TRUST POLICY AND PROCEDURES FOR PATIENT IDENTIFICATION

Transcription

1 TRUST POLICY AND PROCEDURES FOR PATIENT IDENTIFICATION Reference Number POL-RKM/2133/08 Version: 4 Status: Final Author: Sandra Mir Job Title: Patient Safety and Risk Manager Version / Amendment History Version Date Author Reason Oct 2008 G Ogden To meet NHSLA standards 2 Sept 2010 B Youson / G. Ogden Review & Update 3 August 2014 Sandra Mir Review & Update 4 Feb 2017 Sandra Mir Intended Recipients: All staff who come into contact with patients and all staff who deal with samples taken from patients. Training and Dissemination: Dissemination via Trust Intranet. To be read in conjunction with: Trust Blood Products Policy, Trust Theatre User Policy, Trust Intra Hospital Escort Policy, Trust Policy and Procedures for Incident Reporting, Serious Incident Management, Being Open And Duty Of Candour, Searching for Patients using the Personal Demographics Service (PDS) In consultation with and Date: Risk Committee, Patient Safety Group; Theatre User Group EIRA stage One Completed Stage Two Completed Procedural Documentation Review Group Assurance and Date Approving Body and Date Approved Yes N/A Yes November 2010 Patient Safety Committee Date of Issue December 2014 Review Date and Frequency January 2018 Contact for Review Executive Lead Signature Approving Executive Signature Head of Patient Safety Director Of Patient Experience And Chief Nurse Director Of Patient Experience And Chief Nurse Page 1 of 19

2 Nurse Contents Section Page 1 Introduction 3 2 Purpose and Outcomes 3 3 Definitions Used 3 4 Key Responsibilities/Duties Clinical Staff All Staff with Patient Contact Department and Directorate and Senior Managers Patient Safety Group Implementing the Policy and Procedures for Patient Identification Positive Patient Identification 5.2 Patient Identification Bands Patients who do not meet the criteria for an identification band Patients Who Cannot Identify Themselves Neonates Request Forms Specimen Collection STOP Moment Patients who Refuse a Wristband Misidentification 9 6 Monitoring Compliance and Effectiveness 10 7 References Appendices Appendix 1 Appendix 2 Patient Identification Procedure for the unknown, incapacitated Patient Newborn Security. Identification of the Neonate & Ensuring A Secure Environment For The Newborn Page 2 of 19

3 TRUST POLICY AND PROCEDURES FOR PATIENT IDENTIFICATION 1 Introduction Correct patient identification is an essential element of healthcare. It is fundamental in ensuring patients receive the correct assessment and subsequent interventions. 2 Purpose and Outcomes This policy supports the Trust in its commitment to ensuring the delivery of safe care for patients by implementing standard systems to identify patients correctly. The aim of the policy is to ensure positive identification of the patient at every stage of the care pathway, to include: The process for identifying all patients. The process for ongoing checks throughout the patient care episode. Procedure to be followed in cases where patient misidentification occurs. Process for monitoring compliance with the above. 3 Definitions Used Positive Patient Identification In Patient A means of identifying patients which involves the patient recounting their details and these being checked against relevant documentation (health records, request, treatment or consent card). An inpatient is a patient who is admitted to a hospital ward for a procedure e.g. surgery, or for treatment of an acute episode or illness requiring hospitalisation. Any day case patient who is may subsequently require an overnight stay is considered an inpatient. Patients in the Emergency Department who have been through Triage and are receiving treatment ALL inpatients must wear an ID wristband for identification purposes. Out- Patient Clinical Staff Interventional Procedures An outpatient is a patient who attends hospital for a clinic appointment under the care of a consultant or specialist nurse, or attends for a procedure or treatment to a department where it is unlikely they will need to be admitted to a ward. Staff who deliver direct patient care/intervention e.g. nurses, midwives, medical staff, HCAs, therapists. Specialist procedures which require written consent due to the associated risk. Page 3 of 19

