Patient Identification Policy

In recognition of the problems related to patient identification within healthcare organisations, there are a number of national drivers that reinforce the importance of positively identifying patients prior to them having a procedure carried out. The drivers include:

• National Clinical Strategy 2018
• Realistic Medicine 2016 - 2019
• Scottish Patient Safety Programme
• NHSB Clinical Strategy 2018

NHS Borders Patient Identification Audit (data from Person Centred Coaching Tool – weekly audit, BGH and Community Hospitals only 2019), identified a number of issues including:

• patient not having / or refusing to have an identity bracelet in place
• information illegible
• patients being transferred between hospitals without an identity bracelet

Failure to ensure patients are positively identified can result in patients being mismatched to care and potentially have significant consequences when an error is made.

Clinical staff tend to underestimate the extent to which patient misidentification occurs. Data relating to patient misidentification is not routinely collected in NHS Scotland.

• The Senior Charge Nurse/Charge Nurse/Department Manager/Senior Clinician in every area must ensure that all staff are familiar with the Patient Identification Policy.
• The Senior Charge Nurse is responsible for ensuring all patients in their area are identified.
• In areas where identification bracelets are not used there must be local safety procedures in relation to patient identification in place.
• All staff must ensure that they undertake the steps required to guarantee patients are positively identified prior to carrying out any intervention with a patient.
• In areas where identity bracelets are in use they are an important method of validating a patient’s identity but do not eliminate the responsibility of individual staff to check a patient’s identity.

Adverse events and near misses must be reported on the Datix system as a matter of routine following NHS Borders Adverse Event Management Policy, including duty of candour September 2023

NHS Borders staff should

• never be complacent in respect of checking a patient’s identity
• not always rely on the patient correctly identifying himself/herself
• ask the patient to state his/her full name and date of birth if able to do so, prior to carrying out any procedure or intervention.
• take great care when using pre-printed patient identification labels
• check legibility and accuracy of identity bracelets
• not perform two tasks simultaneously that require individual patient identification to be checked e.g. filling out request forms for more than one patient at the same time
• always replace a patient’s bracelet if it has been removed or becomes illegible
• take extra care when updating a patient’s details where there are two patients in the same area with the same surname or same first name and surname, check for/add an alert to TrakCare and the health records.

There are four steps to identification of patients. They should be undertaken in the order below. If the first is not possible, the second should be undertaken and so on.

1. Ask the patient to tell you their name and date of birth. Check this is compatible with the patient identity bracelet.
2. If the patient is unable to tell you their name, refer to the identity bracelet and, if possible, verify the information on the bracelet by asking family, carer or another member of the clinical staff who knows the patient.
3. Ask patient’s relative to identify the patient by name, date of birth and/or address.
4. By means of the TB (Temporary Borders) a number will be generated in the Emergency Department.

1.1       All printed patient identity bracelets will contain core patient identifiers:

• CHI
• Date of Birth
• Surname
• Forename
• Patient address would be a further safeguard but is not a requirement and should not automatically be included.

1.2    Printed identity bracelets must be used in areas where they are available.

1.3    In any area where it is necessary for an identity bracelet to be hand written, it will contain core patient
         identifiers:

• CHI
• Surname
• Forename
• Date of Birth
• GP

1.4   It is recognised good practice for all staff to check the patient’s identity bracelet and ask the patient to            state their name and date of birth, where they is able to do so, prior to carrying out any
        assessment, procedure or other intervention.

Red alert bracelets have been used in NHS Borders from 1 July 2016. The purpose of the red alert identity bracelet is to prompt all staff to seek further information from the patient’s records about any known allergen. The absence of a red alert bracelet should not be used as certainty that the patient has no known allergies. Clinical staff (medical, nursing, allied health and pharmacy staff) should confirm allergy information regularly.

2.1       The admitting clinician (doctor and nurse/ midwife) must ascertain and record in the patient health
            records and on Trak whether the patient has ever had an allergy or an adverse reaction to anything.

2.2       After recording any allergy/adverse reaction identified by the patient, the clinician must ensure that a
            red alert identity bracelet is placed on the patient as soon as possible.

2.3       The red alert identity bracelet is placed on the patient’s wrist in addition to the regular patient
            identity bracelet.

2.4       Details of the allergy or adverse reaction must not be recorded on the red alert identity bracelet. All
            staff should refer to the patient’s health records to obtain details pertaining to the allergen.

2.5       Where red alert identity bracelet is removed for a procedure or treatment, the staff member
            responsible for removing the bracelet is responsible for replacing it following completion of the
            procedure or treatment.

2.6       Patients in Mental Health in-patient units will not routinely wear red alert identity bracelets, all
            patients in Mental Health in-patient units will have known present and past allergies documented and
            care planned for appropriately.

