CLINICAL PROTOCOL FOR THE IDENTIFICATION OF SERVICE USERS RATIONALE All Professionals/healthcare workers are personally accountable for their practice and, in the exercise of their professional accountability, must always act in such a manner as to promote and safeguard the interests and well being of service users; and ensure that no action or omission on their part, or within their sphere of responsibility, is detrimental to the interests, condition or safety of service users. Throughout the healthcare industry, the failure to correctly identify patients/service users continues to result in medication errors, transfusion errors, testing errors and wrong person procedures. This document sets out the roles and responsibilities of the Trust for establishing standards to ensure the correct service user receives the appropriate treatment intended for them. The consequences of delivering treatment and care to the wrong service user may have serious consequences and it is therefore important that systems are in place which alert clinical and support staff to the proper identity of service users with whom they have contact. This document establishes the correct methods for service user identification to be used across all services provided by the Trust. TARGET GROUP The procedure applies to all staff who need to ascertain the identity of service users prior to the provision of care. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trust s Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. RELATED POLICIES Please refer to relevant Trust policies and procedures PRINCIPLES OF SERVICE USER IDENTIFICATION The verification of identity for all service users will be subject to the principles outlined within this protocol. On the rare occasions where doubt exists about the identity of any service user additional information will be collected by the practitioner before treatment proceeds. This may include checking specific identifiers i.e. date of birth, address etc. or 1 of 6
verifying identity with another practitioner of person known to the service user whilst maintaining confidentiality and discretion. The Trust owes a legal and statutory duty of care to service users in its care. The principles that apply are complex, but the organisation and the individual delivering treatment and care will be judged in the light of what was considered to be reasonable and acceptable. On this basis the Trust s primary concern must be for the safety, welfare and protection of the service user in the provision of their safe and effective treatment and care. The details within this protocol apply to all staff involved in the direct or indirect delivery of treatment and care to service users. It is important that the identity of all service users is established when they first contact and receive treatment and care within the Trust. Normally this process of identification is established when referral information is collected at each new care episode and service user records are prepared and forwarded to the appropriate team. This will include the service users name, address, date of birth and NHS number etc. The principles on which the proper identification at this initial point of contact and thereafter will include therefore: - All staff being alert to service user identification - Establishing robust and sufficient information to properly identify the service user - Confidence that the named service user receives safe and effective treatment agreed as part of their care plan - Ensuring that accurate information is entered into the appropriate service user record - Maintaining trust and integrity with service users - Standard operating procedures for verifying service user identification is in place - Monitoring mechanisms are established to update information ESTABLISHING IDENTITY OF COMMUNITY SERVICE USERS It is the primary responsibility of all healthcare workers to check the identity of service users and match the correct service user with the correct care, before care is administrated. Always check details are correct and check spelling of names. A minimum of three identifiers must be used to verify the service user s identity. These are: Service Users Name Service Users Date of birth Service Users address NHS number is to be used in addition to the above, always check with your service manager if you do not have access to NHS Numbers as some services have not yet got online access. 2 of 6
In some instances it will not be possible to identify a service user on admission due to the nature of their mental health state i.e. incoherent, acutely disturbed, deluded, hyperactive, confused etc. In such circumstances every effort must be made to identify the service user as soon as it is practical. All relevant information must be documented at point of contact. Service users should be encouraged to participate in decisions regarding their healthcare. This should include them having active participation in identification, being able to express concerns about safety and potential errors and to ask questions about the correctness of their care by confirming with the staff visiting the procedure they have come for/the staff visiting are to undertake. It should be documented within the service user s records that identification has been checked. Where a service user requires access to translating and interpreting services arrangements must be made to ensure that the identification process is followed. All service users should be asked to identify themselves prior to any diagnostic or therapeutic interventions. When asking service users or carers to verify identifying information to confirm that it is correct, be mindful and observe their rights to privacy and dignity. All containers used for collection of blood or other specimens should be labelled in the presence of the service