Patient identification policy

1 Policy summary

The purpose of this policy is to ensure that all patients within inpatient and community settings trust wide can be correctly identified, to reduce and where possible, eliminate the risks and consequences of misidentification.

The trust provides care to a multi-diverse client group which require different methods of patient identification. Wristbands and photographs are the approved method of identification throughout inpatient services. Although there is no nationally prescribed identification process in the community, it is imperative that accurate patient identification, at the earliest opportunity, is achieved in the community using core patient identifiers.

The policy will provide clear guidance on the procedure for patient identification in all circumstances, including colleague responsibility for storage, use and disposal of identification methods.

2 Introduction

The national patient safety agency (NPSA) (opens in new window) recognises that failure to correctly identify inpatients constitutes one of the most serious risks to patient safety and cuts across all sectors of healthcare practice. Reducing and where possible, eliminating these errors is central to improving patient safety.

Guidance from the national patient safety agency (NPSA) advocates the use of wristbands for the purpose of identification in acute inpatient settings but acknowledges that they may not be appropriate in mental health settings. The never event list for 2012/13 (opens in new window) from the Department of Health also acknowledges that Mental Health Units are excluded from the use of wristbands by local agreement.

The trust, recognising the diversity of its inpatient services advocates the following methods of patient identification:

wristbands across all physical health wards including St Johns Hospice and Magnolia
photographs across all mental health and forensic wards, however, wristbands can be used where clinically indicated

There is no national prescribed process for identifying patients in the community, but accurate patient identification along the care continuum is essential for patient care. Although the emphasis of this policy is on inpatient care, it is the responsibility of all healthcare colleague to confirm the identity of patients and match the correct patient record with the correct care intervention irrespective of the healthcare setting.

3 Purpose

The purpose of this policy is to ensure that all patient identities are confirmed at the point of registration and can be correctly identified thereafter, to reduce and where possible, eliminate the risks and consequences of misidentification.

4 Scope

This policy is applicable to all inpatient and community settings. Amber lodge colleagues should also refer to the admission of a patient to forensic services procedure for further guidance.

For further information about responsibilities, accountabilities and duties of all colleagues, please see section 5.

5 Responsibilities, accountabilities and duties

5.1 Board of directors

It is the responsibility of the board of directors to have policies in place that meet any legislation, national and local requirements and promote best practice.

5.2 Care group directors

Care group directors are responsible for the implementation of the policy within their respective care group.

5.3 Clinical leads, modern matron’s and deputy care group directors service managers

Clinical leads, modern matron’s and services are responsible for:

ensuring colleagues are aware of this policy and monitoring compliance
performing regular patient identification audits as per section 8

5.4 Clinical colleagues

Clinical colleagues are responsible for:

adhering to this policy
taking a photograph or applying a wristband on admission
obtaining, recording, checking the patients’ details, identity
checking the patients’ identity prior to administration of medicines or treatments and care interventions
reporting any incidents involving patient misidentification via Ulysses (IR1) incident management system
replacing photographs and wristbands where required

6 Procedure or implementation

Confirming a patient’s identity at the point of referral or admission to hospital is imperative to ensure accurate registration of the patient in the electronic patient record (EPR).

Furthermore, confirming identity at the point of care delivery is essential in reducing risks associated with patient safety.

A method of identification is particularly important where patients are unable or unreliable in confirming their own details because they are unconscious, confused, lack capacity, or have difficulty communicating.

Across inpatients it is the responsibility of the person in charge of each shift to ensure compliance with this policy and that a method of identification is put in place, even if this is a temporary measure due to equipment or stock issues. However, plans must be made to escalate and rectify these issues in a timely way.

For community services it is the responsibility of the team manager to ensure their team adhere to this policy when registering and treating patients.

6.1 Quick guide

Capacity and consent:
- obtain consent from the patient for either method of identification for inpatients.
- if a photograph or wristbands is refused, consider alternative ways in which the patient can be identified for example confirming date of birth and agree with the patient
- refer to relevant MCA guidance where there are concerns regarding capacity
Documentation:
- confirm the identity of patients at the earliest opportunity which could be at referral, registration first meeting, phone call and always before care is delivered and record in the electronic patient record (EPR)
- on mental health and forensic wards, photographs should be immediately uploaded to the EPR and renewed, stored and disposed as per policy

6.2 Confirming patient identity

Colleagues should refer to the list of core patient identifiers below when confirming or verifying a patient’s identity:

last name
first name
date of birth
NHS number

It is the responsibility of all colleagues to confirm the identity of patients at the earliest opportunity which could be at:

referral or registration
first meeting or phone call
before care is delivered

Confirming the identity of a child or young person may require the support of others. At appointments in CAMHS (child and adolescent mental health services) the young person is often accompanied by a parent or carer who can confirm identity. If there is any doubt about the young person’s identity the parent can be contacted if not present. Very young children are brought or accompanied by parent or carer who will confirm identity with the practitioner.