4 4 Key Responsibilities/Duties 4.1 Clinical Staff Must ensure that patients meeting the criteria identified within this policy are wearing patient identification bands immediately prior to any departmental intervention. For patients who do not require an identification band - staff must ensure positive patient identification is maintained, and again at the point of handover of care, and repeated. 4.2 All Staff with Patient Contact Will apply positive patient identification and conduct the appropriate checks for the care/interventions they are undertaking. 4.3 Departments/Division/Business Unit and Senior Managers Will ensure compliance with the policy by including checks during patient safety walkabouts. Where deficits are identified local Action Plans will be developed to address them. 4.4 Patient Safety Committee Will receive twice yearly reports on compliance with the policy and agree actions to address deficits. 5 Implementing the Policy and Procedures for Patient Identification 5.1 Positive Patient Identification Positive Patient Identification (PPI) is a process which when followed will promote good patient identification practice and reduce the risk of misidentification from occurring. 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 pathway to maintain the patient s safety. PPI ensures the right patient gets the right diagnostic test, treatment, procedure or medication etc, first time every time. 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. This entails: Always asking the patient to tell you their full name, date of birth and address. This can then be checked against relevant documentation (health records, consent form, prescription chart, request slip, GS1 compliant wristband). Never read the patients details out and allowing them to passively agree. If a patient is unable to tell you their details refer to the identification band and if possible verify the information by asking family members or other clinical staff who know the patient. Page 4 of 19

5 Procedures requiring positive patient identification include: First contact (verbal confirmation of identity). Prior to consultation Attachment of identification band. Blood transfusion. Specimen collection. Administration of medicines including chemotherapy Interventional procedures whether in an inpatient or outpatient setting Invasive procedures. Radiological Interventions Transfer of patients between departments. Imaging procedures Any treatment which could result in the patient being unable to identify themselves This list is not exhaustive. Wording on checklists must encourage positive patient identification e.g. ask patient to state name, date of birth and or address. PPI will save time on repeated investigations incident reporting and investigation etc. 5.2 Positive Patient Identification for selecting Patients from the Personal Demographic Service (PDS) To be read in conjunction with the Lorenzo single source of Trust and Standard operating procedures. Whenever possible, patient demographic details including the NHS number, should be collected prior to treatment. If a patient is referred from a GP practice or another NHS organisation the patient should already have an NHS number. If the NHS number is not included in the referral, then it should be requested from the referrer. None NHS referrers should also be asked to provide the NHS number since they will be increasingly expected to use it as the unique identifier. The following patient details should be used for tracing and matching a patient on the PDS: NHS Number (whenever possible) Given name Family name Date of birth Page 5 of 19

6 Gender Postcode and/or address 5.3 Patient Identification Bands During 2010, the Trust has introduced patient identification via bar-coded wristbands in order to comply with NPSA Safer Practice Notice No. 24; with an implementation plan. In 2015, the information on the wristband and encoded in the barcode was updated to comply with GS1 standards. The process consists of 2 parts: i) Production of a bar-coded wristband using text information from either: Lorenzo Extension where users are required to be authenticated via a Smartcard and have the patient selected in Lorenzo The Windows Application which requires users to be authenticated on a Trust workstation and for their account to have access to Trust SQL Service PMI database ii) Ability to read the barcode back into Lorenzo system to verify the patient details using the NHS number as the primary key identifier Auto-identification and data capture system (AIDC) is described within Coding for Success (Department of Health, 2007) as the use of bar codes, radio frequency identification and other machine-readable codes to identify, quickly and accurately, an item or process. In terms of healthcare, barcodes have been used for some time to track and identify bloods and samples, to identify patients, and to identify, track and order inventory items. The following equipment is provided within the clinical areas: Wristband Printer - including power supply unit Label Printer - including battery and charger Page 10 of 19 The GS1 complaint bar-code identification band states: Forename (as stated on Lorenzo no abbreviations or pet names). Surname. Date of Birth. Hospital Number NHS number. A 2D GS1 compliant data matrix barcode A linear barcode containing hospital number In the event of Lorenzo downtime, the Windows Application method of printing should be used. In the event of a complete power and/or system failure, the clinical areas are to resort to the use of hand generated wristbands.

