patient identification policy and procedure

Patient Identification Policy and Procedure

Copyright © Ahsa Cluster. All Rights Reserved.

No part of this work may be reproduced or transmitted in any form or by any means without prior written

permission of CEO

Document Information

Item Description

Document Title Patient Identification

Reference Number

Owner Corporate Excellence

Classification ○ Public ⦿ Internal ○Confidential ○ Strictly Confidential

○

Classified

Version Control

Version Issue Date Revision Date Effective Date Review Due

0.1 23/08/2021 3 years

Change Description Author(s) Record Retention

First Draft 4 years

Attachments

Name Author(s) Date

Organizational Reporting Line

Remark

Section Unit Department General Department


Issue Date Revision Date: Effective Date: Review Due:

Version Reference Number: Number of Pages: Approved by:

E2-Health Cluster of 21

Table of Contents

I. Internal Controls .............................................................................. 3

1. Governance ................................................................................. 3

2. Enforcement ................................................................................ 3

3. Employee Responsibility .................................................................. 3

4. Approval ........................................................ .خطأ! الإشارة المرجعية غير معرّفة

II. Introduction ................................................................................... 5

III. Terms and Definitions ..................................................................... 5

IV. Policy ........................................................................................ 6

1. General Guidelines ........................................................................ 6

2. Policy Section ................................................. .خطأ! الإشارة المرجعية غير معرّفة

3. Policy Section .............................................................................. 6

4. Policy Section ................................................. !الإشارة المرجعية غير معرّفة.خطأ

5. Policy Section ................................................. .خطأ! الإشارة المرجعية غير معرّفة

V. Process ............................................................ .خطأ! الإشارة المرجعية غير معرّفة

1. General Guidelines ........................................... .خطأ! الإشارة المرجعية غير معرّفة

2. Process Overview – (Process Name) ........................ .خطأ! الإشارة المرجعية غير معرّفة

3. Process Flowchart ............................................ .خطأ! الإشارة المرجعية غير معرّفة

4. Process Description ........................................... .خطأ! الإشارة المرجعية غير معرّفة

VI. References ...................................................................................11





I. Internal Controls

Governance

All policies in this document and the associated processes are owned by Al-Ahsa Health Cluster. In this

context, governance means that the quality and patient safety department is responsible for drafting,

periodically reviewing and updating the policies.

This policy must be reviewed and updated every two years to ensure that existing policies are amended and

that new required policies are introduced.

The department ensures that Al-Ahsa Health Cluster abides with all legal-related (i.e. Saudi law, Royal

Decrees, Council of Minister’s resolutions, Executive regulations) including but not limited to the following:

• Saudi Central Board for Accreditation Of Healthcare Institutions (CBAHI) – policies regarding the

Hospitals and/or PHC accreditation standards

• <references to be added per subject area>

It is the responsibility of the Corporate Excellence to study the impact of policy changes in coordination

with Legal and GRC and to issue a new version accordingly.

Enforcement

The Patient Identification manual is considered effective as of <date>

The Corporate Excellence will be implementing the manual once approved.

To ensure Management's confidence in Al-Ahsa Health Cluster policies and processes, Al-Ahsa Health

Cluster’s Internal Audit shall verify without notice, compliance with this Patient Identification Manual.

Employee Responsibility

The Manual has been developed to cater to requirements of all key stakeholders. It has been reviewed and

approved by all business and support stakeholders.

All concerned Al-Ahsa Health Cluster employees are required to observe this Manual.





Approval

Policy updates are only effective upon receipt of the revised policies document as approved by the Board.

This Manual and any amendments made thereto require the following approvals:

This manual has been prepared by Corporate Excellence, reviewed by Strategy and TMO, endorsed by the HQ Executive Council and approved by the Board of Directors. This manual

complies with the requirements and is ready for release

Prepared by: Date:

Reviewed by: Date:

Endorsed by: Date:

Approved by: Date:

Stamp of Approval:





II. Introduction

This document details Patient Identification policies and procedures to be followed by Al-Ahsa Health

Cluster when covering all necessary activities to satisfy internal needs including all patients receiving

treatment, or services at healthcare facilities. This policy applies to all staff involved in patient

identification including permanent, visitor (locum staff), and resident.

Its aims to:

Patient identification is a vital component in maintaining patient safety. Therefore, correct patient

identification and application of patient wristbands is an essential part of the care process. The purpose of

this document is to ensure the accurate identification of patients, by providing guidance to minimize the

risk of patient harm as a result of misidentification.