For medication administration, this will require name and date of birth; often the practitioner will be at the home address enabling a check against the information held in the EPR.

Within schools, the young person will be asked for their details including name, address, date of birth and mobile number and this will be confirmed with the information in the EPR. For younger children, the teacher or other adult who knows the child will support the process of confirming identity. This will be checked against the information in the EPR or the vaccination consent form before any treatment is given.

Patient identity must be verified on every occasion when a colleague:

administers treatment, care intervention or medication
collects a sample or specimen
performs an investigation or examination
undertakes a clinical assessment
provides a diagnosis or management plan
provides results
arranges an appointment
transports or transfers
verifies death

It should be noted that no single method of identification is 100% reliable.

All methods of identification have the potential to raise ethical and legal issues regarding the privacy of personal information and the potential to create discrimination from personal factors.

6.3 Photographs

Photographs are only required across all mental health and forensic wards at this time.

6.3.1 Taking a photograph

A head and shoulders photograph like a passport is sufficient for identification. The photograph may show more of the patient but must have a clear view of their face and features. Colleagues should follow these simple steps to take a reasonable quality photograph:

use a light background with no or minimal pattern
avoid using white or glossy backgrounds as these produces glare
ensure good lighting to the face, avoid shadows
try to ensure hair is brushed away from the face but still in the patients’ usual style
keep glasses on unless they are obstructing the eyes, producing glare, or hiding features

If coloured contact lenses are worn, this must be indicated on the back of the photograph and in the EPR.

All culturally appropriate headwear can be worn and under no circumstances should anybody be asked to remove these items. However, it may be acceptable to ask a patient if they would feel comfortable adjusting certain items to improve the quality of the photograph and the visibility of their face and features.

Photographs should be renewed every 3 months or:

when someone’s appearance changes, for example they restyle their hair, experience significant weight changes, undergo facial or dental work or grow facial hair
if the quality of the printed photograph is impaired
if the patient (reasonably) requests

6.3.2 Equipment and space

All inpatient areas must have access to appropriate equipment to take and print photographs. In acute areas this must be available on a 24-hour basis to accommodate admissions.

Resources may include:

digital or other ‘quick print’ camera and printing device
well-lit area with plain or clear background to take photographs against
access to ‘back up’ equipment in the event of failure or loss
safe and secure storage for the equipment
plans for maintenance and replacement of equipment

6.3.3 Storage of photographs

The ward manager is responsible for developing and monitoring effective systems that assure the security of photographs taken in their area(s).

The photograph must be taken with a digital device and uploaded to the EPR. A printed copy can be attached to a prescription or medication chart where a paper version exists. Only one printed photograph should be in existence at any one time.

The digital image must then be immediately deleted from the device memory (in the presence of the patient where appropriate) so that no additional prints can be made.

Where a new photograph is taken, the old one must be replaced on the EPR, and the printed copy destroyed or returned to patient (consent will be re-affirmed prior to a new photograph being taken).

6.3.4 Use of photographs

Photographs taken for the purpose of patient identification will not be used for any other purposes without prior consent from the patient or their legal representative, unless it is deemed to be in their best interest or when a vulnerable person is reported as missing. Colleagues should also refer to the patients missing or absent without leave (AWOL) policy.

If a photograph is formally requested under section 29 of the Data Protection Act (1998) (opens in new window) this must be referred to the Information Governance team inbox at rdash.ig@nhs.net.

6.3.5 Disposal of photographs

When a new photograph is taken, or a patient is discharged:

printed photographs must be securely disposed of or handed back to the patient
digital photographs must be removed as the ‘demographic photograph’ in the EPR but will remain part of the health care record
colleagues should refer to the patient ID SystmOne user guide (staff access only) (opens in new window) for details on how to ‘un-set’ the demographic photograph

6.3.6 Consent

A full explanation of how the photograph will be used, stored, accessed, and protected must be given to the patient in a form that they can understand.

Services may need to develop localised information leaflets to support with delivering these messages considering patients individual needs.

Colleagues must explain to the patient that the photograph uploaded to the EPR will remain part of the record indefinitely but be removed from the demographic screen at the point of discharge.

Guidance around consent is provided in the trust’s consent to care and treatment policy.

