PATIENT IDENTIFICATION POLICY

PATIENT IDENTIFICATION POLICY Document Author Written by: Deputy Chief Nurse & Interim Head of Clinical Services Date: April 2014 Policy Lead Director: Executive Director of Nursing and Workforce Authorised Signature Authorised by: Chief Executive Date: 20 May 2014 Effective Date: 20 May 2014 Review Date: 19 May 2017 Extension date: 19 August 2017 Extension date: 19 November 2017 Extension date: 19 February 2018 Extension date: 19 April 2018 Extension date: 19 May 2018 Extension date: 19 July 2018 Approved at: Policy Management Group Extensions at: Corporate Governance & Risk Sub-Committee Extensions at: Policy Management Sub- Committee Date Approved: 20 May 2014 Extension Approved: 9 May 2017 Extension Approved: 11 July 2017 Extension Approved: 14 Nov 2017 Extension Approved: 13 Feb 2018 Extension Approved: 10 Apr 2018 Extension Approved: 8 May 2018 Version 7.0 Page 1 of 29

DOCUMENT HISTORY (Procedural document version numbering convention will follow the following format. Whole numbers for approved versions, e.g. 1.0, 2.0, 3.0 etc. With decimals being used to represent the current working draft version, e.g. 1.1, 1.2, 1.3, 1.4 etc. For example, when writing a procedural document for the first time the initial draft will be version 0.1) Date of Issue Version No. Date Approved Director Responsible for Nature of Change Ratification/ Approval Change 29 Mar 12 6.0 Logo and Wording updated for new organisation Apr 14 6.1 Interim Head of Updated Clinical Services 02 May 14 6.1 Executive Director of Nursing and Workforce 20 May 14 7.0 20 May 14 Executive Director of Nursing and Workforce 9 May 17 7.0 Executive Director of Nursing and Workforce 11 July 17 7.0 Executive Director of Nursing and Workforce 14 Nov 17 7.0 Executive Director of Nursing and Workforce 13 Feb 18 7.0 Executive Director of Nursing and Workforce 10 Apr 18 7.0 Executive Director of Nursing and Workforce 8 May 18 7.0 Executive Director of Nursing and Workforce Subject to minor amendments Extension approved for three month Extension to review date approved for three months Extension to review date approved for three months Extension to review date approved for two months Extension to review date approved for one months Extension to review date approved for one month Ratified at Clinical Standards Group Approved at Policy Management Group Corporate Governance & Risk Sub- Committee Corporate Governance & Risk Sub- Committee Corporate Governance & Risk Sub- Committee Policy Management Sub- Committee Policy Management Sub- Committee Policy Management Sub- Committee N.B This Policy relates to the Isle of Wight NHS Trust hereafter referred to as the Trust. Version 7.0 Page 2 of 29

Contents Page 1. Executive Summary 4 2. Introduction 5 3. Scope 5 4. Purpose 5 5. Roles and Responsibilities 5 6. Policy detail / course of action 6 7. Consultation 8 8. Training 8 9. Dissemination Process 8 10. Equality Analysis 8 11. Review and Revision arrangements 8 12. Monitoring Compliance and Effectiveness 8 13. Links to Other Organisation Policies / Documents 9 14. References 9 15. Disclaimer 9 Appendices: A. Key Definitions 10 B. Flowchart Summarising Policy 11 C. Guidelines for Identification of the Newborn 12 D. Identification within Mental Health & Learning Disabilities Services 15 E. Identification within Community services 17 F. Identification of Children 18 G. Collection and labelling of blood samples for pre transfusion testing 20 H. Checklist for the development and approval of controlled 22 Documentation I Impact assessment forms on policy implementation (including 24 checklist) J Equality analysis and action plan 27 Version 7.0 Page 3 of 29

1. EXECUTIVE SUMMARY The policy is designed to ensure the correct procedure for checking a patient s identification in the general Acute, Community and Mental Health settings, to ensure the correct procedure, intervention and information is given to the intended patient. The policy is aimed at all professionals who work within Isle of Wight NHS Trust and who have the responsibility for checking a patients identification. Version 7.0 Page 4 of 29

