PATIENT IDENTIFICATION POLICY

PATIENT IDENTIFICATION POLICY DOCUMENT CONTROL: Version: 1 Ratified by: Clinical Effectiveness Committee Date ratified: 12 th January 2012 Name of originator/author: Clinical Policy Advisor Name of responsible Clinical Effectiveness Committee committee/individual: Date issued: 27 th January 2012 Review date: January 2015 Target Audience All staff in contact with patients/patient records

CONTENTS SECTION PAGE NO 1. INTRODUCTION 3 2. PURPOSE 3 3. SCOPE 3 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4 4.1 Board of Directors 4 4.2 Assistant Directors 4 4.3 Clinical Leads/Matrons 4 4.4 Clinical Staff 4 4.5 Medical Secretaries/Health Records Admin Staff 4 5. PROCEDURE/IMPLEMENTATION 5 5.1 Patient Identification 5 5.2 Mental Capacity Consideration 6 5.3 Identification Steps 6 5.4 Wristbands 7 5.5 Patient s who do not wear wristbands 7 5.6 Photographs 8 5.7 Community Services 8 5.8 Safety Incidents 6. TRAINING IMPLICATIONS 8 7 MONITORING ARRANGEMENTS 9 8. EQUALITY IMPACT ASSESSMENT SCREENING 9 8.1 Privacy, Dignity and Respect 9 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS 9 10. REFERENCES 10 11. APPENDICES 10 Appendix 1 Audit Form 11 Appendix 2- Flowchart for Patient Identification Process 12 Page 2 of 12

1. INTRODUCTION 1.1 The National Patient Safety Agency (NPSA) has recognised that patient misidentification is a widespread problem within healthcare organisations. Failure to correctly identify patients constitutes a significant risk to the organisation and poses a serious risk to patient safety. 1.2 Patient identification practice is intrinsically tied to verification practices. All health care providers must always verify that the person they are attending to is the one for whom the treatment is intended. 1.3 While the NPSA promotes the use of ID wristbands in Acute Hospital settings, their Safer Practice Notice 24 (2010) acknowledges that Mental Health In-patient services need not use patient wristbands, although if they are being used, they must comply with the NPSA standards. 1.4 In areas where wristbands are not worn the relevant Service Areas must have a photograph for validating a patient s identity. For those patients who are unable to provide their own details due to their current health or mental capacity a care plan must be written detailing the way of validating their identity. 1.5 In areas where wristbands are worn care must be taken when completing the information as significant consequences can occur if an error is made. The NPSA has issued guidance on the information required, which includes using the patients NHS Number. 2. PURPOSE The purpose of this policy is: To raise staff awareness of the importance of obtaining, recording and confirming the patient s identity at all times, both in hospital and community settings, and especially prior to any intervention or treatment, thus promoting patient safety. To provide direction to staff on a corporate and standardised approach to patient identification and the use of wristbands/photographs to promote patient safety. To promote compliance with the NPSA Guidelines on standardised wristbands. To enable the Trust to be compliant with the Care Quality Commission s Essential Standards of Quality and Safety, Outcome 4, Care and welfare of people who use our services. 3. SCOPE This policy is applicable to all staff who come into contact with patients and/or their records. Page 3 of 12