III. Terms and Definitions

1. CEO: Chief Executive Officer

2. The Cluster: Ahsa Cluster

3. Facility(ies): Hospitals reporting the Ahsa Cluster

4. Care: a family member or paid helper who regularly looks after a child or a sick, elderly, or disabled

person.

5. ID Band - Wristband: The name given to the encircling, semi-permanent strip(s) provided to all

inpatients (other) and worn on the wrist (or ankle) for identification purposes.

6. Guardian: A person who has the authority and responsibility to make decisions concerning the personal

and physical care of the person with the disability, including health care decisions and living

arrangements.

7. Patient’s Full Name: Refers to the patient’s name to the fourth (4th) level. (The hospital will utilize

all efforts to get the name to fourth level). (eg. Ahmad mohammed Saeed Al Hamad). This definition

applies to all patients excluding new-borns/neonates.





8. Two Unique Patient Identifiers: Refers to ministry of health MOH patient identification process using

two different ways to identify a patient (patient’s full name (to the 4th level) and medical record

number.

IV. Policy

General Guidelines

1.1. All patients must be correctly identified and matched to their records,

investigation and procedure requests, prescriptions, results and all other

documentation. whilst being assessed or undergoing procedures / treatments

within healthcare facilities.

1.2. All inpatients and certain other patients mentioned in this policy MUST wear at

least one ID band for safety purpose.

1.3. The management and monitoring of Patient Identification is an ongoing process

and not something that happens only on admission.

1.4. The patient room and bed number must never be used for identifying a patient.

1.5. The use of wristbands does not remove the individual clinician’s responsibility

for checking patient identity before administering medication or treatment, in

line with existing policies including Policy for Consent, Policy for Blood

Transfusion and Policy for the Administration of Medicine.

Roles and responsibilities:

All healthcare staff who are involved in any aspect of a patient’s care should receive

education in the application of this policy and procedure. It is the responsibility of

all healthcare staff (clinical and non-clinical) who are involved in any aspect of care

to abide to this policy within the scope of their work practice. The policy and

procedure should be available in all care settings where the proper patient

identification is applicable.





This Policy and Procedure for correct patient identification may be adapted for local

implementation but must contain the critical safety steps as outlined within this

document.

Procedure:

3.1. Correct patient identification starts with the patient’s first contact with the

service and it is the responsibility of all staff involved in the admission process,

both clinical and administrative to ensure correct details are obtained and

recorded and that any inaccuracies or queries are highlighted and resolved.

3.2. All patients must be able to be identified at all times whilst being assessed or

undergoing procedures / treatments within the organisation. Therefore, all

hospital inpatients must wear an accurate and valid identity bracelet (referred

to as wristbands in this policy), and in some cases more than one will be worn

with similar information.

3.3. As a minimum staff must check the patient’s:

3.3.1. Patient’s Full Name.

3.3.2. Date of birth.

3.3.3. Address.

3.3.4. Medical record Number.

3.3.5. Next of kin.

3.4. Staff should always use open questions to establish a patient’s identity, i.e.

“What is your name?” rather than “Are you Mrs. Mohammed?”.

3.5. If the patient is unable to respond due to their clinical condition or capacity,

identification should be verified with family or relatives wherever possible.





3.6. If the patient is unable to state their name, then the wristband must be checked

by two members of staff, with the health records available, to ensure all details

match.

3.7. When initially identifying a patient, there may be a language difficulty in

communicating with the patient. In this situation support from an interpreter)

This requirement should be recorded on the notes.

3.8. Particular care must be taken for patients with common names i.e. Mohammed,

and in instances where there are patients with the same or similar names

simultaneously in a clinical area such as: Mohammed Hassan and Mohammed

Hussain are patients in the same area.

3.9. Unknown patients For unknown and unconscious patients (such as trauma

patients), identification is made by Resuscitation or Emergency staff until a

unique identification has been made by means of a number on a band, or until

the patient’s true identity is established.

3.10. The unconscious patient.

3.10.1 Patients can be unconscious for a number of reasons.

Sometimes it is the treatment they are having e.g. trauma,

anaesthetic/sedation, but it may be due to the influence of

drugs or alcohol. Where patients are incapable of identifying

themselves and maintaining their own safety:

3.10.1.1. It is the responsibility of the staff looking after the

patient to ensure they can be identified properly.