6.3.7 Capacity and refusal

Where a patient has capacity and consents to a photograph being taken, a photograph should be taken and used accordingly.

Where a patient has capacity but does not consent to the photograph being taken, the photograph must not be taken, and the patient should be offered a wristband as an alternative means of identification. If a wristband is also declined, alternative ways in which the patient can be identified, such as confirming core identifiers should be discussed and agreed with the patient.

All discussions and decisions regarding identification including alternative methods agreed must be documented in the EPR and recorded on the prescription or medication chart where a paper version is used.

Colleagues should revisit any decision to refuse a photograph regularly with the patient and this action must be captured in the care and treatment plan.

If there are concerns in relation to a patient’s capacity to consent to a photograph being taken, or capacity fluctuates, an assessment of their capacity should be completed. Colleagues should refer to the trust Mental Capacity Act (MCA) policy for further guidance.

If a patient lacks the capacity to consent to their photograph being taken, then a best interest decision should be undertaken with relevant people involved (for example, families or carers) to ensure that patient safety is maintained.

For patients managed under the MCA 2005 carers with a valid registered lasting power of attorney (LPA) or a court appointed deputy for health and welfare donee or deputy consent should be sought. However, if the patient’s carers do not have the appropriate legal authority, then it is important for their opinion to be heard but the decision maker for the “best interest decision” is the clinician.

If a patient is unable or unreliable in identifying themselves, the need for a photograph is greater. If the ‘best interests’ of the person are being served, the photograph is stored safely and the persons privacy and dignity is respected, then the photograph provides the most effective identification method.

6.4 Wristbands

Wristbands may be more appropriate for patients who are sensitive about body image or have cultural or religious or personal reasons for declining the use of photographic identification. Wristbands are only required in inpatients settings.

6.4.1 Completing a wristband

NPSA Safer Practice Notice 2007 advocates the standardisation of wristbands to further improve patient safety and wristbands should only include the following core patient identifiers:

last name
first name
date of birth
NHS number (if the NHS number is not immediately available, a temporary number should be used in the interim)

If any additional identifiers are thought to be necessary, these should be formally risk assessed and documented in the EPR before being added to the wristband.

Colleagues must ensure patient information is recorded accurately and legible.

Only white wristbands with black text should be used.

The nature of any allergy should not be recorded on the wristband. This information should be recorded in the EPR and transcribed onto the drug administration record (where this is not electronic).

Patients must wear only one identity wristband.

When attaching the identity wristband, the Nurse should explain the importance of it to the patient and ask them to report to a colleague if it falls off, if it is removed and not replaced or if it becomes illegible.

6.4.2 Fitting a wristband

Wristbands must fit the range of sizes. They must be small enough to be comfortable and secure and long enough to accommodate:

bariatric patients
patients with oedema
patients with IV lines and bandages

It is essential that patients’ wristbands are checked at least weekly and are replaced where necessary or when information is becoming illegible.

Colleagues must also be mindful of:

wristbands falling off
risk of wristband causing injuries if caught or pulled
wristbands:
- being uncomfortable, causing allergies, irritation, or pain, especially in patients with arthritis
- obstructing medical interventions for example, intravenous drips, Electro-Encephalograph (EEG)

If required, wristbands can be located on the ankle if there is a risk of obstructing medical treatment or for patient preference.

Colleagues must be mindful that patients could swap wristbands and therefore not be solely reliant on wristbands when identifying a patient.

7 Training implications

All areas must have clear induction guidelines for temporary colleagues who may be required to take patient photographs, including area specific training for colleagues on the use of the relevant digital equipment used to take photographs.

All colleagues need to be aware of the key points that the policy covers. Colleagues can be made aware through:

one to one meetings and supervision
continuous professional development sessions
practice development days
group supervision
daily email (sent Monday to Friday)
intranet
team meetings
local induction

8 Monitoring arrangements

8.1 Compliance with this policy

How: IR1 reports.
Who by: Modern matrons.
Reported to: Care group quality and safety assurance meetings.
Frequency: Monthly.

9 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

9.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

9.1.1 How this will be met

No issues have been identified in relation to this policy.

9.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure for that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

9.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the mental capacity Act (2005).

10 Links to any other associated documents

11 References

Document control

Version: 5.1.
Unique reference number: 341.
Approved by: Clinical policies review and approvals group.
Date approved: 29 January 2024.
Name of originator or author: Head of information quality.
Name of responsible individual: Executive director of nursing and allied health professionals.
Date issued: 5 February 2024.
Review date: 31 July 2026.
Target audience: All inpatient and community colleagues.

Page last reviewed: December 10, 2024
Next review due: December 10, 2025

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