Patient identification Policy and Procedure

One of the most common causes of medical errors in healthcare is the incorrect identification of patients. The error can lead to potentially serious consequences such as surgery of a wrong patient or transfusion of wrong blood into a patient. It is vital that hospitals must put into place an effective policy and procedure for identifying a patient. Below are the internationally recommended practices for accurately identifying a patient.

Patient identification details

· At the time of registration, patient’s identification details shall be taken that includes, patient’s full name, date of birth and father’s/mother’s/spouse’s name. At-least one more identifier in addition to the name of patient shall be obtained.
· A unique identification Number (UIN) must be generated for each registered patient. That UIN shall not be used for any other patient, even in future.
· The name of patient and UIN shall be used as a standard identifier for identifying any patient in the hospital
(Refer - Patient Registration Form)
· The same identification details shall be used for admission of the patient

Use of Patient Identification band (ID band)

· An ID band must be placed on each admitted patient’s wrist (Right or left as decided by the hospital). In case the wrist is not suitable for band placement (for eg. Injured or bandaged) then the band can be placed on ankle.
· Patient’s name, UIN and one more identifier (such as date of birth, father’s name etc.) shall be printed on the ID band.
· If the patient is unknown or unidentified, the ID band shall mention as ‘Unidentified -1, Unidentified – 2, etc.), along with UIN, gender, approximate age and ward/location. As and when patient’s identity is obtained, the ID band shall be updated
· The contents of ID band shall ideally be printed. However, if manually written, it shall be ensured that the ink in indelible and the writing is clear
· Patient shall not be able to self-remove the ID band, once placed. ID band shall be removed by cutting at the time of discharge, or if a correction is required in the band.

Procedures before which patient’s identification must be established

·Identification of patient shall be done before all care process. In particular, correct identification shall be established before initiating any of the given procedures
o Surgical intervention and any invasive procedure
o Administration of all kind of medicines through any route
o Transfer of patient from one place to another
o Imaging investigations
o Sample collection for lab tests
o Blood sampling
o Blood transfusion
o Death confirmation

Process of identifying

· Standard process of identifying a patient shall be as follows. Staff shall ask the name of the patient and his/her date of birth and match the response with the name printed on his/her ID band. Staff shall then check the UIN on ID band and match it with the UIN on patient’s record.
· Blood transfusion – Bedside patient identification check is essential before initiating transfusion. Two separate people shall identify the patient using the standard process, one of whom shall be the qualified transfusionist and second person shall be qualified nurse, doctor or above. Transfusion shall be initiated only after both have confirmed the same identification.
· Imaging – The operating technician shall identify the patient before starting the X-ray or investigation. The patients’ identification details on ID band shall be matched with the identification details on request form
· Sample collection – patient shall be identified bedside before collection of sample for a lab test. The container in which sample is collected shall be labelled bedside in the presence of the patient
· Incompetent patient – For patients who are unconscious or incompetent to state their identification, help shall be taken from the accompanying capable adult
· Unknown and unconscious patient – For such patients’ identification shall be done by the emergency staff who handled the patient
· Patients under anaesthesia – patients in operation theatre who is under anaesthesia shall be identified by a staff from the operating team

Identification of Mother and Babies

· Mother’s ID band shall include the identification details as stated above
· On the baby, two separate ID band shall be placed on two separate limbs of the baby (generally both ankles). The baby’s ID band shall contain following details
o First ID band – Mother’s name, age, UIN, and date of admission
o Second ID band – Baby’s gender followed by mother’s name, baby’s UIN, date and time of birth, mode of delivery
· The details of ID band on baby shall be confirmed by the mother. In case, mother is not in a condition to confirm, it shall be confirmed from the father
· Details on baby’s first ID band shall be matched with the mother’s ID band before handing over the baby on every occasion

Identification of deceased patient

· In all deceased patient, two ID band shall be applied. One on the wrist and one on ankle.
· Patient’s name, UIN, date of birth, date of death and religion (if known) shall be printed on both the band
· The body shall be identified using the band before handing over to the relatives