2. INTRODUCTION 2.1 The policy is designed to ensure the correct procedure for checking a patient s identification in the general acute and community settings, to ensure the correct procedure, intervention and information is given to the intended patient. 3. SCOPE 3.1 This policy applies to ALL patients in general and community settings. Mental Health inpatient services need not use patient wristbands, although if wristbands are already being used they should comply with the NPSA/2007/24 recommendations. 3.2 Patients requiring an identity bracelet The following patients require an identity bracelet: All inpatients, day surgery and day case patients A&E attendees who cannot reliably identify themselves e.g. confused, unconscious A&E attendees where a decision to admit has been made Outpatient attendees who cannot reliably identify themselves e.g. confused, Any other patient who in the opinion of a healthcare professional requires an identity bracelet. All patients should be checked once a day by ward/unit staff and at the time of any transfers between wards or department, to ensure that they are wearing an identity bracelet and that the information on the bracelet is correct and legible. If the bracelet is absent, illegible or incorrect a correctly completed, legible bracelet must be applied as soon as possible. 3.3 In conjunction with this policy please see: Identification of Newborns Appendix C Identification within Mental Health & Learning Disabilities Appendix D Identification within Community Nursing and Intermediate Care Services Appendix E Identification of Children Appendix F Collection and labelling of blood samples for pre transfusion testing- Appendix G 4. PURPOSE 4.1 The purpose of this policy is to ensure that the planned and intended actions of clinical care, interventions and information intended for a patient are carried out on the correct patient. 4.2 This policy also incorporates the recommendations of the National Patient Safety Agency, Safer Practice Notice Ref: NPSA/2005/11 and NPSA/2007/24. 5. ROLES AND RESPONSIBILITIES All staff that have responsibility for direct patient care will ensure they follow the patient identification policy to ensure patients can be identified as per the relevant procedure for the clinical setting. Version 7.0 Page 5 of 29

6. POLICY DETAIL / COURSE OF ACTION 6.1 Electronic wristbands must be put on patients as soon as they are admitted and worn throughout their hospital stay. If a member of staff removes a wristband: It is their responsibility to make sure it is replaced. Make clear alternative arrangements for the patient s correct identification if it cannot be replaced immediately. (Hand written wrist band are only acceptable in the Outpatients Department) 6.2 The wristband should be put on the dominant arm that is the side used for writing, it is then less likely to be removed when, for example intravenous access lines are inserted. Also, for patients undergoing upper limb surgery, consider placing the band around the patient s ankle. 6.3 The patient should have a single identification electronic wristband that incorporates all essential information. 6.4 The electronic wristband is to be white and secured with a WHITE clasp, and printed from a designated electronic wristband printer that is located in the clinical area. The non electronic wrist bands used in outpatients department should be white unless patients has an allergy or is not able to receive blood or blood products this should be red. 6.5 Electronic wrist bands If the patient has known allergies or sensitivities, or patients do not want to receive blood or blood products then a RED clasp must be used to secure. 6.6 Wristbands do not remove clinicians responsibility for checking patients identity. They are an important way of validating identification particularly when a patient is unable to provide their own details. It is the responsibility of all health workers to check the patient s identity, via the wristband, before any procedure/action/treatment/specimen collection. 6.7 Any member of staff that discovers a patient does not have a wristband has to assume responsibility for correctly identifying them. To minimise risk, they should also ensure that the correct wristband is immediately placed on the patient. 6.8 If the electronic wristband printer malfunctions then the next nearest clinical area with a printer should be used to gain an electronic wristband for a patient, until the malfunction is repaired or the printer replaced. 6.9 PATIENTS OF KNOWN IDENTITY 6.10 The ONLY information detailed on the electronic wristband will be: First Name(s) Surname Date of Birth Gender IW Number (if the IW Number is not immediately available then a temporary number should be used until it is). NHS Number (when available) Barcode Hand written wrist bands should have the same information as above but without the barcode. Version 7.0 Page 6 of 29

6.11 It is recommended that a single identification wristband that incorporates all relevant information (as above) be used. 6.12 For elderly people who may be agitated and are likely to pick at their wristband, an ankle band in addition or instead of a wristband may be necessary. Further exceptions to use of a single identification wristband are detailed in Appendix B. 6.13 PATIENTS OF UNKNOWN IDENTITY 6.14 On admission, patients whose identity is unknown will be issued with a temporary Isle of Wight case note number. 6.15 This can be obtained by contacting the Patient Planning Team (out of hours 17.00 09.00 the Bed Manager is to be contacted) who will generate the number via PAS. 6.16 In the event of the PAS being off-line, a unique U number will be issued by the Accident and Emergency Department. 6.17 Once the patient s identity becomes known, any previous case note number issued must be Included on the patients wristband until any duplicate case notes and IW numbers are merged by the PAS team. 6.18 Until this occurs the first number issued MUST be used and when an IW number is available the wristband must be changed. 6.19 The PAS team will be responsible for informing Pathology and Diagnostic Imaging of changes to the patient s IW number when records are merged. 6.20 The IW number is the patient s unique identification and is to be used in all circumstances for patient identification. 6.21 PROCEDURE THROUGHOUT THE PATIENT S JOURNEY Prior to any diagnostic test, sample collection and review of results the patients wristband must be checked by the appropriate health worker to ensure the correct patients identity using the wristband and the request form, by asking the patient where the patient condition allows for verbal checking of name and date of birth. In outpatients details should be checked both verbally with the patients checking against the notes and request form. If it is the right patient but the wristband contains the wrong information then the procedure/diagnostic test should be withheld until the patient s identity has been correctly established and a new accurate wrist band secured to the patient. An incident form should be completed indicating a near miss episode. (Record on Datix) All specimens that are incorrectly/incompletely labelled will be discarded and the appropriate personnel informed, to repeat the specimen collection. An incident form should be completed to provide a record so that inadequate practice can be identified and additional training can be completed by the individual. (Record on Datix) 6.22 OUTCOME All departments/ward managers will determine the frequency of auditing the process to ensure that the policy is being adhered to and all patients can be identified. It is recommended that this activity should be carried out at least monthly. Results should be feedback through Directorate board meetings via Modern Matron report. Version 7.0 Page 7 of 29

