PATIENT INDENTIFICATION PROCEDURE

IN PATIENTS

When to apply ID band

For all admissions to hospital an ID Band must be applied. In addition, ID bands are
advised in the following circumstances:

• Patients in Accident and Emergency Department and the acute admission

wards that are receiving opiates and/or are confused secondary to trauma or
physical presentation.
• Patients who are undergoing invasive procedures.
• Patients having blood samples taken (see Outpatient Department)
• Patients having medicines including chemotherapy
• Patients having blood transfusion.
• Patients transferring between wards / departments and sites
• Patients undergoing imaging procedures (see Imaging)
• Any treatment which could result in the patient being unable to identify himself
or herself i.e. sedation / general anaesthesia e.g. prior to surgery

Staff responsibilities
It is the responsibility of the healthcare worker who admits the patient to follow the
policy and ensure that:

• An ID Band stating the patient’s last name (surname), first name, date of birth
and CHI number (if available) and where appropriate the ward, is attached to
an appropriate limb.
• Where the patient is known to have an allergy, this must be clearly stated on
an additional RED band and should contain ONLY the allergy information,
ensuring that where this is a drug allergy that this information is contained in
both the healthcare record and drug kardex.
• Where a patient has multiple allergies the word multiple allergies must be
written on the RED band and staff must check healthcare records to reaffirm
this information. This applies particularly to staff to which the patient is not
known.
• The patient ID band should be placed on the wrist of the patient’s dominant
hand.
• If a limb is not available, for example during surgery, the ID Band must be
securely attached to the patients skin, using a see through plastic adhesive
film, on an area of the body which is clearly visible or alternatively by marking
an appropriate area of skin with patient details using an indelible pen i.e.
shoulder or upper arm.
• It has been agreed that where it is appropriate for patient safety that the name
of the ward and the sex of the patient should be identified on the ID band. This
is particularly important where patients are prone to being confused / leaving
the ward.
• Where clinical areas have identified that it is not appropriate for the patient to
wear an ID band this will be particularly relevant in areas where the clinical
therapy precludes the wearing of a band i.e. dermatology and / or the clinical
 treatment being given may render the patient’s skin sensitive to the ID band
then alternative methods of identifying the patient should be considered.

NB. At the time of writing this policy, work is ongoing in relation to the type and style of
bands to be used throughout the organisation (August 2010).

Patients who do not wear / refuse to wear a band

There may be situations where this is the circumstance e.g.
• Where the patient has multiple intravenous sites
• When the patient refuses to wear/removes the ID Band. This may be as a
result of choice or altered cognitive impairment
• The patient has a clinical condition resulting in the ID Band causing irritation to
the skin
• The patient has a clinical condition, e.g. dermatological or rheumatological and
it is not possible to wear an ID band

It is acknowledged that patients have the right to choose whether or not to wear an
identification band. Some patients may not be capable of making a clear informed
decision in relation to the risk of not wearing an ID band. Patients may also be unable
to comply with the request to wear an ID band. In the event of any of the above, the
patient and where appropriate their relative or carer must be informed of the potential
risks of not wearing an ID Band. An appropriate alternative should be discussed (see
Appendix 1). This discussion and the reason for the patient not wearing an ID Band;
MUST be documented in the patient’s healthcare records.

There may be circumstances where the patient finds it difficult to wear an ID band and
it would be excessive and intrusive to write on the patient’s skin or use adhesive
labels, in these circumstances local procedures must be put in place (see Appendix
1). These procedures must be a result of appropriate risk assessment of the
individual patient.

ID Bands
There are two types of ID bands:

1) Laserband Patient Identification Bands which are generated from TRAK:

• Information that is produced Laserband:

• Last name (surname)
• First name
• Date of Birth
• CHI Number
• Gender
• Ward may be included if the patient is currently at a high risk of leaving
the ward / or absconding / or is confused. This can be added to the
band before it is sealed.

