Western Australian patient identification policy 2010

Acknowledgments
The Office of Safety & Quality in Healthcare acknowledges the input of all individuals and groups who have contributed to the development of the inaugural Western Australian Patient IdentificationPolicy.

Foreword
Western Australians currently enjoy good health care. Nevertheless, although uncommon, failures in the patient identification process continue to result in wrong person, wrong site procedures, medication errors, transfusion errors, and diagnostic testing errors. Accurate identification of patients, and the administration of intended clinical interventions, is one of the most fundamental components of the provision of good health care. The Department of Healths Office of Safety & Quality in Healthcare has developed this Policy in accordance with the Australian Commission on Safety and Quality in Health Cares Specifications for a standard patient identification band, using the following principles as afoundation: Wherever possible inpatients should wear some form of patient identification, and healthcare providers should have a policy in place that guides this identification process; The primary purpose of an identification band or other identification mechanism is to identify the patient wearing the band. The use of identification bands to signify clinical alerts is secondary; Health service providers will need to determine how they meet the specifications for identification bands at a local level. The purpose of this Policy is to describe a standard approach to key elements of patient identification, particularly the useability, colour and content of identification bands in Western Australia. Standardising processes of care such as patient identification is an important strategy to reduce patient safety risks. This Policy, and other relevant resources, can be accessed via the website of the Office of Safety & Quality in Healthcare (www.safetyandquality.health.wa.gov.au/policies). As the safety and quality field is dynamic and rapidly changing, updates can also be accessed via thiswebsite. I encourage all health service staff to read this policy and participate in the continuous drive to improve the safety of health care.

Mr Kim Snowball Director General Department of Health

Table of contents
1.0 Background 2.0 Purpose of policy 3.0 Scope 4.0 Principles 5.0 Mandatory patient identification descriptors 6.0 Patient identification bands 7.0 Guidelines for the use of coloured identification bands 8.0 Process for confirming the patients identity 8.1 Procedures if two or more patients in a ward have the same family name 8.2 Procedures if the patients identity cannot be reliably confirmed 9.0 Identification procedures for neonates 10.0 Procedures for clinical areas where no identification bands are used 11.0 Patient identification procedures for mental health facilities 12.0 Procedures in the event that a patient is incorrectly identified 13.0  Required action in the event of a wrong patient, wrong procedure or wrong site clinical incident 14.0  Guidelines for patient identification in transfusion and pathologyservices References 5 5 6 6 6 7 7 8 8 8 9 9 10 10 11 11 12

1.0 Background
Throughout the health care industry, the failure to correctly identify patients and correlate that information to an intended clinical intervention continues to result in wrong person, wrong site procedures, medication errors, transfusion errors, and diagnostic testing errors. Patient safety incidents and near misses associated with incorrect patient identification are a recognised international problem. Prevention of such incidents has been identified as a key patient safety goal by all of the major international and Australian patient safety agencies including the World Health Organisation1-2, National Patient Safety Agency in the United Kingdom3, Joint Commission International Centre for Patient Safety4, the Veterans Health Administration National Centre for Patient Safety in the USA5-6 and the Australian Commission on Safety and Quality in Health Care.7 For example, between November 2003 and July 2005 the United Kingdom National Patient Safety Agency (NPSA) received 236 reports of patient safety incidents and near misses relating to missing identification bands or bands with incorrect information.3, 8-9 In addition, there is increasing concern about the proliferation of coloured wristbands. There have been near misses in the United States of America associated with confusion about the meaning of different coloured alert wristbands.10 In Western Australia, a state-wide Sentinel Event Program was established in 2003. Procedures involving the wrong patient or wrong body part is one of eight sentinel event categories of which reporting to the WA Department of Health is mandated. In 2009/2010, one sentinel event involving the wrong patient or wrong body part was reported to WA Health. The sentinel event was associated with a wrong side procedure resulting in permanent loss of function.* In 2008/2009, ten sentinel events involving the wrong patient or wrong body part were reported to WA Health. Four of the 10 sentinel events were associated with the wrong patient being identified and six sentinel events were associated with the wrong body part being treated.11 Issues with communication, non-utilisation of pre-operative checklists, and failure to follow correct checking procedures have been recognised as contributing factors for wrong patient or body part, or wrong procedure sentinel events reported by WA health services.11

2.0 Purpose of policy

Wristbands containing patient information have been the standard method of identifying patients in WA hospitals/health services for many years. However, there is currently no standard approach regarding the use of patient identification bands in Australia. This document outlines the policy and procedures that must be followed in public hospitals/ health services to ensure correct patient identification at all times during hospital admission. Itspurpose is to: identify the minimum level of patient identification information that must be collected and documented by WA hospitals/health services set out standards for the content, colour and use of patient identification bands in WestAustralian public hospitals.