7. CONSULTATION 7.1 This policy has been updated with all relevant clinical stakeholders and users of this policy and approved at the correct ratification groups. 8. TRAINING 8.1 This policy should be implemented and disseminated throughout the Trust immediately following ratification and will be published on the Trusts intranet site. Access to this document is open to all. 9. DISSEMINATION 9.1 When approved this document will be available on the Intranet and will be subject to document control procedures. Approved documents will be placed on the Intranet within 5 working days of date of approval once received by the Risk Management Team. 9.2 When submitted to the Risk Management Team for inclusion on the Intranet this document will have fully completed document details including version control. Keywords and description for the Intranet search engine will be supplied by the author at the time of submission. 9.3 Notification of new and revised documentation will be issued on the Front page of the Intranet, through e-bulletin, and on staff notice boards where appropriate. Any controlled documents noted at the Trust Executive Committee will be notified through the e-bulletin. 9.4 Staff using the Trust s intranet can access all procedural documents. It is the responsibility of managers to ensure that all staff are aware of where, and how, documents can be accessed within their areas of work. 9.5 It is the responsibility of each individual who prints a hard copy of any document to ensure that the printed hardcopy is the current version. Current versions are maintained on the Intranet. 10 EQUALITY ANALYSIS This procedure has undergone an equality analysis please refer to Appendix D. 11. REVIEW AND REVISION ARRANGEMENTS This policy will be reviewed every 3 years 12. MONITORING COMPLIANCE AND EFFECTIVENESS 12.1 The compliance of this policy is monitored monthly through the medicines administration audit undertaken by ward and department leaders. 12.2 Compliance of neonatal identity labels is monitored through daily checks and an ongoing audit process. Version 7.0 Page 8 of 29

13. LINKS TO OTHER ORGANISATION POLICIES/DOCUMENTS This policy relates and refers to the following policy and guideline documents, which are in place on the Isle of Wight. Transfusion of Blood and Blood Components policy Diagnostic Imaging: Procedures for Ionising Radiations Medical Exposures Ensure Correct Surgery Undertaken policy Photography of mental health Patients for identification purposes 14. REFERENCES Standardising Hospital Wrist Band NPSA Alert 2008 15. DISCLAIMER It is the responsibility of all staff to check the Trust intranet to ensure that the most recent version/issue of this document is being referenced Version 7.0 Page 9 of 29

Appendix A Gillick and Fraser Principles: KEY DEFINITIONS FOR DOCUMENTATION Gillick competency and Fraser guidelines refer to a legal case which looked specifically at whether doctors should be able to give contraceptive advice or treatment to under 16-year-olds without parental consent. But since then, they have been more widely used to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions. Version 7.0 Page 10 of 29

Appendix B Flowchart summarising Policy Admission: Does the patient need an identity bracelet as per criteria in section 3.2 of policy? NO: Patient does not require an identity bracelet YES: Patient requires an identity bracelet Before intervention, ask patient verbally to confirm their identity by asking them to state their name and date of birth. Compare with patients other documentation e.g. Medical notes, using a minimum of 2 of the following: name, date of birth, unique identification number. Explain the rationale for the identity bracelet to the patient Does the patient have an allergy? NO: Apply Electronic wrist band to dominant arm.- Outpatients white wrist band YES: Apply red clasp to Electronic wrist band Outpatients Red wrist band Does patient s condition remain unchanged? YES NO Before intervention, ask patient verbally to confirm their identity by asking them to state their name and date of birth. Check the patient s identity bracelet and compare with patient s other documentation e.g. medical notes, using a minimum of 2 of the following: name, date of birth, unique identification number. Version 7.0 Page 11 of 29