2.7       All Mental Health patients with known allergies will have a red alert identity bracelet put on when
            attending for Electroconvulsive Therapy ECT in the BGH.

Positive patient identification for BGH in-patients and Community Hospitals (this includes all day case patients) is the responsibility of all staff to ensure positive patient identification.

3.1    All patients admitted as an in-patient or day unit will have their identification confirmed at the point of           admission. Patient’s identity will be confirmed with the patient or if required the relative/carer.

3.2   An identity bracelet will be produced at the point of admission for all in-patients (includes day
        admission) and this will be worn by the patient for the duration of his or her stay in hospital.

3.3   Where possible, if able to do so, the patient will be requested to read the details on the identity bracelet          to verify the name and date of birth to be correct prior to it being put on.

3.4   The identity bracelet will be put on to the patient’s dominant arm (or an appropriate limb where this not
        possible)

3.5   When attaching the identity bracelet staff will emphasise to the patient the importance of wearing it and
        ask the patient to alert staff if it is removed and not replaced, falls off or becomes illegible.

3.6   A daily check at an appropriate time should be undertaken in respect of the presence and integrity of
        each patient’s identity bracelet.

3.7   If a member of staff finds details on the identity bracelet are difficult to read they are responsible for
        ensuring a new one is printed and the illegible one replaced immediately.

3.8   The information on the identity bracelet will be used to check patient identification prior to any
        procedure being undertaken e.g. administration of medication, intravenous fluids or any blood
        component. If the patient’s identity cannot be verified – no intervention should be undertaken, until
        further checks are completed.

3.9   Any member of staff on discovering a patient does not have an identity bracelet or removing an identity
        bracelet for any reason, e.g. procedural access to the wrist, will assume responsibility for correctly
        identifying the patient and replacing the bracelet.

3.10  If a member of staff has occasion to remove an identity bracelet for any reason, e.g. procedural access           to the wrist, it is their responsibility to ensure it is replaced as soon as possible.

3.11  Porters must ask a member of ward staff to identify the patient before removing the patient from the
         ward.

3.12  When an in-patient is attending another department within the hospital, except for where there is                   threat to life or limb, it is the responsibility of staff within that area to verify the patient’s identity,
         date of birth prior to carrying out any procedure or intervention.

3.13  There may be occasions when a patient may not wear an identity bracelet. These are when:

• • the patient has a dermatological or rheumatology condition resulting in the bracelet causing irritation to the skin
  • the patient is receiving medication that can cause the identity bracelet to react unfavourably with the skin
  • the patient lacks capacity to understand or is caused distress by having to wear an identity bracelet
  • The reason why the patient is unable to wear an identity bracelet must be recorded in their healthcare record.

3.14 Where a patient is unable to wear an identity bracelet an alternative form of identification must be used.

3.15 If a patient refuses to wear an identity bracelet a risk assessment will be undertaken and the patient or
       their supporting carer fully informed of the risks associated with choosing not to wear an identity
       wristband. The discussion must be recorded in the patient’s healthcare record.

4.1  Mental Health in-patient units need not use identity wristbands.

4.2  All patients admitted to in-patient and day units will have their identification confirmed at the point of             admission. The patient’s identity will be confirmed with the patient, carer, accompanying staff or                     admitting professional by the member of staff receiving the patient.

4.3  Care of the elderly in-patient wards and day units will maintain a nursing record in which is recorded the         patient’s name, date of birth, unit number and CHI.

4.4  All staff will be introduced to all patients in in-patient and day units.

4.5  New patients admitted to in-patient and day units will be introduced to all staff.

4.6  Mental Health patients attending for ECT must wear an identity bracelet. The bracelet will be put on the           patient’s dominant arm, or appropriate other limb where this is not possible, prior to the patient leaving         the Mental Health ward/unit and this will remain in place until the patient returns to the ward/unit.

4.7  Staff must verify the patient’s identification when administering medication or undertaking any other               intervention with the patient.

4.8 Staff visiting a Mental Health unit to undertake an assessment or intervention with a patient for the first          time will ask a member of the nursing staff to identify the patient.

Mother

5.1   Details on the identity bracelet must be confirmed and checked with the mother as per Procedure for              Checking Maternal Name Bands (appendix 1), prior to it being put on at point of admission.

5.2   An identity bracelet will be worn throughout the admission period.

5.3   Theatre cases must have two identity bracelets applied prior to transfer. They must be applied to                    separate limbs. In medical emergency situations e.g. cord prolapse, it may not be possible to apply a              second identity bracelet prior to transfer.