4. RESPONSIBILITIES, ACCOUNTABILITIES and DUTIES 4.1 Board of Directors It is the responsibility of the Board of Directors to have policies in place that meet any legislation, national and local requirements and promote best practice. 4.2 Assistant Directors Assistant Directors are responsible for the implementation of the policy within their specific areas 4.3 Clinical Leads/ Matrons Clinical Leads/Matrons are responsible for making staff aware of the policy and monitoring that it is adhered to, as outlined in Section 7. Reporting any failures to comply with the policy on the Trust s Safeguard Incident Reporting System (IR1) Investigating any failures to comply with the policy and taking corrective action to prevent recurrence Undertaking random checks on the use of /information on wristbands/photographs in their specific areas, using the audit form - Appendix 1 4.4 Clinical staff Clinical staff are responsible for adhering to this policy Obtaining/recording/checking the patient s details/identity. Checking the patients identity prior to administration of medicines or treatments Reporting any incidents involving patient misidentification Replacing any wristband that has been removed and checking that the information is valid and accurate For ensuring an up to date photograph is used as appropriate. 4.5 Medical Secretaries/Health Records Admin Staff It is the responsibility of staff that comes into contact with Health Records to ensure patient information is in the correct patient s record and that they adhere to the Trust s Healthcare Records Policy. If duplicate/multiple records are found, the person finding them must report this to the ICT Service Desk on 01302 798118 (electronic records) and the relevant Medical Secretaries/Health Records Admin staff for paper records. An IR1, Incident Report must be completed. Page 4 of 12

5. PROCEDURE/IMPLEMENTATION 5.1 Patient identification 5.1.1 Patient identification starts with the patient s first contact with the service and it is important that the correct details are obtained and recorded. Any inaccuracies or queries that are highlighted should be dealt with immediately or as soon as possible after they become known.see Appendix 2. 5.1.2 It is critical that staff acknowledge and accept that the management and monitoring of the patient identification is an ongoing process and not something that happens only on admission or an initial contact. 5.1.3 Healthcare professionals must not proceed with any treatment or intervention if the patient cannot be positively identified. 5.1.4 In areas where white boards are used for the location of patients these boards must not be used as a method for patient identification. White boards must be updated following any admission, transfer or discharge. 5.2 Mental Capacity Considerations In order to determine a patient s ability to identify themselves it is important that an assessment of their capacity to be able to do so is undertaken at both the point of admission and other key points during their episode of inpatient care. The Mental Capacity Act 2005 which came into force in October 2007 sets out the statutory framework for making decisions for people who lack capacity to make such decisions themselves. The Act establishes the overarching statutory principles governing these decisions, setting out who can make them and when. It also sets out the legal requirements for assessing whether or not a person lacks the capacity to make a decision. The MCA defines a person who lacks capacity as someone who is unable to make a decision for themselves because of an impairment or disturbance in the functioning of their mind or brain. It does not matter if the disturbance is permanent or temporary. A person lacks capacity if: they have an impairment or disturbance (for example a disability, condition or trauma or the effects of drugs or alcohol) that affects the way their brain or mind works, and that the impairment or disturbance means that they are unable to make a specific decision at the time it needs to be made A person is unable to make a decision if they cannot do one or more of the following: Understand the information given to them that is relevant to the decision Retain the information long enough to make the decision Use or weigh up the information as part of the decision making process Page 5 of 12

Communicate their decision. This could include speech, sign language or muscle movements such as blinking or the squeezing of a hand. Full Guidance on how people should be helped to make their own decisions is given in the Mental Capacity Act (2005) Code of Practice and staff are to refer to both this,and the Trust Mental Capacity Act policy. In the event that a patient who lacks capacity refuses to comply with either wearing a wrist band or having their photo taken staff are to refer to their local standard operating procedures for guidance. 5.3 Identification steps STEP 1- By asking the patient to tell you their name (first and surname), date of birth and address and check likeness against photograph (if used). (If an in-patient, check this is compatible with the patient ID wristband minus the address). Do not state their name, date of birth etc and then ask them to confirm or deny by a yes/no reply. STEP 2 -If a patient is unable to tell you their name verify the information by asking family relatives, carers, responsible adult or another member of the clinical staff who knows the patient-to identify the patient by name, date of birth and address. STEP 3- Extreme Emergencies- In extreme emergencies and possible life threatening situations clinical care may take priority over attaching an identity wristband to the patient in an in-patient setting. Where this has occurred, the accountable nurse responsible for patient care Must take appropriate steps to identify the patient using the hospital number. If an in-patient, once the surname, forename, date of birth and NHS Number are confirmed, a new identity wristband MUST be attached to the patient immediately. If a photograph is being used please ensure this is attached securely to the medicine card. Record in the patient s plan of care that identity has been confirmed and name of witness. The person in charge of a ward must make sure that staffs are introduced to new patients at the commencement of their shift or handover. When asking a staff member to undertake an activity they must confirm they know the identity of the patient. 5.4 Wristbands 5.4.1 The NPSA believe that it is safest only to use a white wristband with black text. 5.4.2 The information must be printed onto the wristband and be in indelible black ink. 5.4.3 It is good practice to site the wristband on the patient s dominant wrist, following their consent. It must be applied to be comfortable but ensure, as far as possible, it cannot be self removed. 5.4.4 The NPSA recommends that Trust s should use the specified core patient identifiers on wristbands. These are as follows: Page 6 of 12