Appendix C GUIDELINES FOR IDENTIFICATION OF THE NEWBORN 1. PURPOSE OF THE DOCUMENT 1.1 These guidelines are prepared as one component of security on the Maternity Unit and outline the procedure for identification of the newborn within the Unit. 2. SCOPE OF DOCUMENT 2.1 All staff working on the Maternity Unit. 3. COURSE OF ACTION 3.1 Two hand written wristbands to be prepared by the midwife or under the midwife s supervision and attached to the baby in Labour Ward after the birth of the baby. 3.2 An electronic wristband must be prepared for the newborn within 12 hours of delivery. Sooner if the condition of mother and baby allows Data to include on both handwritten and electronic wristbands : Forename of baby if known (if forename unknown, on the electronic wristband it will print as ZZZ. If it is a set of twins the electronic wristbands will have ZZA on the first baby and on the second baby it will be ZZB) Mother s surname Date of birth Time of birth Gender Mother s IW number Newborn IW number [for electronic wristbands] 3.3 Once the electronic wristband is available it will be checked against the handwritten wristbands and will replace one of the handwritten bands. The one handwritten band that has been removed will be given to the mother. 3.4 Electronic / hand written wristbands to be checked by mother or partner and then applied to each ankle. Document in mother s notes that labels were checked, applied or changed before baby leaves the Labour Ward. 3.5 All babies being transferred in an incubator or on a resuscitaire to the NNICU should have the wristbands checked by mother or partner before leaving Labour Ward. 3.6 Prior to transfer ensure cot is labelled. Data to include: Mode of delivery Forename of baby or sex Mother s surname Date and time of birth Mother s IOW number Birth weight Version 7.0 Page 12 of 29

Ongoing checks Under no circumstances should mothers and babies be separated without the mother s consent / knowledge. Electronic wristbands to be checked on warding of mother and baby and on returning baby to mother if separated during the day or night. Daily checks of electronic wristbands to be made and documented on baby observation chart monitored as per daily check process Electronic wristbands to be checked prior to discharge and left in situ until baby leaves hospital premises. ALL MOTHERS SHOULD BE INSTRUCTED TO INFORM MIDWIFERY STAFF IMMEDIATELY IF LABELS ARE NOT INTACT / NOT IN SITU 4. BABIES READMITTED TO THE MATERNITY WARD 4.1 On admission two electronic wristbands to be made by midwife / under midwife s supervision Data to include: Forename of baby Mother s surname Date of birth Gender IW Number Mother s IW number [if thought appropriate] Barcode 4.2 Both electronic wristbands should be checked by mother or partner and applied to each ankle. 4.3 Cot heads must also be labelled with above data. 4.4 Documentation should be made of the electronic wristbands and identification of baby on baby observation chart or in mother s notes if baby is greater than 10 days of age. 4.5 Electronic wristbands should be checked daily and on returning baby to mother if separated during the day or night. They should be checked prior to discharge and left in situ until the baby leaves hospital premises hospital premises. 5. PROCEDURE WHEN LABELS ARE NOT IN SITU 5.1 RATIONALE To ensure consistent procedure when an infant is found not to have an electronic wristband on each ankle. There are three possibilities: Only one electronic wristband in place No electronic wristband in place More than one baby on the unit with no electronic wristband in place Version 7.0 Page 13 of 29

5.1.1 One Electronic wristband in place Mother is informed by the midwife that only one electronic wristband is in situ. Using baby s medical notes, a second electronic wristband must be written and checked by mother or partner prior to attachment. Details to be checked to ensure compatibility with other electronic wristband and cot head. Document that electronic wristband reapplied on baby s observation chart with date time and signature of midwife. 5.1.2 No Electronic wristbands in place Mother is informed by midwife that there are no electronic wristbands in place. All other babies on the unit must have their identification labels checked If all other babies electronic wristbands are correct two electronic wristbands must be printed (using the baby s medical notes), checked with mother or partner and applied to each ankle. Document that electronic wristbands have been re-applied on baby observation chart with date time and signature of midwife. Inform Supervisor of Midwives on call that an incident has occurred. An incident form must be completed. 5.1.3 Procedure if two or more babies are not labelled Mothers informed of situation by senior Midwife on duty. Senior Midwife on duty to inform Supervisor of Midwives on call. They will notify Clinical Governance Manager (out of hours this will be senior Manager on call). The Head of Clinical Services will be informed at the earliest opportunity. The Provider Quality Manager will counsel the parent(s) in the presence of the Supervisor of Midwives and Head of Clinical Services, as to the procedure to be followed. Parents wishes to be considered regarding care of the babies whilst investigations are being undertaken. Consultant Paediatrician on call to be informed by Provider Quality Manager. Subsequent procedure to be determined by Consultant Paediatrician. When agreement is reached both babies to be re-labelled in accordance with the identification of the newborn guideline. An incident form must be completed. Subsequent action will be determined by the outcome of an investigation chaired by Provider Quality Manager together with Supervisor of Midwives, Head of Clinical Services and hospital personnel representative. Links to other policies, documents, guidelines Guidelines for Newborn Security Transfusion of Blood and Blood Components policy Immediate Care of the Newborn Version 7.0 Page 14 of 29