5.4   A mother’s identity will be confirmed by checking the identity wristband and confirming the patient’s              name and date of birth prior to any procedure being undertaken e.g. administration of medication or i            intravenous fluids.

Baby

5.5   Following delivery, during the initial baby check, two identity bracelets will be produced and attached to          each ankle as per Procedure for Checking Babies Name Bands in Labour Ward (appendix 2).

5.6    Baby identity bracelets will record:

• • boy or girl and mother’s surname
  • date of birth
  • time of birth

5.7   The details on the baby’s identity bracelet must be checked with the parent(s) or if this is not possible            two midwives will check/confirm the information on the identity bracelet is correct prior to them being            put on.

5.8   The baby will not leave the labour room/theatre without identity bracelet having been put on.

5.9   Identity bracelets will be checked by the labour midwife and the receiving midwife at the point the                  mother and baby transfer to the post-natal ward or Special Care Baby Unit as per the procedure for                Checking Babies Name Bands in Postnatal Ward (appendix 3)

5.10  At transfer if any discrepancies are found in the identity bracelet the midwife must ensure these are               rewritten and the details checked with the parents.

5.11  Prior to any procedure, with the mother’s consent, the baby’s identity bracelets will be checked in her             presence.

5.12  The baby’s identity bracelets will be checked daily by a midwife.

5.13  The baby’s identity bracelets will not be removed on discharge from the unit.

6.1  The nurse caring for the child/young person is responsible for producing an identity bracelet

6.2   Information to be included on the identity wristband is:

• Surname
• Forename
• Date of birth
• CHI
• Ward 15
• Allergies written on red alert identity bracelet or in red ink on white name band

6.3   Details on identity bracelets must be checked with parent or guardian of the child/young person. In                instances where the parent or guardian is not available, the identity bracelet will be checked by two                members of Ward 15 staff, one of whom must be a registered nurse.

6.4   A child/young person going to theatre will have a second identity bracelet containing the same                        information as the original, attached to a separate limb.

6.5   Should the child/young person be unable to wear an identity bracelet for any reason e.g. allergy, skin              infection, etc. The identity bracelet will be attached to the child’s clothing by the nursing staff on duty,            and the parents of guardian informed.

6.6   Any child/young person not wearing an identity bracelet will be identified at the twice daily safety                  briefing.

6.7   The child/young person will wear an identity bracelet until discharge.

6.8   Identity bracelet must be replaced if ill-fitting or illegible.

6.9   Identity bracelet will be checked by two registered nurses prior to the administration of any medication          or intravenous fluids.

7.1   On arrival at a department or the reception area, the patient will have their name, date of birth,                    address and appointment time confirmed.

7.2   Clinical staff must verify a patient’s identification prior to undertaking any procedure or intervention.              The patient’s personal and demographic details will be checked.

8.1       All patients arriving at the Emergency Department will have their identification established and                      confirmed. The patient’s identity will be confirmed with the patient, relative or carer or staff                          accompanying the patient.

8.2       On a patient’s arrival at Emergency Department an identity bracelet will be produced containing core              patient identifiers:

• • CHI
  • Date of Birth
  • Surname
  • Forename

8.3       Patients identified for admission will have an identity bracelet produced and put on the dominant arm             (or appropriate limb where this is not possible).

8.4       Unknown or unconscious patients will be given a TB and gender specified on arrival at the                              Emergency Department.

            This number and gender will be used until the patient’s true identification/gender identity can be                    established (this complies with current policy for an individual requiring a blood transfusion in this                  situation).

8.5       All patients treated in the Resuscitation Room will have an identity bracelet applied on arrival.

8.6       All patients requiring intravenous (IV) opiate medication in the Emergency Department will have an                identity bracelet applied prior to administration.

9.1      All patients must have two identity bracelets attached to separate limbs prior to arriving at theatre.                 This ensures that there is always at least one identity bracelet visible during surgery when the patient              is positioned and covered by surgical drapes.

9.2      Identity bracelets should not be attached to a limb which is to be operated on.

9.3      In an emergency situation if there is insufficient time to apply two bracelet positive patient                             identification must be made by alternative means. Suitable judgement of this is an expectation of                   individual professional codes of conduct.

9.4     Where the pre-operative checklist has not been completed by an anaesthetics nurse, the nurse                      completing this must check core details as per the identity bracelet and ask the patient to verify their            signature on the consent form, correct surgical site, allergy and fasting status, and any metal work                from previous surgery.

9.5      In an emergency situation where there is insufficient time to repeat the pre-operative check list                     positive patient identification may be made by verbal confirmation from the patient which can be                   checked against case notes/addressograph label

10.1     Staff visiting patients in their own home will, on first contact with the patient confirm their identity.               The patient’s identity will be confirmed with the patient, relative or carer prior to staff initiating any                treatment or intervention with the patient otherwise no procedure will be undertaken until                              clarification achieved.

