. However, the risks of this action must be explained fully to them and the discussion must be recorded in the patient’s healthcare records. Other staff must also be made aware of this and must take extra care when administering medication or treatment. 6.4

Information to be provided on the name band

Identification must include •

full name


date of birth

NHS number

Ward and hospital where being treated

Single capital letters should be used where possible to aid legibility. The surname must be underlined. Information must be written in waterproof ink. It is good practice for the patient to be informed why the wristband is important. Patients with increased risks eg known drug allergies will be provided with a red name band. When this system is used, it is essential that no other name band is worn at the same time. If a patient develops a drug allergy during their in-patient admission, their existing name band should be immediately replaced with a red one. 6.5

Location of identity band

The name band should be place on the patient’s wrist on their dominant arm. Where this is not practical, staff should use professional judgement to select the most appropriate location to secure the band. The name band should be attached comfortably but securely at all times.

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Nurses allocated the care of patients on a shift are responsible for ensuring that each patient has a name band. Any nurse finding a name band that is illegible, missing or incorrect is responsible for replacing it immediately. Any member of staff discovering a patient without a wristband must assume responsibility for identifying them and applying a name band immediately. Any healthcare professional who removes a name band (e.g. to perform a procedure) is responsible for ensuring another is applied immediately. If an error occurs in patient identification, senior clinical staff should be notified. It must also be reported through the Incident Reporting procedures. Any discrepancy between verbal identification provided by a patient and relatives and any written information should be dealt with appropriately so that the problem can be rectified prior to any treatment or intervention. 6.6

Patients unable to wear a wrist name band

Patients unable to wear a wristband for whatever reason must still be clearly identified. Appropriate risk assessments must be carried out to ensure the safety of the patient. It may be necessary to apply a wristband to clothing and reapply when the garment is changed. In the case of allergy, it may be necessary to apply the wristband carefully taped over a lightweight bandage. Any such change in name band location must be documented within the patient’s records immediately. The responsibility for correct identification remains with the staff caring for the patient at that time. 6.7

Removal of identification bands

Name bands must not be removed until discharge procedures have been completed. 6.8


Within in-patient areas, it is necessary to record some patients’ identification details on a board in an area visible to clinical staff. This is to ensure easy and safe identification and does not contravene the right to privacy and confidentiality. Such details must be placed away from public view and the patient’s forename and surname only should be listed.


Positive Patient Identification within Community Settings

Patients being treated within their own homes or other community settings are unlikely to be wearing an identity band. Healthcare professionals who treat patients in these settings must ensure that correct identification procedures are followed. On the first visit, identification details must be verified with the patient or, if this is not possible, with their carers/partners. This includes any healthcare records remaining in the patient’s home. The responsibility for ensuring that any treatment or medication is administered correctly lies with the health professional undertaking the procedure. 7.1

Identification of Children

The correct identification of children is extremely important. Any health professional working with children should ensure that full consent of the relevant parent/guardian

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has been obtained and that the correct child has been presented by checking name, date of birth and address. Parents should be encouraged to provide an up-to-date photograph of their child when regular or emergency medicine is to be given. This practice has been shown to improve care and reduce risk.


Training Needs Analysis.

Training on patient identification procedures should form part of all induction procedures carried out in clinical areas. The clinical manager in each area has responsibility for ensuring that this takes place and is noted within induction records and personal files.


Monitoring Compliance with this Policy / Procedure.

Local audit and review of the effectiveness of this policy will include: •

Annual update of the policy with amendments made, as necessary and cascaded to staff

Review of all safety incidents concerning patient identification issues

Audit of reasons why some patients have not worn name bands and the efficacy of alternative arrangements

Annual audit of number and percentage of patients wearing name bands within in-patient areas, including compliance with information requirements

These audits will be led by the manager within the area and the outcomes reviewed by the Provider Services Risk Group with monitoring of any remedial plans.



Mallet J and Dougherty L (2006) The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7th Edition, Oxford, Blackwell Sciences NPSA (2004) Right Patient Right Care, Framework for Action NPSA (2005) Safer Practice Notice 11: Wristbands for hospital in-patients NPSA (2007) Safer Practice Notice 24: Standardising wristbands improves patient safety Lincolnshire tPCT (2007) Policy for Patient Identification Northamptonshire tPCT (2007) Identification of Patients Policy Nursing and Midwifery Council (2006) Medicines Management Advice Sheet

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APPENDIX A Equality Impact Assessment. All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.� This obligation has been increased to include equality and human rights with regard to disability age and gender. The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. The Kirklees PCT Provider Services Patient Identification Policy has been written to enable staff to follow agreed standards when providing care for patients. This policy is intended to benefit patients, relatives and carers; general public; staff.

Equality Group Age

Positive Impact

No impact 9



Faith belief

Negative Impact





Sexual orientation


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Reasons for decision

Appendix B Stakeholder Consultation

Involvement and participation of others in the process of developing these guidelines as shown below: Stakeholders name and designation Catherine Smyth, Professional Development Nurse Julie Livesey, Head of Localities

Key participant

Feedback requested

Feedback accepted













Pam Lumb, Head of Therapies

Policy Development Group Sharon Brown, Lead Nurse, CaSH

Chair: Tina Quinn

Shirley Tabner, Clinical Lead, CaSH

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