Appendix D IDENTIFICATION WITHIN MENTAL HEALTH AND LEARNING DISABILITIES SERVICES 1. INTRODUCTION 1.1 The patients/clients cared for by staff within the Mental Health and Learning Disability Services Care Group receive this care in a wide variety of environments. The nature of the patient/client group makes it inappropriate to adopt systems commonly used in general hospital/ward-based environments. The principles of the majority of mental health and learning disability care are based around the development of a trusting nurse patient/client relationship. Therefore, it is this that forms the foundations for ensuring that the correct patient/client is identified when administering care (in particular, the administration of medication). 1.2 Given the wide range of skill mix, qualified staff/patient ratios and environments applicable within the Mental Health and Learning Disability Services Care Group, actual practices vary. They are summarised in outline form as follows: 2. LEARNING DISABILITY SERVICES 2.1 All clients using Learning Disability Services are known by staff, having been identified at commencement of care provision through a series of introductory visits to services or through regular home visits. Clients generally use services long term (for all or most of their lives). As a result, staff know clients very well and use this relationship as the basis for identification. If, for any reason, a member of staff is unsure of the identity of a client (e.g. if the staff member is new/temporary), they are required to establish this before any identity specific care is given. 3. MENTAL HEALTH INPATIENT SERVICES 3.1 At each of three nursing handovers that take place through the day, any patient that is not known to the nurse in charge of the shift is identified. The incoming nursing staff team are introduced to the patient before the previous shift goes off duty. A registered nurses always undertake medication administration. If the registered nurse has any doubt about the identification of a patient, this is established before proceeding with administration. If a patient cannot be clearly identified, medication is withheld until their identity is established. 4. COMMUNITY BASED MENTAL HEALTH TEAMS 4.1 The medication administered by Community Mental Health Nurses consists mainly of intramuscular injections of long acting (depot) anti-psychotics and potentially controlled drugs (IDAS). These are administered either in the patient s own home or at a clinic within a Community Mental Health Team base, or other premises such as a Health Clinic or GP Practice). Nursing staff administering depot injections or medication are either the patient s care co-ordinator or clinic coordinator. The process of awareness of the identity of a patient occurs when the nurse checks the persons name and their prescription sheet with them and in the case of controlled drugs, a nurse colleague. 4.2 There are separate protocols and guidance for staff in the delivering of TTO medications, home detoxification regimes and one off prescriptions prescribed in a crisis situation. Staff are required to ensure the persons identity matches the prescription through their personal knowledge of that person or through asking them to check their names with them. Version 7.0 Page 15 of 29

5. Electro-Convulsive Treatment (ECT) 5.1 Identification bands are used for all patients undergoing Electro-convulsive treatment. These are placed on the patient pre treatment so staff can ensure the right patient/right wristband. Identification is confirmed when the patient enters the clinic and all staff are aware of any concerns pre treatment. The identification wristband stays on the patient throught treatment and is removed by staff once they leave the clinic. No intervention shall be carried out on any patient unless the member of staff is satisfied that they are applying the intervention to the individual for whom it is intended. If it becomes apparent that misidentification of a patient has occurred then the untoward incident policy to be invoked Revised April 2014 Version 7.0 Page 16 of 29

Appendix E 1. INTRODUCTION IDENTIFICATION WITHIN COMMUNITY REHABILIATION TEAM AND INTERMEDIATE CARE SERVICES 1.1 The patients cared for by staff within the Community Rehabilitation Teams receive care in a wide variety of environments; patients own homes, residential care homes and clinics. The nature of the patient group makes it inappropriate to adopt systems commonly used in general hospital/ward-based environments. 1.2 Patients are known by staff, having been identified at commencement of care provision through a referral system. Community Rehabilitation Teams are required to ensure the person s identity matches the referral through their name, address, date of birth, also personal knowledge of that person and/or through asking them or their carer or other health or social care professional to confirm their identity. 1.3 Community Rehabilitation Teams administering medication will ensure correct identity following the Trusts Medicine Policy, by checking with the patient or their carer that the patient s name, address, date of birth and prescription chart correspond exactly. 1.4 No intervention will be carried out on any patient unless the member of staff is satisfied that they are applying the intervention to the individual for whom it is intended. Version 7.0 Page 17 of 29