10.2    Staff visiting a patient in a residential home, nursing home or other care establishment will on first                contact confirm the patient’s identity whenever possible with the patient and always verify the                        patient’s identity with a member of the care staff prior to undertaking any treatment or intervention              with the patient.

11.1    All deceased patients must have two identity bracelets attached.

11.2    In the event of a deceased patient from a ward arriving at the mortuary without an identity bracelet              in place, the nurse in charge of the ward from where the deceased patient came will be notified and a            member of ward staff will be dispensed from the ward to attach an identity bracelet.

11.3    When a viewing of a deceased patient is requested, the Anatomical Pathology Technician or deputy                 will  set up the body only after checking the identity bracelets.

11.4    The nurse accompanying relatives to view the deceased patient will be asked to verify the patient                   identity by checking the identity bracelet.

Misidentification of a patient may result in the wrong person being given a diagnosis, treatment, medication, blood transfusion, etc. This can potentially result in an adverse event with significant risk of harm. Any adverse event or near miss resulting from misidentification of a patient must be reported on the Datix incident reporting system, in compliance with the Adverse Event Management Policy.

Medical Director and Director of Nursing and Midwifery

Will  secure  agreement  on  assuring Positive patient identification and procedures required to ensure this.

General Manager / Associate Director of Nursing / Associate Medical Director

Will incorporate compliance and audit in relation to procedures for ensuring positive patient identification within objectives with the aim of eliminating the risk of adverse incidents resulting from mis-identification of patients.

Clinical Effectiveness Team

Will support audit of compliance with the policy.

Ward/Departmental Managers

Will ensure that all staff are familiar with the Patient Identification Policy and must supervise compliance and audit in relation to the policy.

All Staff

All staff must ensure that they undertake the steps required to guarantee patients are positively identified prior to carrying out any intervention with a patient.

Professional responsibilities

Professional Leads/Partnership Forum/Public Representatives

Disseminate the policy

Clinical Governance & Quality Department

Support compliance with the Policy and support audit of compliance

Clinical Executive

Agree and sign off the Policy

Senior Managers

Ensure the Policy is implemented in their area.

Supervise compliance with the Policy, organise audits comparing practice with the standard described in this Policy

Respond to audit results, take corrective action when required and ensure re-audit.

Clinicians

Ensure that their practice complies with this Policy.

Participate in regular audit and engage in training and development as necessary.

Review

The policy will be reviewed two years after issue or following any change in National Standards.

The results of clinical audits will be used to inform the review of the policy.

• The Maternal identity bracelet has forename, surname, DOB and CHI number on it, these are white printable ID bracelets that are printed from a printer linked to TRAK.
• The baby’s identity bracelet has name, mother surname (for security reasons) - Date and time of birth and type of delivery. 
• On the back of the baby’s identity bracelet is the mother’s CHI number. These are white Identity bracelets which are attached to the ankles of a baby, which currently are hand written.
• Identity bracelet are printed either prior to or once an admission is confirmed.
• The identity bracelet is checked with the mother before it is applied. If any errors occur another identity bracelet is printed.
• Theatre cases have two identity bracelets applied prior to transfer if time allows i.e. it is unlikely in some emergency situations that the second identity bracelet would be a priority.
• The identity bracelet is worn until discharge.
• The identity bracelet would be checked prior to administering medication, or intravenous fluids.

• Just after delivery, 2 identity bracelets are written by a midwife during the initial baby check.
• Information recorded on the identity bracelets
• Baby’s gender and mother’s surname
• Date of birth
• Time of birth
• The mother’s unit number is recorded on the back of the baby’s identity bracelets
• The identity bracelets are checked with the parent or parents. If this is not possible two midwives should check the identity bracelets are correct before they are applied to both of the baby’s ankles.
• Babies do not leave the Labour Room or Theatre without the identity bracelets having been applied.
• The identity bracelets are checked with another midwife when the mother and baby transfer to the Post Natal Ward or Special Care Baby Unit.

• The receiving midwife and the labour ward midwife check the identity bracelets on transfer to the postnatal ward. The postnatal notes are used for this check and it takes place in the mother’s presence in most circumstances.
• If any discrepancies arise the identity bracelets are rewritten and checked with the parent or parents by the midwives.
• Prior to any procedure, in the presence of the mother and with her consent, the baby’s identity bracelets are checked.
• The midwife’s daily baby check will include a bracelet check.
• The baby does not have the identity bracelets removed on discharge

If errors are found a clinical incident form is completed.