7 The information on the identification band must be taken from reliable documentation (health records) and confirmed with the patient using positive patient identification (Section 5.1 & 5.4). The hand generated identification band states: Forename (as stated on Lorenzo no abbreviations or pet names). Surname Date of Birth Hospital Number NHS number Page 10 of 19 The following patients must wear an identification band: Inpatients, Day case patients undergoing interventional procedures, Out patients receiving blood transfusion, Out patients who are unable to clearly identify themselves. Clinical staff or an appropriately trained receptionist who has first contact with the patient will ensure an identification band is attached on all the above patients on admission/attendance. In the case of patients within the Emergency Departments (Adult / Child) those undergoing assessment & investigation within Majors ; awaiting admission; and procedures requiring sedation in Minors ; will have an identification band generated. All patients must be asked if they are allergic to anything before they are admitted / treated. Patients with allergies will wear a red identification band (allergies includes latex and significant foods as well as medicines) and those without allergies will wear a white identification band. Patient identification bands are to be placed on the dominant arm (the side used by the patient for writing), unless this is a limb being operated on. This will reduce the likelihood of removal for cannulation. Any member of staff who removes a patient identification band is responsible for ensuring another is applied immediately. Should a member of clinical staff identify a patient without an identification band, they must assume responsibility for correct identification and labelling. If an identification band cannot be worn due to multiple access lines or skin integrity consider placement of the band on a lower limb, alternatively attach 2 or 3 bands together to attach to the upper arm. As a last resort the band can be attached to the patients clothing (but will require changing with clothing). If a patient refuses to wear an identity band, a clear explanation of the risks should take place and be documented in the health records. The patient identification band will be used in conjunction with positive patient identification to ensure that patients receive correct treatment/intervention.

8 Procedures requiring checks involving the patient identification band include: Blood transfusion. Specimen collection. Administration of medicines. Interventional procedures. Invasive procedures. Imaging procedures. This list is not exhaustive. o Patients who do not meet the criteria for an identification band. PPI must be adhered to at the point of handover from healthcare professional to another i.e. prior to patient s consultation and care delivery. A reflective pause moment should take place immediately prior to any departmental intervention. The pause will include rechecking the patient s identity and the intended intervention for that patient. The pause will be led by the healthcare professional responsible for the care / treatment / intervention delivery, and the patient must be involved in the checking process. o Patients Who Cannot Identify Themselves If a patient is unable to confirm their identification details, information will be taken from family members/carers. If the patient is unaccompanied, information will be taken from ambulance records until such times as it can be verified. For children details will be taken from the adult with parental responsibility, in partnership with the child where they have the mental capacity to be involved. For patients who are unable to confirm their identification details and there is no accompanying carer/information follow the flow chart in Appendix 1. o Neonates Neonates require two GS1 compliant identity bands identifying the mother s details in addition to those of the neonate (see Appendix 2). o Request Forms Staff completing paper request forms must always ensure addressograph labels are attached to each page and relate to the correct patient. For imaging procedures this check is confirmed on by initialling the label. For electronic requests staff must ensure that all the PPI checks are carried out prior to selecting the patient from the computer. Page 10 of 19 o Specimen Collection

9 Specimen containers must not be labelled in advance. Once the specimen is received in the container labelling should occur using both positive patient identification and reliable documents (request form and identification band). The minimum information required is the unique identifier (hospital number or NHS number), full name and Date of Birth. Blood Samples must be labelled at the patient s bedside using the patient s identification band Page 10 of 19 o STOP Moment (Theatres) / Pause Moment (Out-Patients) All invasive procedures require a STOP Moment in the operating theatre immediately prior to commencement of surgery the surgeon, anaesthetist, and the scrub practitioner must undertake a time out to verbally confirm the intended site, operation, side and identity of the patient checking this information against the patient s identification band, the operating list and the consent form/patient health records. The PAUSE moment is good practice for all interventional procedures, to be led by the healthcare professional responsible and the patient: rechecking the patient s identity the intended intervention for that patient This is good practice for all interventional procedures. o Patients Who Refuse to Wear a Wristband 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 given a patient wristband information leaflet, however they do have the right to refuse. An appropriate alternative should be discussed. This discussion and the reason for the patient not wearing an ID wristband MUST be documented in the patient s health record. o Misidentification If an error occurs e.g. there is a misidentification and / or the wrong patient receives treatment / investigations or consultation, staff must take immediate local action to remedy the error where possible and to minimise the risk of further harm. The patient s safety is the priority. It is important that staff involved in the occurrence are informed of the error as soon as possible. All errors including near miss incidents involving patient identification must be