*  Note that for the 2009/2010 financial year the category definition was amended nationally to read procedures involving the wrong patient or body part resulting in death or major permanent loss of function.

3.0 Scope
The WA Patient Identification Policy (the Policy) is based on standards for patient identification and patient wristbands developed by the United Kingdom National Patient Safety Agency7-8, Australian Commission on Safety and Quality in Health Care (ACSQHC)6 and WA public hospitals/health services.12-18 This policy applies to all West Australian public inpatients and day procedure patients. Health Service Managers and Clinical Directors are advised to bring this policy to the attention of staff to ensure its prompt implementation within their jurisdiction. All inpatients, emergency department patients and day procedure patients must be correctly identified at the time of admission and throughout their hospital stay. Compliance with this policy is required by the following health service staff: Clinicians (medical, nursing, midwifery, pharmacy and allied health staff) Relevant clerical and ward staff (including ward clerks, patient care assistants and cateringstaff) Quality/Clinical Governance Coordinators.

4.0 Principles
The following principles have guided the development of the WA Patient Identification Policy. All inpatients, emergency department patients and day procedure patients must be correctly identified at the time of admission and throughout their hospital stay. Wherever possible, inpatients should wear some form of patient identification, and health care providers should have guidelines in place that guides this identification process. The primary purpose of an identification band or other identification mechanism is to identify the patient wearing the band. The use of identification bands to signify clinical alerts is secondary. Hospitals/health services will need to determine how they meet the specifications for identification bands at a local level.

5.0 Mandatory patient identification descriptors

A complete system of unique identification for each patient is mandatory at all WA public hospitals. As a minimum, the following core patient identifiers are mandatory: FAMILY NAME and Given Name/s Family and given names should be clearly differentiated. Family name should appear first using UPPER case letters followed by given names in Title case. That is, FAMILY NAME, Given Name/s. For example, SMITH, JohnPaul UMRN (Unit Medical Record Number or equivalent) DOB (Date of Birth written as DD/MM/YYYY). Issues that will need to be determined locally at the hospital / health service level include: inclusion of additional identifiers, such as barcodes or the patients gender, on the identification band inclusion of substitute identifiers, in the instance that one or more of the mandatory identifiers listed above is unknown (for example, date of birth) cultural naming conventions use of preferred names rather than correct names use of names for neonates.

6.0 Patient identification bands

All inpatients, day procedure patients and Emergency Department patients (if practical) shall have an identification band securely attached immediately after patient registration/ admission and before any treatment, collection of pathology samples, blood transfusion, drug administration or X-rays are undertaken. The design and specifications of the patient identification band should comply with the ACSQHCs National Specifications for Patient Identification Bands.7 The identification band must include family name, given name, UMRN, and DOB. Where possible, the patient must view and verify that these details are correct. If the patient is unable to do so, the next of kin/legal guardian/carer may undertake this responsibility; otherwise, a second staff member must check the information on the identification band against the admission details. Where possible, the identification band shall remain on the patient throughout the hospitaladmission. Where identification bands interfere with medical procedures (e.g. Theatres) they may be removed/relocated/reattached as soon as practicable. Patients going to theatre should have two identification bands (e.g. wrist and ankle). If an identification band inadvertently comes off, or is removed for treatment and not replaced immediately, it cannot be reattached. In this case, the patient must be re-identified and a new identification band attached. Prior to procedures, sample collection, investigations, intravenous infusions and medication administration, the patient shall be positively identified by: Checking the identification band that is securely attached to the patient  Asking the patient (if conscious and able) to spell their family name and given name, and state their date of birth. Where necessary, the next of kin/legal guardian/carer may undertake this responsibility. Verification of the patients identification should be documented in the patients health carerecord.