3.10.1.2. All unconscious patients must wear an ID wristband for

identification purposes.

3.10.1.3. Staff must provide a unique identifier for the patient

until such time as their identity is established. This





number should be used for all procedures and

interventions to identify the patient.

3.10.1.4. The senior staff responsible for the patient’s care will

ensure that all records are merged or when the patient’s

identity is established.

3.11. Clinical staff must always validate that the verbal identification given by the

patient (or their relatives) matches the information on the patient’s wristband

before carrying out any procedure, administering any prescribed medications,

instigating examinations, investigations or treatments as appropriate.

3.12. The positive patient identification process should include asking the patient if

they have any allergies that staff need to be aware of.

3.13. Procedures requiring positive identification the list below is not exclusive:

3.13.1. In-patients should always wear an identification band.

3.13.2. Blood sampling.

3.13.3. Blood transfusion.

3.13.4. Collecting of patient bodily fluid samples.

3.13.5. Confirmation of death.

3.13.6. Administration of all medicines.

3.13.7. Surgical intervention and any invasive procedure.

3.13.8. Transport / transfer of the patient.

3.13.9. X-rays and imaging procedures.

3.14. When an internal transfer occurs, the receiving staff member should check the

patient wristband with the patient where the patient has the capacity to do so,

along with the medical notes, for positive patient identification.





3.15. Patients who are transferring in from other facilities must have the receiving

facility wristband applied immediately on arrival, and the wristband from the

transferring facility removed.

3.16. If the patient wristband is removed or becomes wet, faded, damaged or

unreadable, a replacement wristband will be applied immediately, by the nurse

or midwife caring for the patient.

3.17. Before any intervention or procedure is carried out, it is the responsibility of the

staff member undertaking the intervention or procedure to check the patient’s

identity.

3.18. Prior to the administration of any medication, it is the responsibility of the

member of staff to check the patient’s identity in accordance with the facility

medication management policies.

3.19. When a patient is to be admitted to Theatres it is the responsibility of the

member of staff receiving the patient to check the patient’s identity with:

3.19.1. The nurse transferring the patient to theatre.

3.19.2. The patient.

3.19.3. The patient’s health record (name and identifying number) to

verify that the patient has been correctly identified.

3.20. Wristbands must be applied in all cases so that any member of staff needing to

check the patient’s identity can easily access and read the information.

3.21. Ideally the wristband must not be removed until the discharge procedure is

completed and the patient leaves the ward/department or clinical area.

Exceptions to this practice are given below.





3.21.1. Emergency Department:

3.21.1.1. In the Emergency Department setting there will be

patients where patient identification wrist band must be

applied; these are as follows:

3.21.1.2. All patients who are streamed to Emergency

observation/or treatment area, Majors and Resus (or

awaiting movement to these stream areas in the

ambulance bay) must have a wrist band in situ; this

should be printed following triage and attached to the

patient.

3.21.1.3. Ambulatory/ minor streamed patients where it is

professionally judged to be appropriate, for example for

patients who lack capacity, or who are having procedural

sedation/blocks.

3.21.1.4. All patients where a decision to admit has been made.

3.21.2. In the Outpatient clinic setting:

3.21.2.1. It is not normally necessary for patients to wear

wristbands as verification of the patient identity will be

made by reception staff when the patient arrives and

books onto the clinic (exceptions detailed below).

Reception staff will ask the patient or their

carer/relative to state:

3.21.2.1.1. Patient’s full name.

3.21.2.1.2. Patient’s date of birth.

3.21.2.1.3. Patient’s address.





3.21.2.2. Where patients use the In-touch, self-booking system,

then OPD clinical staff should validate patient

information directly with them.

3.21.2.3. The Reception staff will be responsible for validating the

information given by the patient and/or their

carer/relative with the HIS (Health Information system),

the patient’s notes (when available) and, where

necessary their appointment card or letter.

3.21.2.4. There are exceptions where an outpatient must wear a

wristband. A wristband is required for those patients who

are attending as an Outpatient to undergo therapy or

procedures. Wristbands may be applied in the

Outpatients’ Department if clinical staff perceives there

is a risk of mistaken identity and feel that it is expedient

to do so.

3.21.2.5. Patients who return for regular assessment of anti-

coagulant therapy must have their full details checked

against the facility HIS, their patient notes and therapy

card and the specimen request form and specimen bottle

before the sample is obtained.

