POLICY AND PROCEDURE Subject: Patient Identification and Wrist Bands POLICY NO.: PC_01 ORIGINAL DATE: SUPERSEDES: PAGE: 04/01/1998 12/2012 1 of 6 Key Words: Color Coded Alert, ID Applies to: Inpatient: Outpatient: Provider: All: X Video:. I. POLICY: All patients will be accurately identified prior to receiving any care, treatment or services consistently in all inpatient and outpatient settings. To establish guidelines to ensure patient safety and communicate specific health care information for appropriate intervention utilizing preprinted color coded alert wrist bands. II. DEFINITIONS: Restricted Limb - Identifies conditions that restrict the use of a certain extremity. A pink band on the affected extremity alerts staff to avoid using the limb for blood draws, IV insertions, and other medical procedures. Identifiers: The following two identifiers will be used to accurately identify all patients: a. Patient s name b. Patient s date of birth If the patient s date of birth is not available, the second identifier will become the patient s medical record number. Exception: Patients unable to provide identifying information experiencing conditions requiring emergency care will receive treatment prior to identification if such care and treatment is necessary to stabilize the patient s condition. An example is an unidentified patient arriving in an unconscious state to the Emergency Department. Outpatients Requiring ID Band: Outpatients including, but not limited to: Same Day Surgery, Cardiac Cath Lab, Endoscopy/Specialty Health, Invasive Radiology, Diagnostics receiving services on the day of registration, ie. lab, Imaging, Electrodiagnostic, emergency department. Exceptions to this are recurring patients (see definition below). Recurring Patients: A patient receiving services on a routine basis, requiring more than one outpatient visit is designated as recurring. Patient is registered as recurring and may present directly to the designated department, bypassing the registration process after the initial registration. This includes, but is not limited to: Lab, Imaging, Hyperbaric, Rehabilitation Outpatient Services, Cardiac Rehabilitation, Pulmonary Rehabilitation, Radiation Oncology, MEL Program (Health Promotion), any off-site location, and patients who present to an inpatient unit for services such as obstetric patients. Wristbands: 1
Specific healthcare information alert bands. Color Coded Alert Wristbands: White = PATIENT IDENTIFICATION Yellow=FALL RISK Green=LATEX ALLERGY Red= ALLERGY Purple= FULL DNR Lavender= MODIFIED DNR Blue = BLOODLESS MEDICINE Pink = RESTRICTED LIMB Non-hospital ( community ) wristbands: Social or other agency bands. III. A. PROCEDURE FOR IDENTIFICATION: Registrar 1. Compare patient s stated name and date of birth with a photo ID or other proof of identity. Confirm identifying information with documentation from physician s office, if available. 2. Scan patient s driver s license of photo ID to the electronic file, if available. 3. If verbal identification is not possible (ie. patient is confused or unable to communicate), verbal verification may be provided by a responsible party, ie. family or health care representative. Patients arriving by ambulance transport from nursing homes will be accompanied by a responsible party or nursing home employee who will verbally identify the patient if necessary, and will remain with patient until ID band is placed on patient. Registrar or Patient Care Provider 2 1. All inpatients and designated outpatients (see definition) will have an ID band placed BEFORE treatment is initiated. The ID band is placed on the extremity (preferably the arm) only after asking the patient (or responsible party) to look at the armband to verify that the name and date of birth on the band is correct. 2. If an extremity is not available, the ID band will be secured to the body in an area that is easily accessible. 3. EXCEPTION TO PLACEMENT OF ID BAND PRIOR TO TREATMENT: Patients unable to provide identifying information requiring emergency care to stabilize condition: As soon as possible, the patient will be assigned a hospital ID number (medical record number) and assigned an alias name, ie. John Doe, and will have an ID band created using this number until the patient is identified. (Reference GL-68 Trauma Patient Identification) Recurring patients (see definition) presenting directly to the designated department, bypassing the registration process. A recurring patient requiring services in a second department will have a ID band from the registration department placed prior to presenting to the 2nd department using the verification process in a
above. Patient Care Provider at Point of Care (Inpatient and Outpatient) 1. Upon arrival/transfer to a new unit, have the patient visually confirm the information on the ID band. If patient confirms accuracy, staff will then identify the patient using the two patient identifiers. If the patient confirms the information incorrect, contact the preceeding unit/department to identify the patient and place a new ID band 2. Prior to care, treatment, or procedure, the patient is to be identified by verifying the two identifiers (see definition). 3. Upon initial contact with the patient each day services are provided in the inpatient or outpatient setting, all care providers must complete a 3-point comparison: Stated name and date of birth Name and date of birth printed on ID band, if applicable Name and date of birth on appropriate care document, ie. Medication administration record, test requisition ** If verbal verification is not possible, (ie., patient is confused or unable to communicate), the name and date of birth on the ID band must be compared to the care document. 