2) Red Alert ID Bands

 All patients must be asked if they are allergic to anything when they are
admitted / treated. It is recommended that for patients with a confirmed allergy
that they wear both a standard ID band and a red ID band together on the
same dominant wrist / limb where they can be easily seen. Allergies should be
identified in the patient’s healthcare record. Where it is a drug allergy this
should also be noted in the drug kardex under allergy section.

See Clinical Warning Alerts Policy – Clinical warning alerts must only be added
to healthcare records when there is an urgent clinical need for the information
to be made available to staff.

Unknown / unconscious patient

Unknown / unconscious or patients incapable of identifying themselves who are
admitted to the Accident and Emergency Department / Assessment Unit, must be
identified as” Unknown Male / Female” and be given a unique A&E record number.

NB. In the event of multiple emergencies, the Major Incident Policy must be followed.

As soon as more details are available, a new ID Band including the surname, first
name, date of birth, and CHI number, MUST be attached to the patient
IMMEDIATELY.

Addressograph labels
Addressograph labels represent a risk to the patient because they are prepared in
advance of the patient being present and may have been inadvertently filed in the
wrong notes. Addressograph labels should not be used for this purpose.

ID labels (not addressograph)

Some areas within NHS Lothian have access to patient ID labels from the Trak
system. These should not be used with Laserband Patient Identification Bands as the
information contained is generated form TRAK. In the event of TRAK being
unavailable or the printer being unavailable the Laserband Patient Identification Bands
can be hand written.

Under NO CIRCUMSTANCES should either of these labels be applied to pre-

transfusion sample tubes as this is known to increase the likelihood of inadequate
patient identification.

Procedure for identifying patient

The nurse / midwife in charge of the clinical area must ensure that there is a process
in place to ensure that each patient admitted has an ID Band throughout his or her
stay in hospital.

If this ID band is removed for any reason the responsibility for prompt replacement lies
with the person who removed the ID band or the staff member that first noticed that
the band was missing.
In situations where it is inappropriate to attach the ID Band to the wrist, place the ID
Band on the ankle (pay particular attention should the patient have oedematous
extremities) see also theatre / sedated patient.

If the patient is known to have an allergy this MUST be clearly identified. This
information should also be confirmed with the patient if possible. A RED ALERT band
must be used. NB. Some patients claim to have an allergy when what they have has
been a side effect from previous treatment. This can be detrimental if treated as an
allergy either in the provision or the non-provision or withholding of appropriate
treatment.

There are TWO steps to positive patient identification. These steps should be
undertaken before any intervention.

1. Wherever possible ask the patient to tell you their full name, date of birth or
address as appropriate and explain to the patient why you are checking this
information.

2. The name and date of birth given must be checked against the ID band for
accuracy.

NOTE. A relative or responsible adult known to the patient can be asked to identify the
patient when the patient is incapable of doing so. Within community settings local
procedures must be in place.

For all newborn babies in the Maternity Units, the Maternity guidelines will be followed.

For all babies admitted to the Neonatal Intensive / Special Care Baby Unit, the
Neonatal Department guidelines will be followed.

The Edinburgh Fertility and Reproductive Endocrine Centre (EFREC) have Human
Fertilisation and Embryology Authority (HFEA) guidelines on patient identification of
bodily fluids.

Administration of the ID band

NHS Lothian is currently using the Laserband Patient Identification Bands for all
patients within the Acute Hospitals. These Patient Identification Bands are generated
from TRAK.

The following core patient identifiers are on the ID band:

- Last name (surname)

- First name
- Date of Birth
- CHI Number/unit number
- Gender
- Ward may be included if the patient is currently at a high risk of leaving the
ward / or absconding / or is confused. This should be written in Black,
before sealing the Laserband Patient Identification Band
In the event of TRAK being offline or the printer being unavailable for a period of time,
the Laserband Patient Identification Bands can be handwritten.

In clinical areas that do not have Laserband Patient Identification Bands the following
information should be included on the patient identification bands.