3.21.2.6. Exceptions to the Application and Removal of patient

wristbands - there are some rare and exceptional

situations where a patient cannot wear a wristband or

the wristband needs to be removed. (Refer to 3.23.3

regarding the application of an identification band to the

ankle).





3.22. Where a patient is incapable of identifying themselves, verification of identity

should be made by asking the carer or relative and checking the patient’s

medical records.

3.23. Patient Wristband details:

The information on the patient wristband will be checked with the patient

/carer/ relative and health record prior to application. The patient wristband

shall contain the following information:

• Patients’ full name.

• Unit number.

• Medical Record number.

• Date of birth.

3.24. Application of Wristbands:

3.24.1. Patients must be given a clear explanation of the importance of

wearing a wristband for their own safety at all times during their

hospital stay or Outpatient attendance and their consent gained. If

the patient is confused or unable to respond, the same explanation

should be given to the relative/carer so that they are made aware.

3.24.2. The patient’s wrist band should be placed on the dominant wrist

unless contraindicated. If the arms are both swollen or injured,

then the ankle should be used.

3.24.3. If the patient’s limbs are too large, then 2 patient wristbands may

be joined together.





3.24.4. If a patient is unable to wear a wristband either due to their clinical

condition or treatment, an alternative method of identification,

should be sought wherever possible.

3.24.5. The patient wristband shall be applied to be comfortable but secure

enough that it cannot be removed by the patient.

3.24.6. In the absence of a patient representative who knows them well,

the identity bands of patients who cannot confirm their own

identity (e.g. those who cannot communicate, young children, the

critically ill, unconscious, or confused) must be checked by two

Registered Nurses/Midwives prior to the identity band being placed

on the patient.

3.24.7. Where a patient is unconscious and unaccompanied and there is no

possibility of positively identifying the patient, the information will

be taken from the Health Record.

3.24.7.1. The patient wristband must contain the following

information:

3.24.7.1.1. Unknown male /unknown female.

3.24.7.1.2. Unit number.

3.24.8. The patient wristband shall only be removed when the entire

discharge process has been completed for the patient.

3.24.9. If a patient refuses to wear a wristband, the patient should be

advised of the associated risks. The discussion and reason should be

clearly documented in the patient’s health record.





3.25. Exceptions to the Application of ID Band:

3.25.1. There are some rare and exceptional situations where a patient cannot

wear an ID Band or the ID Band wristband needs to be removed.

3.25.1.1. Clinical condition or treatment e.g. intravenous access

lines or dermatology conditions and treatment.

3.25.1.2. Refusal to wear a wristband despite clear explanation of

the risks of not doing so.

3.25.1.3. Allergy to the materials used in the wristband.

3.25.2. If and when such a situation arises it is important that staff assess and

manage the associated risks for correct identification of the patient.

This will include:

3.25.2.1. After patient’s/patient’s relative consent photographic

identification can be considered as an alternative means of

identification.

3.25.2.2. Documenting details in the patient’s nursing notes.

3.25.2.3. Staff will need to be even more vigilant in ensuring that the

correct patient is identified prior to any procedure or

intervention.

3.25.2.4. Staff must ask the patient to identify themselves by stating:

3.25.2.4.1. Patient’s full name.

3.25.2.4.2. Address.

3.25.2.4.3. Date of Birth.





3.26. Discovery of a patient without a wristband:

3.26.1. Any member of staff discovering a patient without a wristband should

assume responsibility for correctly identifying the patient and

applying a wristband.

3.26.2. Primarily, it will be either nursing or midwifery staff, or support staff

who will be responsible for the generation and application of the

patient wristband. However, it is the responsibility of all staff to

check the validity and accuracy of patient identification before

carrying out any actions relating to patient care.

3.27. Removal of ID Band:

3.27.1. where a wristband is removed, it is replaced immediately and that

the information on the replacement wristband is valid and accurate.

If immediate replacement is not possible then it is the responsibility

of the member of staff to make clear alternative arrangements for

the patient’s correct identification.

3.27.2. For infection control purposes identification bands should be changed

if they become visibly soiled, otherwise they are not a risk.

3.27.3. Where it is necessary to remove a patient’s wristband, for whatever

reason, it is the responsibility of the member of staff removing the

wristband to ensure that it is replaced immediately. If this is not

possible, then they are responsible for making sure the reason for

removal is documented in the patient’s notes and alternative means

of identification specified.





