Standards › Standard 1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · ID-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 1.1
At a glance
- Ask the patient to say their full name and date of birth. If they cannot, check the wristband and a second identifier.
- Compare both identifiers with the request, prescription or wristband. Every identifier must match.
- Label each specimen at the bedside, with the patient present, using two identifiers, the date and time, and your initials.
- If anything does not match, stop, do not label, and get help.
- Record the check on ID-FRM-001.
- Stop and get help straight away if: identifiers do not match, a wristband is missing and cannot be replaced, or the patient cannot confirm identity and no second identifier can be found.
1. Purpose
To make sure the right care, medicine, procedure, blood product or specimen goes to the right patient, every time [E-007]. Most misidentification errors happen at the bedside, when a label is applied away from the patient or when a bed or room is used instead of a name.
2. Scope
| Applies to | All staff, students and contractors who give care, medicines, blood products, or take or label specimens |
| Locations | All wards, clinics, day care, theatres, imaging, laboratory collection points and home-visit teams at the facility |
| When | Before every medicine, procedure, blood product, specimen collection or transfer, and at admission and discharge |
| Does not apply to | Anonymous emergency care, where the emergency patient identification process (section 10) applies |
3. Definitions
| Term | Meaning |
|---|---|
| Two identifiers | Two separate pieces of information that identify one patient: full name, date of birth, or the hospital identification number. Bed number, room number and diagnosis are not identifiers. |
| Wristband | The identification band with the patient’s identifiers, fitted on admission |
| Specimen | Any sample taken from a patient: blood, urine, swab, tissue or other |
| Bedside labelling | Applying the label while the patient is present and the specimen is in front of you |
4. Background
Patients are misidentified when staff rely on the bed, the room or the order of the list rather than on two identifiers checked with the patient. The risk is highest when several patients have the same surname, when patients are sedated or confused, and when labelling is done at the desk.
This SOP is the working method for the non-negotiable criterion 1.1: every patient is verified using at least two identifiers before any medicine, procedure, blood product or specimen. The audit is in section 12.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Staff member giving care or taking a specimen | Check identifiers, label at the bedside, record the check where required | Trained and observed in this procedure (section 14) |
| Ward or department head | Makes sure the procedure is followed, supports staff, reviews any event | Management training in incident review |
| Quality lead | Runs the monthly audit of the last 20 specimen labels and reports results | Audit training |
| Laboratory director | Rejects specimens that are unlabelled or wrongly labelled, and records the rejection (SOP-071) | Laboratory competence |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Patient wristband | Hospital standard band with full name, date of birth or identification number | Present, legible, correct patient, not damaged |
| Specimen labels | Printed or handwritten label with two identifiers, date, time and initials | Printed correctly, not already used on another patient |
| Request form or electronic order | Matches the patient in front of you | Name and date of birth match the wristband |
| Pen (for handwritten labels) | Permanent ink, not erasable | Working |
7. Safety
- Wear gloves when taking a specimen; follow hand hygiene before and after contact (see the hand hygiene SOP, SOP-037).
- Do not label specimens from another patient, from memory, or from a list you have not checked with the patient.
- Keep the request form and the specimen together. Never carry specimens from several patients in one pocket or tray without individual labels.
8. Before you start
- Check the request or prescription is for this patient and this ward or department.
- Check the labels you will use are for this hospital and are in date.
- Check the wristband is on the patient and is legible. If it is missing, follow the hospital process to replace it before any care.
- Explain to the patient what you are going to do, and why you are checking their name.
9. Procedure
Step 1. Ask the patient to state their full name and date of birth.
- Say: “Please tell me your full name and date of birth.”
- Do not say the name first, and do not nod or confirm if the patient gives a different name.
- If the patient is sedated, confused, a young child or cannot speak, go to step 2 and the special situations in section 10.
Key point: The patient is the best source. Prompting the patient with the name increases errors.
Step 2. Check the wristband.
- Confirm the band is on the patient, legible, and not damaged.
- Check the full name and date of birth on the band match what the patient said.
- If they do not match, stop and go to section 11.
Key point: A band that does not match is an error until proven otherwise.
Step 3. Compare the identifiers with the request.
- Check the full name on the request matches the patient and the band.
- Check the date of birth on the request matches the band.
- If the request has no date of birth, do not proceed. Ask for the order to be corrected.