- Last name (surname)

- First name
- Date of Birth
- CHI Number/unit number
- Ward may be included if the patient is currently at a high risk of leaving the
ward / or absconding / or is confused
- Gender may also be included, if thought necessary

Black text should be used on a white/yellow background.

• Patient details should be recorded on the ID band at the patient’s bedside

• Acknowledgement of accuracy of detail on the band should be confirmed in
the patient’s healthcare records and signed for by the patient or an
appropriate other

NB. Previous comments re identifying the patient’s ward base (see section “staff
responsibilities”).

Transferring / Moving of patients – Portering responsibilities

When a Porter is asked to report to a ward or department to move a patient for
transfer to another department for admission, to the discharge lounge, or to a therapy
department for treatment then the Porter is asked to ascertain:

1) From the work list the name of the patient

2) Identify who the patient is on the ward
3) Confirm prior to moving the patient that the patient’s identity band can be
matched with their request and / or that the patient can confirm who they are
against the identity band.

If this is not the situation then the Porter should ask the Nursing / Midwifery staff to
rectify this situation by putting on an identity band, where appropriate or confirming
that an alternative means of identification has been agreed for this particular patient.

A patients’ care should not be compromised as a result of a missing identity band and
Porters are asked to be respectful of this situation when having to wait for a band to
be applied.

Transfer to the ward from Accident and Emergency / CAA / ARAU

Patients who have been admitted to the wards following treatment in any of the above
units MUST have a CHI / hospital number and not an A&E number on their ID Band,
unless the patient still requires formal positive identification. The patient’s ID Band
should be checked and amended if necessary on arrival in the ward.
Transfer between wards
Where patients are transferred from one ward to another the band should be renewed
on arrival in the new ward. Where an ID Band is in poor condition or inaccurate, it
should be replaced with a new one.

Imaging (e.g. X-Ray, Ultrasound. CT, MRI, etc)

It is ultimately the responsibility of the Operator to ensure that the correct patient is
being examined according to the request that has been made.

If the patient details stated on the request form are incomplete or have not been
completed correctly, further information must be obtained before an exposure is
performed. Except in life or limb threatening situations the exposure must not be
performed until the patient’s identification has been verified.

Imaging Outpatients
The operator must correctly identify the patient prior to performing any exposure:

• Ask the patient to state their full name, date of birth and address. DO NOT ask
them to confirm the details against those on the request form.
• Check the details given against those on the request form. If the details match,
proceed with the investigation / treatment. NB If there is more than one
patient on the radiology information system with the same name double confirm
the identity by asking the patient their home address.

Imaging Inpatients
• When collecting a patient from a ward, portering staff must ask the ward staff to
identify the patient. Details of the patient to be collected are then checked
against the patient’s ID Band. Except in cases of threat to life or limb patients
without ID Bands MUST NOT be moved from the ward until an ID Band has
been supplied and fitted. Porters will refuse to move an inpatient from one
clinical area to another unless there is an ID band in situ with the correct core
patient identifiers, except those patients that are not required to have an ID
band in situ and those who have refused.

• Except in cases of threat to life or limb at the imaging department the patient
MUST be positively identified by asking for a full name and date of birth, which
should be checked against the ID Band and the request form prior to exposure.

• Exceptions are those patients who present in Accident and Emergency

Departments and have been deemed by Accident and Emergency Staff to be
“walking wounded”, and able to identify themselves and the reason for their
examination.

• If an inpatient arrives for an radiographic / radiological examination without an

ID Band:

- They must be identified by asking for their full name and date of birth
provided that the patient is capable of doing so
 - Staff should check the request card to ensure they are the correct person
for the investigation / procedure

- Wherever possible, if this is the situation, the ward must be informed that
the patient is not wearing an ID band and

- If an inpatient a nurse should be asked to come to the department and fit

one, unless the patient refuses

Children
As per policy and in addition where the child is under 13 or is unable to verify
information then the parent / carer should confirm.