3.28. Newborns/Neonates Identification:

3.28.1. Neonates Two identification bands are put on the baby immediately

after birth (1 on the arm and 1 on the leg). The ID band must also

include the mother’s name. This should state “baby of... (Mother’s

name)".

3.28.2. The baby MUST have the mother’s name and not the father’s on the

labels even though the baby will be registered with the Father’s

name.

3.28.3. The identification bands should be checked with the parents prior to

being attached and again each day the baby stays in the unit.

3.28.4. If the baby needs to be taken into a different room, for example for a

blood sample to be taken, the identification bands should be checked

with the Mother prior to the baby being moved and when the baby is

returned.

3.29. Psychiatric Patient Identification:

3.29.1. If the patient’s mental state is adversely affected by having a hospital

armband fitted, photographic identification should be considered as an

alternative means of identification.

3.30. The identification of a body:

3.30.1. Deceased patients All deceased patients MUST be correctly identified

with 2 identification bands - one attached to the wrist and one

attached to the ankle. If a limb(s) is missing then attach one label to

an available limb and the other to the patient’s skin using transparent

tape.





3.30.2. Identification arising from death in the community or in the emergency

room requiring identification will be dealt with in the following

manner:

3.30.2.1. All deceased patients MUST be properly identified with 2

identification bracelets one on the wrist and one on the

ankle before leaving the ward or department.

3.30.2.2. Should a patient not have an identity bracelet it is the

responsibility of the nursing staff from the transferring ward

or department to go to the mortuary to affix the bracelet.

3.30.2.3. In the event of the patient’s name not being known, then

the identification bracelet must state: UNKNOWN MALE /

FEMALE.

3.30.2.4. Notification of death: one copy of the notification of death

card must be taped securely to the shroud. The second

notification of death card must be taped securely to the

outside of the sheet or body bag.

3.30.2.5. PRINT the patient’s name, hospital number/medical record

number, and date of birth.

3.30.2.6. Identification of bodies arising from deaths in the emergency

unit under the supervision of nursing staff and/or police

officers.

3.30.2.7. With regard to identification of bodies, if a person dies in

the presence of a relative, established acquaintance or

friend, or is found dead by the same and the death is

confirmed either at the scene or on arrival at hospital, then

it is not necessary for a further formal identification to be





made to a police officer except in specific cases, e.g.

homicide, road traffic accident.

3.31. Reception of Bodies in the Mortuary:

3.31.1. Bodies from within the hospital:

3.31.1.1. The porter must ensure that an ID Label is attached to

the outer sheet covering the body by the ward nursing

staff before transferring the body to the mortuary.

3.31.1.2. The identification of bodies from within the hospital

must be thoroughly checked on arrival at the mortuary

by the Porter/Caretaker who must examine the ID band

for name, ward and date of birth.

3.31.1.3. A body transfer sheet will have been taped by the ward

to the shroud – this sheet should also contain details of

any valuables remaining on the body which must be

recorded in the appropriate column in the mortuary

register.

3.31.1.4. When a body is moved from a ward the porter will be

responsible for placing the body into a refrigerated

store, labelling the door of the fridge and registering the

body within the mortuary register.

3.32. Procedure to be Followed in Cases where Mis-identification Occurs:

3.32.1. Any staff member who discovers any deviation from this policy

must complete a the facility Occurrence Variance Report form in

accordance with the facility OVR Policy.





3.32.2. If an error occurs, for example a patient receives the wrong

medication; or the wrong investigation or procedures are carried

out; or an incorrect result is reported; all appropriate actions must

be initiated to resolve the error and report the occurrence as a

sentinel event where applicable,

3.32.3. Instances of misidentification, particularly where patients have

received unwarranted treatment will be fully documented in the

patient’s records, including any actions necessary to minimise risk

to the patient.

4. Training of Staff on the Policy:

• All staff (clinical and non-clinical) must be oriented on this policy.

• It is the responsibility of departmental managers to ensure that staff have

received the appropriate orientation.

5. Monitoring compliance:

Compliance with this policy will be monitored by the Clinical Director, and relevant

units (such as the admission office) with support from the Quality department,

analysis and trending will discussed in the department meeting and in Quality patient

safety committee.

6. Review and Update Cycle:

This policy must be reviewed and updated every two years and as needed.





V. References

patient identification policy and procedure

Documents