Appendix F IDENTIFICATION OF CHILDREN 1. PURPOSE 1.1 The purpose of this document is to ensure that the planned and intended actions of clinical care, interventions and information intended for a child are carried out on the correct child. This policy was written with reference to the National Patient Safety Agency (NPSA) safer practice notice November 2005 2. SCOPE OF DOCUMNET 2.1 This policy applies to all children/adolescents admitted to the Children s Unit within St. Marys Hospital. 3. POLICY 3.1 At the point of admission, the admitting nurse will check with the parent/carer the child s name; date of birth and with the notes the recorded IW number. 3.2 The admitting nurse will then print an electronic wristband from the designated wristband printer within the clinical area. 3.3 The nurse will then recheck the child s name and date of birth with the parent/carer prior to attaching the electronic wristband to the child s wrist or ankle with a WHITE clasp, dependant on age. If the parent/carer is not available and the details may be checked with the child if the paediatric nurse assesses them to be Gillick competent (Frazer ruling). 3.4 The nurse will document date and time of attaching the identification band in the Integrated Care Pathway (ICP). 3.5 If the child has known allergies or sensitivities a RED clasp must be used to secure the electronic wristband. 3.6 The information detailed on the electronic wristband will be: First Name(s) Surname Date of Birth Gender NHS Number (when available) IW Number Barcode The Isle of Wight number is the patient s unique identification and is to be used in all circumstances for patient identification. 4. REMOVAL OF IDENTIFICATION BAND 4.1 Any member of staff that discovers a patient does not have an identification band has to assume responsibility for correctly identifying them (NPSA 2005), and ensuring a wristband is attached either to the patient or their cot / bed Version 7.0 Page 18 of 29

5. ALLERGY OR INTOLERANCE TO IDENTIFICATION BAND 5.1 Any child who cannot wear the identification bands because of allergies/skin conditions, or children who do not tolerate a wristband in place. 5.2 The nurse will: Tape the child s electronic wristband to their cot/bed/wheelchair so it is available to check with the parent/carer prior to administration of any treatment/care. The nurse will record in the care plan where the identification band is placed. Check the child s name and date of birth as well as the identification band with the parent/carer prior to any administration of treatment/care. 6. ADMINISTRATION OF TREATMENT TO TWINS/TRIPLETS 6.1 If twins/triplets are admitted the correct identification band is to be checked with the parent/carer before application and the child s details will be checked by two nurses as well as with the parent/carer prior to administration of treatment. An electronic wristband audit will be carried out on the Children s Unit a minimum of once a month to ensure that there is 100% compliance to this policy. 7. OUTCOME 7.1 All children will be issued with an accurate electronic wristband on admission to the Unit. 7.2 An audit will be carried out monthly on the Unit to ensure that the policy is adhered to and all children can be identified. References: www.npsa.nhs.uk/advice Wristbands for hospital inpatients safety. November 22 2005 Version 7.0 Page 19 of 29

Appendix G COLLECTION AND LABELLING OF BLOOD SAMPLES FOR PRE TRANSFUSION TESTING 1. The process of collecting and labelling a sample should be completed on one patient before commencing another. 2. The patient must be positively identified immediately prior to sample collection by the use of open questioning i.e. by asking the patient to state their full name and date of birth. Details must be checked / confirmed against patient s identification wristband (or by documentation in the outpatient setting only). Patients suffering from dementia or are unconscious or sedated and children must be identified by the information on their wristband. 3. Samples must be labelled immediately after blood collection, at the bedside, by the same person that took the sample. 4. Samples and request forms will need to be re-written if changes are made and key information is not readable ( alterations to the request form are allowed if minor), 5. Sample tubes must not be pre-labelled. 6. Addressograph labels MUST NOT be used on samples 7. Labels produced from the electronic blood tracking system by scanning the barcodes on the patient s wristband together with identification badge of the person obtaining the sample are acceptable. Staff identification barcodes MUST not be used by any other person than the person it was issued to 8. The minimal acceptable labelling requirements are: (a) Surname (b) Forename (for unnamed infants use MI or FI) (c) Date of Birth (d) IW number (NOT case note or NHS number), U Numbers will be issued by A&E and M Numbers will be issued by Maternity, in the event of a computer failure. E Numbers will be issued in the event of a Major Incident. (e) Signature of person taking the sample (f) Date of collection For emergency admissions of unknown patients, the minimal acceptable labelling requirements are: (a) Surname Unknown (b) Forename Female or male (c) Hospital No IW Number or Unique U or E Number (d) Signature of person taking the sample (e) Date of collection Version 7.0 Page 20 of 29