4. On subsequent encounters for treatment or service the same day, each care provider must verify that the following information is accurate: 5. Procedures include, but are not limited to: Administration of medication Transfusion of blood or blood components Obtaining blood or other specimens Performing a treatment Performing a diagnostic test Transporting a patient III. B. PROCEDURE FOR ARM BAND PLACEMENT/REMOVAL/REFUSAL: Registrar or Patient Care Provider 1. When patient s identity cannot be verified because the imprinted band is defective, illegible, or missing, no services will be performed until the patient ID band is properly replaced. 2. Defective, illegible, or missing bands shall be replaced immediately with a new band, utilizing the two patient identifiers (patient name & date of birth). 3. A Risk Control Report will be completed when a patient ID band is found to be missing, defective, incorrect, illegible, or patient refuses to wear band. 4. If a patient s ID band must be removed in the OR, a new band must be affixed to the patient on an unaffected limb immediately. 5. If a patient refuses to wear the ID band, they must have the ID band in their possession and present it to the department for testing/treatment/procedure. Photo ID or other identification is to be requested. If photo ID is not available, the patient or responsible party will verbalize the name and date of birth, and it 3
will be compared to the requisition and ID band. If the patient is a minor, the responsible party may verify the identity. 6. Refusal to wear the ID band is documented as follows: At Registration: Registrar will write Refused to Wear ID band on Consent to Hospital Care Form and complete a risk control report On Patient Care Unit: Nurse will document in Patient Care Record patient s refusal and complete a risk control report. 7. Discharged Patients: The ID band must be worn by the patient until he/she is discharged. In the event of death, the ID band shall remain on the patient s body until after the patient is removed from the hospital. III. C. PROCEDURE FOR COLOR CODED ARM BAND PLACEMENT: Registar Patient Care Providers 1. Every patient will be evaluated on admission or registration, and whenever the patient s condition changes to determine the need for placement or removal of an alert wrist band. 2. Alert wrist band instructions and purpose will be provided to patient and family members at the time of admission or registration and any time a wristband is needed. 3. In the event that any color-coded band or bands have to be removed for the treatment of the patient, the nurse will remove the wristbands, new wristbands will be made, risk reconfirmed and the wristbands placed on another extremity immediately by the nurse 4. Education will be provided to all healthcare providers, patients and their family on the patient safety risk correlated with refusing to wear the colored coded wristbands and the meaning of colored coded wristbands. Document as a nurses note in the EMR patient s refusal and submit a Risk Control Report. 5. Education will be provided to patient and family that Nonhospital (Community) wristband are not to be worn in the hospital setting and are to be removed or covered with tape upon admission. 6. The patient and family will be instructed to remove the color coded alert bands after they leave the hospital. III. D. PROCEDURE FOR PLACING ALLEGY BAND: Patient Care Provider When a patient confirms an allergy, the following steps should be implemented: 1. The allergy and reaction is documented under the allergy routine in the electronic medical record (EMR). 2. Ascertain patient's typical response to allergen 3. Write the specific allergens on the red wristband 4. Place wristband on patient. III. E. PROCECURE FOR PLACING BLOOD BANK ID: 4
Patient Care Provider With each Type and Screening &/or Type and Crossmatch, The Patient Care Provider will have the patient confirm the name and date of birth printed on the Blood Bank ID prior to placing on the patient s wrist. IV. REFERENCE: Hospitals must standardize patients wristband to reduce risk of wrong care. Retrieved March, 2013 http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1925228/ NPSA/2005/2011 Safer Practice Notice: Wristbands for hospital inpatient improves safety. Indiana Hospital Association. Retrieved March, 2013, http://www.ihaconnect.org/communications/wristbandtoolkit/educationaltools/default.aspx Newborn Security /Infant Identification Policy Nursing Blood/Blood Component Transfusion Policy Nursing Administration of Medication Policy General Latex Allergy Precaution Policy Risk for Fall and /or Entrapment Guidelines Policy Do not resuscitate (DNR) /withdrawal of artificial life support Policy V. DOCUMENT INFORMATION: A. Prepared by Dept. & Title Nursing Professional Development B. Review and Renewal Requirements This policy will be reviewed annually and as required by change of law, practice or standard. C. Review / Revision History Reviewed on: 12/98; 12/99; 12/00; 12/01; 11/02; 8/04; 11/04; 3/05; 8/05, 10/08, 1/09, 2/14, 1/15, 9/16, 10/2017, 2/2018 Revised on: 12/98; 11/02; 8/04; 3/05, 10/10, 12/12, 9/15 D. Approvals 1. This Policy has been reviewed and approved by the Department Director & Vice President(s) of the Service Group(s): Department Director Date Acute Care & Critical Care 3/2018 Vice President(s) Date CQO 3/2018 2. This Policy has been reviewed and/or approved by the following committee(s): Committee(s) Shared Governance Culture of Safety LPIC Date 3/2018 4/2018 4/2018 5
6 Medical Council 4/2018