7.0 Guidelines for the use of coloured identification bands

A single white identification band should be used for patient identification. As per current hospital procedure, the admitting clinician must ascertain and document whether the patient has an allergy, has ever had an adverse reaction or another known risk. Patients with a known allergy should be issued with a RED patient identification band. It is recommended that no other coloured identification bands be used to indicate other known risks.7 Although not recommended, coloured wristbands (not identification bands) may be used to indicate other known risks for the patient (for example, risk of falls or pressure ulcers) as per local policy. It is recommended that the meaning for each non-identification band is clearly displayed on the band to minimise risk of misinterpretation. Such wristbands must not contain patient identification details. Only one colour identification band should be used at any one time. When an allergy alert condition exists the white identification band is replaced by a RED identification band. If an allergy is identified subsequent to admission the standard white identification band will be replaced by a RED identification band by nursing staff caring for the patient. Where RED identification bands are used they should comply with all requirements of the ACSQHC Patient Identification Band Standards. The RED identification band will have patient identifiers in black text on a white background.

 The RED identification band should not contain details of the meaning of the alert. This information should be recorded in the patients health care records. The patients health care record will need to be reviewed by clinical staff to determine the meaning of the alert. In the instance that a RED identification band is removed for a procedure or treatment, the staff member responsible for removing the identification band must also take responsibility for replacing it as per Section 6.

8.0 Process for confirming the patients identity

All patients shall be positively identified prior to patient registration/admission by: Asking the patient, or accompanying next of kin/legal guardian/carer to spell their family and given names and state their date of birth and address Where the patient is unable to give this information, the legal guardian or carer may identify the patient, and this should be documented in the patients health care record This information will be used to identify existing records in the Central Patient Index (CPI). Any discrepancy with an existing record shall be investigated and rectified according to local operating procedure. If a CPI record does not already exist, a new UMRN shall be created and the patient or legal guardian/carer must complete a Patient Registration Form Wherever possible a Medicare card and/or other documented identification should be provided by the patient or next of kin/legal guardian/carer. 8.1 Procedures if two or more patients in a ward have the same family name If two or more patients in a ward have the same family name a local PATIENT WITH THE SAME NAME IN WARD cautionary card must be applied to each patients health care record. Alerts must also be applied to all ward bed lists and other patient documentation while both patients remain in the ward. The patients given name should also be printed on these cards. 8.2 Procedures if the patients identity cannot be reliably confirmed When a patients identity cannot be reliably confirmed (e.g. patient is unconscious, intoxicated, mentally impaired, or experiencing language difficulties) they must be registered as Unknown Male or Unknown Female using an emergency UMRN. Pre-printed Unknown files are recommended for emergency patients for resuscitation where samples/investigations must be initiated prior to patient registration. Once the patient is identified, patient information should be updated and a new identification band attached. Local operational policy must stipulate procedures to ensure that such patients can be correctly identified throughout their admission; particularly, in relation to the reconciliation of samples/investigations using either UMRN, with the right patient. If a previous UMRN is found, the pre-existing medical record will be merged with the new medical record. In the event that core patient identification details (Family name and given names, DOB) are legitimately changed or updated (e.g. Unknown patient or baby name change): Patient details must be updated in the Patient Administration System (UMRN must notchange) A new identification band must be attached to the patient If the Transfusion Medicine Unit has already performed tests or cross matched blood they must be notified immediately Departments that have performed investigations, such as blood tests and X-rays should benotified.

9.0 Identification procedures for neonates

The same patient identifiers outlined in this Policy should also apply to neonates, however neonates should wear two identification bands at all times (i.e. same details on two different limbs). Either white or clear patient identification bands should be placed on the neonate at birth to indicate the mothers identification details (i.e. Mothers UMRN). Once the infants name is registered, the identification bands with the mothers details can be removed and replaced with identification bands listing the infants details. Whilst not mandatory, this Policy supports the continued use of the pink (Girls) and blue (Boys) coloured identification bands for neonatal admissions13-14 in WA hospitals/health services in order to indicate infant identification details (i.e. Infants UMRN). A white or clear identification band should be used where gender is indeterminate, until such time that gender is determined.