The Blood Transfusion Laboratory will not accept inadequately or inaccurately labelled samples. (See NHS Isle of Wight Primary Care Trust ) BLOOD ADMINISTRATION Checks MUST be performed at the bedside 1. Proper identification of blood or blood components and the recipient must be carried out. This should be by two people, one of whom must be a Medical Practitioner, or holding current registration of the UKCC Professional Register as a Registered Nurse (RGN) / Midwife (RM) / Sick Children s Nurse (RSCN), or Operating Department Practitioner / Assistant and will take responsibility for the checks and sign the Blood Transfusion Chart. 2. Positive Identification of the patient MUST be carried out before each unit is transfused as per the Trust The following checks MUST be performed at the bedside. (a) PID: Surname Forename(s) IW Hospital No. Date of Birth These must be checked where possible, by asking the patient to confirm their Full Name (i.e. Surname and Forenames). Date of Birth This MUST be checked and found to be identical with: Patient s wristband Blood Transfusion Chart Compatibility Label Patient s Medical Records. If there is any discrepancy it MUST be investigated before the transfusion is commenced. Version 7.0 Page 21 of 29

Appendix H CHECKLIST FOR THE DEVELOPMENT AND APPROVAL OF CONTROLLED DOCUMENTATION To be completed and attached to any document when submitted to the appropriate committee for consideration and approval. Title of document being reviewed: Y/N/ Comments Unsure 1. Title/Cover Is the title clear and unambiguous? Does the title make it clear whether the controlled document is a guideline, policy, protocol or standard? 2. Document Details and History Have all sections of the document detail/history been completed? 3. Development Process Is the development method described in brief? Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? 4. Review and Revision Arrangements Including Version Control Is the review date identified? Is the frequency of review identified? If so, is it acceptable? Are details of how the review will take place identified? Does the document identify where it will be held and how version control will be addressed? 5. Approval Does the document identify which committee/group will approve it? If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? 6. Consultation Do you have evidence of who has been consulted? 7. Table of Contents Has the table of contents been completed and checked? 8. Summary Points Have the summary points of the document been included? 9. Definition Is it clear whether the controlled document is a guideline, policy, protocol or standard? 10. Relevance Has the audience been identified and clearly stated? 11. Purpose Are the reasons for the development of the document stated? 12. Roles and Responsibilities Are the roles and responsibilities clearly identified? 13. Content Is the objective of the document clear? Version 7.0 Page 22 of 29

Title of document being reviewed: Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 14. Training Have training needs been identified and documented? 15. Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 16. Process to Monitor Compliance and Effectiveness Are there measurable standards or Key Performance Indicators (KPIs) to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance within the document? Is it clear who will see the results of the audit and where the action plan will be monitored? 17. Associated Documents Have all associated documents to the document been listed? 18. References Have all references that support the document been listed in full? 19. Glossary Has the need for a glossary been identified and included within the document? 20. Equality Analysis Has an Equality Analysis been completed and included with the document? 21. Archiving Have archiving arrangements for superseded documents been addressed? Has the process for retrieving archived versions of the document been identified and included within? 22. Format and Style Does the document follow the correct style and format of the Document Control Procedure? 23. Overall Responsibility for the Document Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation? Committee Approval Y/N/ Unsure Comments If the committee is happy to approve this document, please sign and date it and forward copies for inclusion on the Intranet. Name of Committee Print Name Date Signature of Chair Version 7.0 Page 23 of 29

Appendix I IMPACT ASSESSMENT ON DOCUMENT IMPLEMENTATION Summary of Impact Assessment (see next page for details) Document title Totals WTE Recurring Manpower Costs Business as normal Training Staff N/A Non Recurring Equipment & Provision of resources Cost picked up at ward /service level Budget Summary of Impact: Ni Impact Risk Management Issues: Benefits / Savings to the organisation: Patient safety Equality Impact Assessment Has this been appropriately carried out? YES Are there any reported equality issues? NO If YES please specify: Use additional sheets if necessary. Version 7.0 Page 24 of 29

IMPACT ASSESSMENT ON POLICY IMPLEMENTATION Please include all associated costs where an impact on implementing this policy has been considered. A checklist is included for guidance but is not comprehensive so please ensure you have thought through the impact on staffing, training and equipment carefully and that ALL aspects are covered. Manpower WTE Recurring Non-Recurring Operational running costs N/A Additional staffing required - by affected areas / departments: Undertaken on the job Totals: Staff Training Impact Recurring Non-Recurring Affected areas / departments e.g. 10 staff for 2 days Totals: Equipment and Provision of Resources Recurring * Non-Recurring * Accommodation / facilities needed Building alterations (extensions/new) IT Hardware / software / licences Medical equipment Stationery / publicity Travel costs Utilities e.g. telephones Process change Rolling replacement of equipment Equipment maintenance Marketing booklets/posters/handouts, etc Totals: Capital implications 5,000 with life expectancy of more than one year. Funding /costs checked & agreed by finance: Signature & date of financial accountant: Funding / costs have been agreed and are in place: Signature of appropriate Executive or Associate Director: Version 7.0 Page 25 of 29