Last Name First Name Date of Birth Patient s NHS Number The first and last name must be clearly differentiated by using lower case letters for first name (with upper case first letter) and UPPER Case for last name. They must be presented in the order of LAST Name, First Name. The date of birth must be DD Mmm-YYYY eg; 01-Jan-2011. The NHS number consists of 10 digits the first 9 digits constitute the identifier and the tenth is a check digit that ensures it s validity. Where possible, digits should be displayed 0 0 0 as this format aids accuracy and reduces the risk of transposing digits when information is taken from a screen. 5.4.5 Prior to the wristband being attached, the patient will be asked to read the details on the wristband to confirm that they are correct and if not advise on the corrections. 5.4.6 If a patient s first language is not English refer to the Trust s Policy for the provision of, access to and use of Interpreters. 5.5 Patients who do not wear wristbands Patients may not wear a wristband for several reasons: They may refuse to wear identity wristbands They may remove wristbands Wristbands cannot be worn due to skin irritation. If the patient is in an area where it is expected that they wear a wristband staff should explain the reasons why it is in their best interests to wear one. If they still refuse the reason why must be documented in their records. Any other agreed alternative method used to identify them should be care planned.. Staff must be extra vigilant and seek other means of positively identifying the patient before any treatment/procedure is given No procedure should be carried out unless the staff member is satisfied they are applying it to the intended individual. If more than one member of staff is seeing a patient, then each one of them is responsible for checking the identity of the patient. 5.6 Photographs In areas where patients do not wear wristbands, photographs should be used. Consent to take a photograph should be obtained from the patient. If they are unable to consent a decision must be made, by staff, in the patient s best interest. Page 7 of 12

The photograph must be a good likeness, and updated when necessary. Photographs will be securely attached to the Medicine card. Documents with photographs attached must be kept in a secure area, and at no time left unattended. Photographs will be destroyed when the patient is discharged. If a patient significantly changes their appearance then a new photograph must be taken and replace the old image. Only one photograph per patient shall be used and any other images destroyed and images removed from the camera. On Discharge the photographic image shall be destroyed. Where the local procedure is to have a photographic identification of the patient and they refuse to have one taken, this must be recorded in their specific health record and an agreed alternative method care planned. 5.7 Community Services Staff Check the patient s identity verbally by asking them to state their full name, date of birth and address. Check if they can tell you the purpose of the proposed care delivery. Where the patient is not able to confirm their identity due to their current health or mental capacity, confirm their identity with a known carer, person with parental authority ( if a child) or another member of clinical staff who knows the patient. 5.8 Safety Incidents Any patient safety incidents, including near misses relating to patients who have no wristband or one with incorrect information, must be reported via the Trust Safeguard Incident Reporting System (IR1). The Trust accepts that some services may, in exceptional circumstances, be required to provide immediate intervention or treatment to a patient who is not able to identify themselves due to their clinical condition, and no form of identification can be found on the individual concerned. In an emergency situation immediate actions required will take priority based on risk assessment of the patient s condition. 6. TRAINING IMPLICATIONS There are no specific training requirements. Staff will be made aware of the policy at local induction, team meetings and 1-1 meetings. When the policy is reviewed this will be publicised in the Trust s Weekly Bulletin. Page 8 of 12