Maternity
Mother ID Band on Admission: (this includes admission to triage and for
External Cephalic Version) mother’s ID Band should contain:
• Last name
• First name
• Date of birth
• CHI number
• Ward may be included if the patient has a high risk of wandering from the ward
area or absconding

Baby ID Ankle band

Best practice is to attach the ID bands before the cord is cut. One ID ankle band
should be applied to each leg where not possible alternatives sought and must
include:

• Baby surname
• Boy/Girl
• Date of birth
• Time of birth

The baby's ankle bands should be checked with the mother or father before being put
on the baby. The baby must have the same name as its mother for the duration of the
hospital stay.

If the baby needs to be taken away for resuscitation, either in theatre, labour ward or
Labour, Delivery, Recovery and Postnatal (LDRP) checked namebands, should be
taken along with the baby by the midwife and applied as soon as appropriate, prior to
baby being returned to mum or transferred to neonatal unit. On admission to the
postnatal ward the babies ankle bands should be re-checked by two midwives and
reaffirmed with the mother or father.
Baby identification policy must also be adhered to when baby delivered outwith
maternity unit but within the hospital e.g. HDU.
Local procedures should be in place in the event that a baby is found to have no band.
Separation of Mothers and Babies
Ideally this should not happen. If the baby is separated from the mother, the ID bands
should be checked with the mother prior to separation and checked again with the
mother on the baby’s return.

Exceptions
It may be inappropriate to put ID bands on very small / preterm infants (>24 – 28
weeks). The ID bands should accompany the baby to the Neonatal Unit where they
will be attached to the incubator.

Dead babies of < 20 weeks gestation need to be identified. The ID band in some
instances may be placed around the baby’s waist.

In the case of multiple births, the babies should be numbered in the order that they
were born and identified as e.g. Twin 1 Boy etc. This information must be updated with
the appropriate demographics as soon as they are known.

Babies admitted to Neonatal Intensive / Special Care Baby Unit.

The ID bands MUST ONLY include the baby’s details to avoid confusion.
This should read:
• Boy / Girl Infant’s last name (full name if applicable)
• Date of birth
• Time of Birth

Theatre / Sedated patients

All patients going to theatre must have on, at minimum, two name bands. It is
suggested one on both arms or alternatively one on the leg and one on the arm or as
per local procedure. For example, within Neurosciences it is recommended that three
ID bands are in situ, as it is known that numerous lines are used and access to limbs
may be difficult, therefore local procedures must be adhered to. Once the patient has
been received within theatre:
• The patient must be asked for their full name and date of birth by reception
staff.
• These details must be exactly the same as the details on the theatre list and
healthcare records, to ensure the correct patient is being received.
• This details must be checked against the ID Band, which the patient MUST be
wearing.
• Where a limb is not accessible the identification band should be taped to a
visible area i.e. chest or alternatively mark with an indelible pen the patient
details to an appropriate area of skin i.e. the shoulder or upper arm. In some
circumstances it may be appropriate when no direct accessible area of a
patient is available that identification is made by securing a name band to the
catheter mount of the anaesthetised patient – see local procedure

Unknown patients
• For unknown or unconscious patients (such as trauma patients) identification
will be made by Resuscitation or Emergency Room staff by means of a unique
A&E number on an ID Band, this number should be used until the patient’s true
identity is established.
People with communication difficulties i.e. adults with incapacity, patients
whose first language is not English and / or they have a sensory impairment
It is especially important that these patients have an ID Band to assist
identification.

• An accompanying adult may be asked to give the patient’s full name and date
of birth, where the patient is incapable of doing so for himself or herself e. g
young children, unconscious, confused, language difficulties.
• Wherever possible an interpreter MUST be used if there is a language problem
• Staff should be aware that in some ethnic minority communities naming
structures are different to that of European names, reference should be made
to the religion and cultures handbook (NES Handbook).

People with mental health problems / learning disabilities including dementia

and Aspergers
Within Adult Mental Health and Learning Disabilities it is not essential that patients
wear identity bands. All patients admitted or being cared for within the healthcare
setting should have their identification confirmed at the point of admission.