Points to consider IMPACT ASSESSMENT ON DOCUMENT IMPLEMENTATION - CHECKLIST Have you considered the following areas / departments? o o o o o Have you spoken to finance / accountant for costing? Where will the funding come from to implement the policy? Are all service areas included? Ambulance Acute Mental Health Community Services, e.g. allied health professionals Public Health, Commissioning, Primary Care (general practice, dentistry, optometry), other partner services, e.g. Council, PBC Forum, etc. Departments / Facilities / Staffing Transport Estates o Building costs, Water, Telephones, Gas, Electricity, Lighting, Heating, Drainage, Building alterations e.g. disabled access, toilets etc Portering Health Records (clinical records) Caretakers Ward areas Pathology Pharmacy Infection Control Domestic Services Radiology A&E Risk Management Team / Information Officer responsible to ensure the policy meets the organisation approved format Human Resources IT Support Finance Rolling programme of equipment Health & safety/fire Training materials costs Impact upon capacity/activity/performance Version 7.0 Page 26 of 29

Appendix J Equality Analysis and Action Plan (This template should be used when assessing services, functions, policies, procedures, practices, projects and strategic documents) Step 1. Identify who is responsible for the equality analysis. Name: Shane moody Role: Interim HOCS Other people or agencies who will be involved in undertaking the equality analysis: Step 2. Establishing relevance to equality Show how this document or service change meets the aims of the Equality Act 2010? Equality Act General Duty Eliminates unlawful discrimination, harassment, victimization and any other conduct prohibited by the Act. Advance equality of opportunity between people who share a protected characteristic and people who do not share it Foster good relations between people who share a protected characteristic and people who do not share it. Step 3. Scope your equality analysis What is the purpose of this document or service change? Who will benefits? What are the expected outcomes? Why do we need this document or do we need to change the service? Relevance to Equality Act General Duties Applies to all relevant patient and service groups Applies to all relevant patient and service groups Scope To maintain patient safety at all times Patients Patients kept safe Relevance Protected Groups Staff Service Users Wider Community Age Gender Reassignment Race Sex and Sexual Orientation Religion or belief Disability Marriage and Civil Partnerships Human Rights Pregnancy and Maternity To ensure all staff follow the same procedure It is important that appropriate and relevant information is used about the different protected groups that will be affected by this document or service change. Information from your service users is in the majority of cases, the most valuable. Information sources are likely to vary depending on the nature of the document or service change. Version 7.0 Page 27 of 29

Listed below are some suggested sources of information that could be helpful: Results from the most recent service user or staff surveys. Regional or national surveys Analysis of complaints or enquiries Recommendations from an audit or inspection Local census data Information from protected groups or agencies. Information from engagement events. Step 4. Analyse your information. As yourself two simple questions: What will happen, or not happen, if we do things this way? What would happen in relation to equality and good relations? In identifying whether a proposed document or service changes discriminates unlawfully, consider the scope of discrimination set out in the Equality Act 2010, as well as direct and indirect discrimination, harassment, victimization and failure to make a reasonable adjustment. Findings of your analysis No major change Adjust your document or service change proposals Continue to implement the document or service change Stop and review Description Your analysis demonstrates that the proposal is robust and the evidence shows no potential for discrimination. This involves taking steps to remove barriers or to better advance equality outcomes. This might include introducing measures to mitigate the potential effect. Despite any adverse effect or missed opportunity to advance equality, provided you can satisfy yourself it does not unlawfully discriminate. Adverse effects that cannot be justified or mitigated against, you should consider stopping the proposal. You must stop and review if unlawful discrimination is identified Justification of your analysis No Change required 5. Next steps. 5.1 Monitoring and Review. Equality analysis is an ongoing process that does not end once the document has been published or the service change has been implemented. This does not mean repeating the equality analysis, but using the experience gained through implementation to check the findings and to make any necessary adjustments. Version 7.0 Page 28 of 29

Consider: How will you measure the effectiveness of this change When will the document or service change be reviewed? Who will be responsible for monitoring and review? What information will you need for monitoring? How will you engage with stakeholders, staff and service users 5.2 Approval and publication The Trust Executive Committee / Policy Management Group will be responsible for ensuring that all documents submitted for approval will have completed an equality analysis. Useful links: Under the specific duties of the Act, equality information published by the organisation should include evidence that equality analyses are being undertaken. These will be published on the organisations Equality, Diversity and Inclusion website. Equality and Human Rights Commission http://www.equalityhumanrights.com/advice-and-guidance/new-equality-act-guidance/equality-actguidance-downloads/ Version 7.0 Page 29 of 29