10 reported on an incident report form, these include: Wrong addressograph labels in health records or attached to documentation. Wrong information on name band. No name band. Other patient s documentation within the health records. Misidentification of diagnostic images. Misidentification of investigation requests. Misidentification of appointments. Incorrect patient seen at consultation by a clinician Patient incorrectly assigned to another patients record Incorrect procedure or intervention performed must be reported as an internal incident escalated incident and escalated according to the Policy and Procedures for Incident Reporting, Serious Incident Management, Being Open and Duty of Candour The patient /carer or relative should be informed of the error where appropriate as soon as possible. 6. Monitoring Compliance and Effectiveness The key requirements will be monitored in a composite report presented on the Trusts Monitoring Report Template: Monitoring Requirement: Monitoring Method: The Trust can demonstrate compliance in relation to : Identifying the process for all patients Procedure to be followed in cases where misidentification occurs Compliance with wearing patient identification bands will be monitored through the medicines administration audits by the ward assurance audit and the Blood Component Audit via the National Comparative Audit of Blood Transfusions. Compliance with positive patient identification (PPI) will be monitored through the ANTT audits completed by the Infection Control team. Compliance with newborn identification (Appendix 2) is monitored through the Midwifery Supervisor Of Midwives Health Records Audit Incidence of misidentification of patients will be measured through the trend analysis of incident reports. Report Prepared by: Head of patient Safety Page 10 of 19

11 Monitoring Report presented to: Frequency of Report Patient Safety Committee Six Monthly Page 10 of 19

12 7 References NPSA (2004). Right patient right care NPSA Safer Practice Notice No.11 Wristbands for hospital in patients improves safety NPSA Safer Practice Notice No. 24 Essence of Care Department of Health (2007) Coding for Success NHSLA (April 2008) Risk Management Standards for Acute Trusts. Page 11 of 19

13 Appendix 1 Unknown incapacitated* patient admitted * patient has no capacity to provide information or limited capacity to provide information No Yes Full information ascertainable Examples: Companion/Carer knows full details Young child pt. knows full details Prepare & apply identification band with unique identifiers i.e First name Last name Date of Birth Hospital number Patient unaccompanied? Able to ascertain any reliable detail concerning patient identifiers ( i.e first name, last name and date of birth) from companion/carer and/or patient? Examples: No Unconscious, unaccompanied pt. Very confused, unaccompanied pt. Small unknown child accompanied by a carer eg. social worker, police officer. Prepare & apply identification band with following information as applicable: Unknown Male / Female or Unknown Male/ Female Child. Yes Yes Partially Examples: Carer knows only partial details. Child pt. can provide name but not date of birth. Prepare & apply identification with the reliable identifiers that are known substituting detail from box opposite where identifier unknown. i.e. Last name(if known) First name (if known) Date of birth (if known) Temporary Hospital Number* *Once complete information is known about the patient ensure original wristband is replaced with a wristband that contains all necessary detail i.e. First name, Last name, Date of Birth, & Hospital number. NB if blood or blood products have been requested do not change the identification band unless a fresh blood sample has been sent to blood bank with the new identification Page 12 of 19

14 NEWBORN SECURITY Appendix 2 IDENTIFICATION OF THE NEONATE & ENSURING A SECURE ENVIRONMENT FOR THE NEWBORN Contents Page 1 Introduction 13 2 Purpose and Outcomes 13 3 Abbreviations 13 4 Practical Aspects of Newborn identification at Birth At Birth Each baby band will contain The format for neonatal labelling 14 5 Hospital Number for baby 14 6 Transfer to ward 314 and NICU 15 7 Lost Identity Bands Should a neonate identity band become detached 15 8 Discharge Home 16 9 Follow-up appointments for the baby or further investigations Security Arrangements: Areas Where Newborns Receive Care Monitoring Compliance and Effectiveness References 18 Appendix A Process at Birth 19 Appendix B Postnatal Admission to Hospital 20 Page 13 of 19