Within inpatient settings for psychiatry of old age it is expected that identity bands will
be worn. The patient’s identity should be confirmed by the patient, carer, relative or by
accompanying staff. In some circumstances it may be appropriate to keep
photographic records of each patient attached to the patient’s nursing / healthcare
record. This should be kept along side the recording of the patient’s name, date of
birth and CHI number.

All new patients admitted to a unit should be introduced to staff and where visiting staff
are attending to patients to undertake an assessment or intervention for the first time
the patient’s identity should be confirmed with both the patient and with other staff
within the unit.

Where it is considered practice not to use a patient identification band within such
settings constant review of the situation should be undertaken to look at strategies that
will allow positive patient identification.

OUTPATIENTS / COMMUNITY

All community, outpatients and emergency department attendees must have their
personal and demographic details checked at each attendance.

Patients who require any treatment or diagnostic investigations should have their
personal and demographic details confirmed against their health records either paper
based or electronic. Any inaccuracies discovered should be amended as appropriate.
It is acknowledged that it is not practicable for all community/outpatients requiring
blood sampling to have an ID band put in place, however mechanisms to ensure
correct patient identification and subsequent labelling of samples must be in place.

Patients identity in the community / homecare setting

Staff visiting patients in their home will at first contact with the patient confirm their
identity. The patient’s identity should be confirmed with the patient, relative or carer
prior to staff initiating any treatment or intervention with the patient.

Staff visiting a patient in a residential home, nursing home, or other care

establishment will at first contact confirm the patient’s identity whenever possible with
the patient and always verify the patient’s identity with a member of the care staff,
prior to undertaking any treatment or intervention with the patient.

BLOOD TRANSFUSION

Blood Transfusion collection

This has been identified as an area where errors occur (Annual Reports, Serious
Hazards of Transfusion 1996-2005)

The correct identification, collection, transport, delivery and hand over of blood and
blood components is the responsibility of the member of staff who is collecting that
blood / blood component.

Staff removing blood from the blood fridge should have undertaken specific training
provided by the Transfusion Practitioner.

They must take information to the blood fridge with them including:

• The patient’s full name

• Date of birth
• CHI number
• Component/s for collection and quantity.

Blood Transfusion Administration

The bedside check is the last opportunity to discover an error prior to
administration (Serious Hazards of Transfusion (SHOT))

The bedside check is a vital step in preventing transfusion error.

• Two people, one of whom must be a registered Doctor, Nurse or Midwife are
responsible for checking blood.
• The patient must be positively identified by asking them to give their full name
and date of birth.
• The patient must wear an ID Band for transfusion and the information on it must
match the information that the patient has given verbally. (check A&E)
• The patient’s identification details on their band must then be checked against
the patient’s identification details on the blood component pack.
• Where the identity of an unconscious patient has been verified and detail on
name band is correct then the transfusion nurse may confirm procedure.

If you are unsure-DO NOT give blood until the situation is clarified and alternative
volume replacement should be considered.
Deceased patients
All deceased patients MUST be properly identified with 2 ID bands. One should be
applied to the ankle and one should be applied to the wrist. Both ID bands MUST
include the patients:
• Last name
• First name
• Date of Birth
• CHI number

In the event of the patient’s name not being known, then the identification ID Band
must state UNKNOWN MALE / FEMALE with a unique A&E record number.

Two mortuary cards DC 1 and DC 2 MUST be available at the time the deceased is
being removed from the ward or department. DC 1 should be handed to the Porter
and DC 2 should be attached to the sheet or on the outside of the body bag.
REFERENCES
National Patient Safety Agency (2005) Bands for hospital inpatients improves safety.
Safer Practice notice 11

Serious Hazards of Transfusion, (SHOT) Annual Report 2005

Religions and Cultures Handbook (NES)

NHS Lothian Clinical Warning Alerts Policy

NHS Lothian Blood Transfusion Policy

ACKNOWLEDGEMENT
Thanks to Gateshead Health NHS Foundation Trust and Forth Valley for sharing their
policies.