10.0 Procedures for clinical areas where no identification bands are used
The primary focus of this Policy is to ensure the correct identity of patients and correct wearing of patient identification bands by inpatients. The Policy has been developed based on the principle that all patients must be correctly identified, and wherever possible, inpatients should wear some form of patient identification. The Policy recognises that there are some situations where a patient may not be able to wear a patient identification band, including: mental health patients patients who refuse to wear the patient identification band patients who cannot wear a patient identification band because of their clinical condition ortreatment. In situations where the wearing of a patient identification band is inappropriate, due to a patients condition or treatment, consideration may be given to the use of photo identification. Any form of identification should comply with the ACSQHCs National Specifications for Patient Identification Bands.7 While patient identification bands may not be acceptable or appropriate for outpatients, WA hospitals/health services should implement alternative strategies to ensure that all patients are correctly identified before treatment is commenced. Consideration could be given to the use of name tags or identification cards that can be reused. If this was done, some aspects of these specifications could be used (such as what identifying information was provided and how it waspresented). In non-inpatient areas where the identity of a patient needs to be checked and the patient is not wearing a name band, the patients name, address and date of birth must be checked against the health care record identification label.

11.0 Patient identification procedures for mental health facilities12

Wherever possible, mental health patients should be provided with identification bands. However, should a patients condition or treatment make this option impractical, other identification methods may be considered. Identification of patients should be made, where necessary, by staff who can reliably identify the patient, and this should be documented in the patients health care record. In cases where staff may be unsure of a patients identity (e.g. medication rounds) they may, if reasonable, ask for the patients name and date of birth, which can be checked against the patients record/medication sheet. Patients receiving Electroconvulsive Therapy (ECT) must have a name band attached after identification by two staff who can reliably identify the patient. Where there are patients of the same or similar name admitted to the same ward a cautionary label or other notation should be inserted in the patients health care records, medication charts and any other pertinent documentation to alert staff. Mental Health inpatients not wearing an identification band will need to have their allergies documented and communicated in accordance with local policy (see Operational Circular OP2079/06).19

12.0 Procedures in the event that a patient is incorrectly identified

If a patient is incorrectly identified: the previous identification band with incorrect patient details should be removed patient health care records should be corrected and a new identification band with the correct patient details should be provided immediately all departments that have performed investigations and treatment, such as X-rays, pathology and pharmacy, should be notified as a matter of urgency the event should be thoroughly documented in the patients health care record and reported as a clinical incident. Transfusion medicine presents a particularly high risk to patient safety with regard to patient misidentification. It is therefore critical that incidents relating to patient and/or sample misidentification are communicated appropriately and immediately.

13.0  Required action in the event of a wrong patient, wrong procedure or wrong site clinical incident
In the event of a patient being incorrectly identified or a clinical incident occurring as the result of incorrect patient identification, the most senior member of the clinical team must ensure the patient involved in the incident is safe and that all necessary steps have been taken to support and treat the patient and to prevent injury to others. If the procedure was incorrect or performed on the wrong patient or wrong site, the clinician should also ensure that relevant steps are taken to perform the correct procedure on the correct patient as soon as practicable. The WA Department of Health requires all hospital/health service staff to identify, report, investigate and disclose clinical incidents that occur in public hospitals (and private hospitals providing health care services to public patients) across Western Australia. In the event of a wrong patient, wrong procedure or wrong site clinical incident, please refer to the following policies for further guidance: Department of Health (2007): Clinical Incident Management Policy for WA Health Services using the Advanced Incident Management System (AIMS) (2nd Edition)20 Department of Health (2008): Western Australian Review of Mortality (2008 Edition)21 Department of Health (2008): Sentinel Event Policy (4th Edition)22 Department of Health (2009): WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals Working in Western Australia.23

14.0 G  uidelines for patient identification in transfusion and pathologyservices

WA Health Pathology Service laboratories are accredited with the National Association of Testing Authorities (NATA) Australia and the Royal College of Pathologists of Australasia. A requirement of accreditation is that all specimens should be clearly and unambiguouslylabelled. Accurate reconciliation of patients with their clinical samples, and the appropriate labelling of samples, is a critical element of correct patient identification. Refer to the PathWest Laboratory Medicine WA standard operating procedure, Minimum requirements for clinical samples and request forms24, for procedures to follow with regard to the collection and accurate identification of clinical samples.