15 1. Introduction It is imperative that neonates in hospital can be correctly matched to their in-patient mothers in the hospital setting. 2. Purpose and Outcomes Correct neonatal identification will avoid the occurrence of incorrect baby / mother matching and will ensure that babies are correctly identified prior to investigations and for efficient follow up of results. It is also an essential requirement in case of fire or other major disaster where patient evacuation may be necessary. 3. Abbreviations Lorenzo - Patient Administration Service NICU - Neonatal Intensive Care Unit HN - Hospital Number 4. Practical Aspects of Newborn identification at Birth 4.1 At Birth Before leaving the room following birth or prior to removal of the baby from the room, the midwife must attach 2 identity bands to the baby s ankles (one to each ankle). Appendix A. Confusion can arise when the baby is to be registered in a different surname to that of the mother. To ensure correct neonatal identification, continuity for future appointments, to avoid the baby being inadvertently entered onto Lorenzo twice, and to ensure accurate records for Child Health the following will be adhered to: 4.2 Each baby band will contain: The mothers first name and surname The mother s hospital number/nhs number. Baby s first name (if known) Baby s surname Gender Date and time of birth For multiple births, each baby must have 1 band attached to each ankle. In addition, twin 1 or 2, triplet 1, 2 or 3 should be added to each identity band. 4.3 The format for neonatal labelling is illustrated below: Mother s name: Jane Jones (HN: /NHS Number) Baby William Smith NHS number, (when available) HN :( must be added if admitted to NICU or if any investigations are ordered) Male DOB 5/2/06 at 02.30hrs, Page 14 of 19

16 The labels must be written using indelible black ink. A registered midwife and the mother must check all bands. If checking by the mother is not possible, e.g., Caesarean section with general anaesthesia, the band must be checked by 2 qualified members of staff prior to application. The baby s intended surname (if different from the mother s) will be documented on the Delivery sheet and the Birth Notification by Labour Ward staff. On the PAS system, the baby will be registered using the intended surname. For babies born very prematurely or those babies with fragile epidermis, two labels must be secured inside the incubator/cot. 5. Hospital number for the baby All babies require a hospital number as soon as practical after birth; the baby s details must be registered on Lorenzo by the receptionist and a number will be generated. If the baby is admitted to NICU or any investigations are requested a set of notes will also be generated for the baby. The baby s hospital number must be added to the name band when available. This is the responsibility of the named midwife or nurse caring for the baby. Labels on investigation request forms should show the baby s intended name and its own hospital number. In this way, the baby s details will match the PAS label on request cards. 6. Transfer to ward 314 and NICU On transfer to 314 / NICU the admitting midwife or nurse will check the identity bands. The bands will then be checked at each neonatal examination by the midwife / nurse and prior to the baby receiving any drugs, or investigations, e.g., x-rays, hearing tests, blood tests. If the baby has been transferred without a hospital number the baby s details must be registered on Lorenzo by the receptionists. This is the responsibility of shift coordinator Once the mother is no longer an in-patient, the identity bands of the baby can be changed to include the baby s details only including hospital number. Appendix B 7. Lost Identity Bands. As inpatients, identity bands must be checked on admission or transfer between area and prior to performing any investigations, invasive procedures or giving drugs. In addition, midwives will check that 2 bands are in-situ and that details are correct on a daily basis. Parents should be encouraged to inform a member of staff if bands become detached. 7.1 Should a neonate identity band become detached This must be replaced and again checked by a registered midwife and the mother against the delivery sheet details, (or by 2 trained staff when not possible). Page 15 of 19