7. MONITORING ARRANGEMENTS Area for Monitoring How Who by Reported to Frequency Compliance with the policy Number and percentage of patients wearing wristbands Accuracy of information on the wristbands IR1 Reports Matrons Assistant Director Observation Matrons Service Manager Observation Matrons Service Manager When incidents occur Random spot checks Random spot checksusing audit tool (Appendix 1) 8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). Indicate how this will be met No issues have been identified in relation to this policy. 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS Policy for Consent to Examination or Treatment Policy for provision of,access to and use of Interpreters for Service Users and Carers Mental Capacity Act (2005) Policy Page 9 of 12

10. REFERENCES NPSA (2004) Right Patient-Right Care www.npsa.nhs.uk National Patient Safety Agency (2007) Standardising wristbands improves patient safety. Safer www.npsa.nhs.uk Practice Notice No 24 July National Patient Safety Agency (2009) Risk to patient safety of not using the NHS Number as the National Identifier for all patients. NPSA Safer Practice www.npsa.nhs.uk National Patient Safety Agency (2009) Standardising wristbands improves patient safety: Guidance on implementing the Safer Practice Notice (SPN 24, July 2007) and the related information standard on core patient identifiers approved by the Information Standards Board for Health and Social Care in March 2009 www.npsa.nhs.uk Department of Constitutional Affairs (2007) Code of Practice Mental Capacity Act (2005) 11. APPENDICES Appendix 1 Audit Form Appendix 2 Flowchart for Patient Identification Process Appendix 3 Adult Inpatient Protocol for Patient Identification Page 10 of 12

Appendix 1 PATIENT IDENTIFICATION AUDIT FORM Audit Statement Managers in Clinical areas are required to schedule in an audit of compliance with this policy, 6 months after it s launch and subsequently review. Please note the percentage of in-patients wearing wrist bands within the in-patient area. Please note the percentage of name bands which comply with the standards outlined in this policy Audit the reasons why a patient is not wearing a wristband and state the efficacy of alternative arrangements Review staff awareness of the content of this policy as below: Please survey a minimum of 10 staff or if the team is less than 10 people survey the whole team. 1 2 3 4 5 6 7 8 9 10 Is the member of staff aware of the Patient Identification Policy? Can the member of staff list the minimum requirements for patient identification as described in the policy and appropriate to their area of work? Is the member of staff aware of the appropriate action to take if misidentification of a patient occurs? Where NO is recorded as an answer, the manager to note remedial action Page 11 of 12

FLOW CHART FOR PATIENT IDENTIFICATION PROCESS Appendix 2 All staff at every patient contact should verify the identification of the patient. This Policy therefore applies equally to the identification of a new service user or to a staff member who is meeting a known individual for the first time and at any subsequent patient contact. In following this process staff must be aware of any communication/ understanding difficulties which may arise through their own use of language, terminology, dialect, accents. Ask the person their name, Verification: Ask the carer/ friend/advocate or other staff member to verify NO address and date of birth information given Ask the person who they are expecting to see and what they expect from the contact Verification: Check that you have the correct referral information/cross reference to the First Name, Last Name, Date of Birth, Unique NHS Identification Number, address, visual observation of person against clinical information given NO Ascertain the Patients level of understanding regarding the treatment or intervention prior to commencing or administering Verification: Visual observation of person against available clinical information/ do you have the correct notes/do you have the correct clinic list/ visit schedule check date does the information correlate to your understanding and the Patient understanding, regarding the care, intervention and treatment? NO Proceed with treatment or intervention required Yes Verification: if necessary check against electronic record systems and or recheck with referral information prior to intervention should a discrepancy occur. If in doubt do not continue until identification is confirmed unless this is an emergency. In an emergency situation immediate actions required will take priority based on risk assessment of the patient condition Record any discrepancies regarding patient identification in the clinical Page 1 record of 12