ID-SOP-001: Patient Identification and Specimen Labelling

This is a controlled copy when approved. Printed copies are uncontrolled; check the version against the document register before use.

Contents

Abbreviations

Purpose

To make sure each patient receives the right care, and that every specimen, medicine, blood product and record is linked to the right patient. Most wrong-patient errors happen at the point of care, when a task is done for a patient whose identity has not been checked against the record. This SOP sets out how identity is confirmed before each task, how specimens and blood products are labelled, and what to do when identity cannot be confirmed. This SOP supports the identification requirements of the ASF hospital standard.

Scope

Definitions

Background

The Joint Commission requires two patient identifiers to be used, and states that a room number is not a unique identifier [1]. Identification is one of the nine WHO Patient Safety Solutions published in 2007 [2]. Wrong-patient errors are often caused by a task being done on the patient in the bed rather than on the patient named in the order. The check must therefore be made with the patient, against the order, every time.

Responsibilities

Materials and equipment

Safety and exceptions

• Patients who cannot confirm identity (unconscious, confused, sedated, or non-verbal): use the wristband and the record, check with a second member of staff where possible, and record how identity was confirmed.
• Unidentified patients on arrival (for example, an unresponsive patient in the emergency department): assign a temporary name and a unique number, use them on every order, label and record, and link to the real identity as soon as it is confirmed [1].
• Pre-labelled items: a label printed or applied before the patient is seen is never used. Unused labelled containers are discarded at once [1].
• Language barrier: use a qualified interpreter. A nod or “yes” from a patient who has not understood is not confirmation.

Procedure

Before you start

• Check the order, request or prescription: it names the patient and the task.
• Check that wristband stock and label supplies are available on the unit.
• Check for a name alert before you approach the bed.

Step 1. Apply and check the wristband on admission or first contact

1. Confirm the patient’s full name and date of birth with the patient, and check them against the registration or referral.
2. Apply the wristband with at least two identifiers and the record number, and check the details aloud with the patient before you leave.
3. The wristband must stay on the patient at all times. Do not leave it on the bedside table or tape it to the bed [1].
4. If the wristband is missing, cut or illegible, confirm identity with the patient and the record, then apply a new band and record the event.

Step 2. Confirm identity before each task

1. Ask an open question, for example: “Can you tell me your full name and date of birth?” Do not offer the answer. Do not ask a question that can be answered “yes” or “no”.
2. Compare the patient’s answer with the wristband, then with the order or request, reading each identifier aloud.
3. Where the patient cannot answer, use the wristband and the record, and confirm with a second member of staff.
4. Do not start the task until the identifiers match.

Step 3. Label specimens at the bedside

1. Confirm identity (Step 2) before you collect the specimen.
2. Label the container in front of the patient, straight after collection, with two identifiers, the date and time, and your initials [1].
3. Urine containers may be labelled before collection, but only after identity is confirmed, and the label must be applied in the patient’s presence. Discard any unused labelled container at once [1].
4. Send the specimen with the matching request. Do not send a specimen whose label was written before the patient was seen.

Step 4. Give blood products and high-risk medicines

1. Follow the transfusion policy. Check the blood product label, the request and the wristband together, at the bedside, against the patient’s identifiers.
2. Where the policy requires two staff to check, both check the identifiers aloud before the transfusion starts.
3. Record the check on the transfusion chart, with both names or initials.

Worked examples

Decision points

Escalation

Monitoring and compliance

Records

Training and competence

• Induction: the two-identifier check, the open question, bedside labelling, temporary identifiers and the mismatch rule, with a supervised session on a ward.
• Annual competency: direct observation of identification at three tasks, including one specimen and one medicine.

Related documents

References

1. The Joint Commission. Standards FAQ: National Patient Safety Goals, patient identifiers, specimen labelling, temporary names and armbands. Available from: https://www.jointcommission.org/standards/standard-faqs/home-care/national-patient-safety-goals-npsg/000001545/
2. World Health Organization. WHO Patient Safety Solutions, launched 2 May 2007 (patient identification is one of the nine solutions). Available from: https://www.who.int/news/item/02-05-2007-who-launches-nine-patient-safety-solutions

Change history

Annex A. Identification audit record

Use this record for each audit session. Record one line per task observed. Enter Y, N or NA as shown in the column heading.