17 Should both bands become detached: Ascertain whether mother and baby have ever been separated. Two members of staff must check the identity of all other babies in the ward or clinical area to ensure all babies are correctly labelled. Should 2 neonates have no ID bands within the clinical area seek advice from your line manager or the manager on-call. inform the midwife in charge of the shift; then what do we do to assure that we have the correct baby with the correct mother? Complete an Incident form on Datix web forward to your line manager. 8. Discharge Home. On discharge the neonatal ID bands must be left in situ, the parents should be advised that the community midwife will remove them on her first visit to the home. The check should be made with the mother and her hospital records to ensure the details match correctly prior to removal of the bands. This is the final failsafe to ensure that the correct baby is discharged home with the correct parents. Should a baby be going to foster care, please ensure that the social worker collecting the baby has the appropriate identification available before leaving the ward. 9. Follow-up appointments for the baby or further investigations These must be made in the name the child is to be known as. This will enable correct identification of the child for any follow-up at the Children s Hospital. This will also reduce the risk of children being registered twice on the PAS system. 10. Security Arrangements: Areas Where Newborns Receive Care 1. All entrances and exits are on a lock-down security system in Neonatal Intensive Care/Labour Ward/Ward Clinical staff in the maternity services have swipe card access and exit. All other staff are asked the purpose for their visit and must show valid Trust Identification prior to admittance. 3. Public access is monitored by a visual panel and requires all visitors to declare themselves to staff before being allowed entry. This is the same for exit. 4. In the Maternity Services, babies are not separated from their mothers at any time, unless admission to NICU is required. If newborn tests are required in another department, a parent is encouraged to accompany the baby. If this is not possible, a member of the Maternity Service staff will accompany the baby. 5. If a baby requires foster care, the Social Worker collecting the baby will need to bring suitable identification and authorisation for removal of the baby. 11. Monitoring Compliance and Effectiveness All cases where errors or security failures are identified will be reported and reviewed on an individual basis. 1. Any errors in baby identification are reported via Datix Web. Page 16 of 19

18 2. Spot checks to ensure that baby identification is correct during monthly patient safety audit are carried out by the Matron and the Head of Midwifery any irregularities will be escalated to the Clinical Facilitator for Maternity Services. Monitoring locally of correct identification and labelling will be carried out through the Midwifery Records audit by supervisors of midwives on a monthly basis, 3 monthly reports are submitted to the Supervisor of midwives group. The Supervisors of midwives group is responsible for the review of results and subsequent monitoring, development and implementation of action plans as necessary. Why SOMs? should this sit with Risk? 3. The security doors on the Labour Ward, NICU and the Post natal ward are checked by an external company every 6 months. Are they? The access system is checked every 3 months by another external company. Reports are monitored by the Trust Estates Team. I did not know this! The access is checked daily by the security staff. Any failure would result in a report to the security manager and a security officer being placed at the access doors until the problem was sorted. Thjs did not happen when we had an issue previously, not sure that security are aware of this arrangement Such failures will constitute a red potential future risk and will therefore require full investigation and escalation to the Trust Incident Review Group. 12. References National Patient Safety Agency. (2008). Identification of neonates: antenatal. NPSA. Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. (2007). Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London: RCOG Press. Page 17 of 19

19 Process At Birth Yes Antenatal admission to hospital Is the mother booked to deliver at this hospital? No Pos tnat al Ad mis sio n to Ho spit al Check mother s ID against her records and produce wristband Take mother s details Compile a set of medical records Check and apply wristband Produce, check and apply wristband Baby/Babies born Singleton Multiple Birth As soon as possible and before leaving the delivery suite produce TWO wristbands for each baby Midwife to ensure adequate number of umbilical cord clamps/ligatures to enable identification of babies at delivery: One cord clamp/ligature for Twin 1 or Triplet 1 Two cord clamps/ligatures for Twin 2 or Triplet 2 Three cord clamps/ligatures for Triplet 3 etc... Check wristband(s) before applying to the baby s/babies ankles. (Extra cord clamps, if applied, can then be removed). As soon as possible and before leaving the delivery suite produce TWO wristbands for each baby Page 18 of 19

20 Post-natal admission to hospital Yes Was the mother booked with this trust? No Check mother s and baby s/ babies ID against their records Take details of mother and baby/ babies. Compile a set of medical records for baby/babies (and mother if necessary) including the NHS number if known (or local hospital number until this is available) Yes Are both mother and baby being admitted? No Just baby/ babies Produce and check wristband for mother Apply to mother As soon as possible produce TWO wristbands for each baby As soon as possible produce TWO wristbands for each baby Check both wristbands and apply to baby s/babies ankles Check both wristbands and apply to baby s/ babies ankles Page 19 of 19