References
1.  World Health Organisation. Nine Patient Safety Solutions 2009: Available from: http://www.who.int/patientsafety/solutions/patientsafety/Preamble.pdf 2.  World Health Organisation. WHO Surgical Safety Implementation Manual 2009: Available from: http://whqlibdoc.who.int/publications/2009/9789241598590_eng.pdf 3.  National Patient Safety Agency. Safer Practice Notice 11: Wristbands for Hospital Inpatients Improves Safety 2005: Available from: http://www.nrls.npsa.nhs.uk/ resources/patient-safety-topics/documentation/?entryid45=59799 4.  Joint Commission International Centre for Patient Safety. Patient Identification Patient Safety Solutions 2007: Available from: http://www.ccforpatientsafety.org/Nine-PatientSafety-Solutions-Press-Kit/ 5.  Veterans Health Administration National Centre for Patient Safety. NCPS Patient Misidentification Study: A Summary of Root Cause Analyses 2003: Available from: http://www4.va.gov/ncps/TIPS/Docs/TIPS_Jul03.pdf 6.  Veterans Health Administration National Centre for Patient Safety. Ensuring Corrective Surgery and Invasive Procedures 2004: VHA Directive 2004-028: Available from: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1106 7.  Australian Commission on Safety and Quality in Health Care. National Specifications for a Standard Patient Identification Band 2008: Available from: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PatientIDResources-NatStd_Bands 8.  National Patient Safety Agency. Your guide to implementing standard wristbands 2007: Available from: http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetI D=48264&type=full&servicetype=Attachment 9.  National Patient Safety Agency. Safer Practice Notice No. 24: Standardising wristbands improves patient safety 2007: (3 July 2007): Available from: http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60137&type=full&se rvicetype=Attachment 10.  Pennsylvania Patient Safety Authority. Patient Safety Advisory: Use of colour-coded patient wristbands creates unnecessary risk 2005: 2(Suppl. 2): Available from: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2005/dec14_2(suppl2)/ Documents/dec14;2(suppl2).pdf 11.  Department of Health. Delivering Safer Healthcare in Western Australia: WA Sentinel Event Report 2009/2010: Available from: http://www.safetyandquality.health.wa.gov.au/ docs/sentinel/WA%20Sentinel%20Event%20Report%2020092010.pdf 12.  Department of Health. Graylands, Selby-Lemnos & Special Care Health Services Clinical Policy and Procedure Manual - Identification of Patients (CLIN30). 2000. 13.  Department of Health. Womens and Newborns Health Service Pathology Handbook - Patient Identification Procedures. 2005. 14.  Department of Health. Womens and Newborns Health Service Patient Identification Policy (W160). 2007. 15. Department of Health. Osborne Park Hospital Policy on Admission of Patients. 2006.

16.  Department of Health. Child and Adolescent Health Service Patient Identification Policy (C160). 2007. 17.  Department of Health. Sir Charles Gairdner Hospital Patient Identification Policy (048).2007. 18.  Department of Health. Swan Kalamunda Health Service Nurse Practice Guidelines Identification of Patients. 2007. 19.  Department of Health. Red Alert Bracelet for Patients with a Known Allergy. 2006 [updated 10 July 2006; cited 2010 6 April]; Available from: http://www.health.wa.gov.au/ circularsnew/circular.cfm?Circ_ID=12081 20.  Department of Health. Clinical Incident Management Policy Using the Advanced Incident Management System (AIMS) 2007: Available from: http://www.safetyandquality.health.wa.gov.au/docs/aims/Incident_Reporting_policy.pdf 21.  Department of Health. Western Australian Review of Mortality: Policy and Guidelines for Reviewing Inpatient Deaths 2008: Available from: http://www.safetyandquality. health.wa.gov.au/docs/mortality_review/3_WARM_FINAL_2008.pdf 22.  Department of Health. Sentinel Event Policy 2008: Available from: http://www.safetyandquality.health.wa.gov.au/docs/sentinel/Statewide%20Sentinel%20 Event%20Reporting%20Policy.pdf 23.  Department of Health. WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals working in Western Australia 2009: Available from: http://www.health.wa.gov.au/circularsnew/attachments/395.pdf 24.  PathWest Laboratory Medicine WA. Global Documents and Forms Manual: Minimum Requirements for Clinical Samples and Request Forms 2009: Available from: http://pathlines.health.wa.gov.au/FastTrack/

This document can be made available in alternative formats on request from a person with a disability.
Department of Health 2010

HP 11893 DEC10