Key point: Two matching identifiers are required. A matching bed number is not enough.
Step 4. Label the specimen at the bedside.
- Label the specimen in front of the patient, immediately after collection.
- Write or print: full name, date of birth (or ID number), date, time and your initials.
- Check the label against the wristband again before the specimen leaves the bedside.
Key point: Labelling away from the patient is a known cause of errors. Label at the bedside, every time.
Step 5. Before giving a medicine, blood product or procedure, repeat steps 1 to 3.
- Do the check again at each new activity, even if it was done an hour ago.
- If the patient has moved bed, been to another area or returned from a procedure, repeat the full check.
Key point: Identity can change through transfers. Each activity is a new check.
Step 6. Record the check where required.
- For each specimen in the audit sample, record the identifier check on ID-FRM-001 with date, time and initials.
- Keep the completed form in the ward or department file for the period stated in section 13.
Key point: The record is how the audit shows the check was done, not only that it should have been.
10. Decision points
- If the patient gives the correct full name and date of birth, and the wristband matches, continue to step 3.
- If the patient cannot confirm their identity, check the wristband and one identifier from the record with a second member of staff, if available, before proceeding.
- If any identifier does not match, stop. Do not label or give anything. Go to section 11.
11. Special situations
| Situation | Action |
|---|---|
| Unconscious, sedated or unable to speak | Check the wristband and at least one identifier from the medical record with a second member of staff. Record who was present. |
| Newborns and infants | Use the hospital neonatal identification process, including matched bands for the infant and the mother. Check both bands before each activity. |
| Patients with the same name on the ward | Use both identifiers and, where possible, a second member of staff. Consider a visual flag on the record, agreed with the ward head (EC). |
| Emergency patients with no identity | Use the hospital temporary identification number. Link it to the true identity as soon as known. Record the link in the record and on the specimen (EC). |
| Patients returning from theatre or procedures | Repeat the full check on return, using the wristband, before handing over care. |
12. Escalation
- If identifiers do not match, stop, inform the ward or department head, and report the event through INC-POL-001 on the same shift.
- If a specimen is labelled incorrectly, do not send it to the laboratory. Relabel only through the hospital correction process, and record the correction.
- If the audit finds a missing check, review the individual practice the same week and record the action.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Last 20 specimen labels show two identifiers and an identifier check | 100% (non-negotiable) | Monthly | Quality lead | Immediate review of all labels in that period; retraining of staff involved; report to clinical director |
| Bedside labelling observed during spot checks | 100% of observed samples | Monthly, at least 10 observations | Ward or department head | Coaching and re-observation within two weeks |
| Incidents involving misidentification | Zero harm events; every event reviewed | Monthly | Quality lead | Root-cause review for every event |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| ID-FRM-001 Patient Identification Check Log | Ward or department file; quality lead for audit | the period set by the facility’s records policy years |
| Incident report (INC-POL-001) | Incident log | the period set by the facility’s records policy years |
15. Training
- Before working alone, every member of staff who takes specimens or gives medicines is observed doing this procedure and signs off competence (EC).
- Refresher training and a repeat observation each year, and after any event involving identification (EC).
- Staff new to a ward receive a briefing on local identification rules (wristband colours, neonatal process) on their first shift.
16. Related documents
| ID | Title | Use |
|---|---|---|
| ID-FRM-001 | Patient Identification Check Log | Record used in step 6 |
| REC-FRM-001 | Mandatory Records List | Identifiers are a mandatory record entry |
| INC-POL-001 | Incident Reporting and Management | Used when a check fails |
| SOP-037 | Infection Prevention and Control Procedure (generic) | Used before and after specimen collection |
| SOP-071 | Specimen Rejection Procedure (generic) | Laboratory rejects unlabelled specimens |
17. Evidence
| Reference | Note |
|---|---|
| E-007 | World Health Organization. Patient Safety Solutions series (2007), correct patient identification. |
| E-009 | ASF Expert Committee consensus. Special situations and audit sample size are EC decisions. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | Full procedure expanded from the short form; added steps, decisions, special situations and monitoring | Approved by the ASF Expert Committee |
E-learning for this document
- Correct Patient Identification (—)
- Patient Identification, Informed Consent and Patient Rights (T-07)
References
- World Health Organization (2007). Nine patient safety solutions, including correct patient identification. Geneva: WHO. Open source (E-007)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)