user. This policy needs to be used in conjunction with the Trust s record keeping policy with all the relevant points adhered to. For all service users admitted to caseload in the community it will be the responsibility of the receiving team to ensure that appropriate information about the service user is collected to confirm their identity in accordance with this procedure. This must be part of the normal referral procedure where it may be the responsibility of the administration team to arrange for the service user s details to be collected. Once collected this will be recorded in the service user s health records. Clinical staff meetings with service users for the first time should introduce themselves and use their professional judgment to verify service user identity before proceeding as part of the engagement process, unless already known to them. On the rare occasion where there is doubt about the service user s identity, additional information will need to be collected by the practitioner to confirm their identity which is consistent with the presenting circumstances. In such cases confirmation of identity will be recorded in the service user s clinical notes prior to treatment commencing i.e. Additional information collected (identity confirmed). There will be instances where practitioners see service users for the first time i.e. clinical assessment. In such cases were both the service user and member of staff are unknown to each other it will be necessary for introductions to be made and a judgment made to verify service user identity before proceeding as part of the engagement process. Such details will be subject to recording in the service user s clinical notes (i.e. visited service user (identity confirmed) to where doubt exists about the identity of a service user in the provision of treatment i.e. administration of medicines, psychological therapies, psychosocial interventions etc. staff should withhold treatment until such time as the 3 of 6
service users identity is confirmed. All efforts should be made to confirm identity as soon as possible to prevent any delay in the provision of treatment except in life threatening situations when the best interests of the service user should be considered. ONGOING IDENTIFICATION OF SERVICE USERS For the purpose of this policy it will not be necessary to confirm the ongoing identity of service users once their identity has been established with the health care professionals who are providing treatment, except when non routine physical treatments are recommended. This includes for example the administration of medicines, taking blood or other samples for investigation etc. Where confirmation of identity is required a judgment to verify service user identity will be taken by practitioners before proceeding as part of the engagement process. i.e. comparing presenting information against the information known to the practitioner to confirm their identity. Any doubt about a service user s identity will result in further evidence being required before treatment can proceed. MISIDENTIFICATION OF SERVICE USERS Where a member of a team has misidentified a service user resulting in an incident (such as inappropriate treatment/therapy being administered and/or provided) it is expected that this will be reported using the Trust incident reporting system and the appropriate manager informed. A local investigation will result, including a review of the local standard operating procedures, and actions recommended to prevent further misidentification occurring. Members of staff are encouraged by the Trust to report any incident of misidentification where service users have been given inappropriate. Where staff conceal such incidents, which are later discovered, they will be subject to disciplinary action which may result in serious consequences to their continuing employment. In all cases where a service user s identity has been mistaken and inappropriate treatment given, they must be informed and examined by a doctor (preferably one familiar with the service user) immediately to ensure their continuing health and well being. Where the service user s health is deemed at risk they must be transferred to the nearest A&E department via the emergency 999 system. QUALITY MONITORING This will occur via the Trust s annual record keeping audit WERE TO GET ADVICE FROM Trust staff should contact their Line Manager if further advice is required. 4 of 6
INCIDENT REPORTING Clinical incidents or near misses must be reported using the Trust s incident reporting system. Serious cases of misidentification where there has been a deterioration in the health status of a service user resulting from the error would be monitored by the Quality, Patient Experience and Risk Group. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. EQUALITY ASSESSMENT During the development of this protocol the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed via the Trust s Incident Reporting system and an appropriate action plan put in place. REFERENCES Care Quality Commission (2010) Essential standards of quality and safety. 5 of 6
CONTROL RECORD Title Clinical Protocol for the Identification of Service Users Purpose To set out the roles and responsibilities of Trust staff for establishing standards to ensure the correct service user recieves the appropriate treatment intended for them. Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Caroline Hewitt Document Librarian QGS Groups consulted with :- Clinical Policies and Procedures Group Infection Control Approved N/A Date formally approved by Quality, Patient Experience and Risk Group June 2012 Method of distribution Email Intranet Archived Date 25 th June 2012 Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Quality and Governance Service N Updated version of previous policy 6 of 6