IPSG#1- Patient Identification Committee

King Abdulaziz Medical City-Riyadh

National Guard Health Affairs

JCIAJCIA Requirement: Requirement: Use at least two ways (MRN and patients full name) to Use at least two ways (MRN and patients full name) to identify a patient when giving medications, blood, or identify a patient when giving medications, blood, or blood products, taking blood samples, and other blood products, taking blood samples, and other specimens for clinical testing; or providing any other specimens for clinical testing; or providing any other treatments or procedures. The patient’s room number treatments or procedures. The patient’s room number can’t be used to identify the patient.can’t be used to identify the patient.

NGHANGHA Relevant Policies Relevant Policies APPAPP: : QMHA-00-06-10 QMHA-00-06-10 : :PATIENT IDENTIFICATIONPATIENT IDENTIFICATION

It is the policy of NGHA to ensure that all patients It is the policy of NGHA to ensure that all patients are properly identified prior to any care, are properly identified prior to any care,

treatment/service provided using treatment/service provided using

““Two Unique Identifiers”Two Unique Identifiers”Medical record number and the Patients’ full nameMedical record number and the Patients’ full name

Goal # 1Goal # 1 Identify patients correctlyIdentify patients correctly

Do We Often Face This??Do We Often Face This??

• Use the patients’ room and bed number for identifying patients• Conduct treatment/service when the patient’s identification

can not be verified• Keep the patient without Armband. Defective or missing

Armband shall be replaced immediately with new one

• Remove the Armband. However, in some situations where it can’t be avoided (e.g. the band is interfacing with medical test or procedure), the person removing the band must reapply it to another extremity.

• Stamp the Patient Demographics on the Armband. Pre-printed labels shall be printed from QuadraMedQuadraMed System

• Ask the patient to verbalize his/her full name before rendering any treatment/service

• Match verbalized details to ID band

• In the event of death, keep the band on the patient’s body during transfer to the morgue

• Stamp Each page of patient specific documentation with the stamp which contain the “Two Unique Identifiers”

• If treatment or any procedure or service given to the wrong patient , the attending physician must be immediately notified and an OVA Report must be completed

• Educate Patients and Families about the patient identification process, and the importance of wearing the

Identification Armband

Attach the “The Two Unique Identifiers ” directly to:

• Medications

• Prescriptions

• Inpatient orders

• Blood products

• Appointment slips

• Specimen labels

Emergency Settings• Confirm names with patient, relative or sitter• Issue and Affix the identification Armband upon patient

entry to (Adult Care Unit, Critical Care Unit,

Pediatric Care Unit, or Urgent Care Center) • Unconscious & unidentified patients will be issued with a

temporary MRN & named ‘UNKNOWN’ until formally identified.

• Disaster patients will be issued with pre-printed registration cards with Unknown name &

Temporary MRN

Inpatient Settings:• The Patient Registration Technician shall issue

the patient’s Identification Armband upon patient’s admission to the hospital, following initial identification of the patient

• The Receiving nurse in the inpatient units will affix the identification armband upon patient entry to the units

Ambulatory Care Settings: (Ambulatory Care Clinics, Adult & Peds day care units, hemodialysis, chemotherapy suites, cardiac cath, endoscopy,

In-Vitro Clinic, Medical Imaging, Laboratory services)• Pre-printed Armband must be issued for

all patients undergoing Specialized Diagnostic Procedures by unit assistants.

• It is the responsibility of the Staff Member having

initial contact with the patient to Affix the patients Armband before rendering any treatment or procedures.

For the newborn• ID bracelets are placed on both ankles of the infant• This identification is applied in the delivery area prior to

separation from the mother. • The mother/father or significant other should have a matching numbered-bracelet applied also at this time on

their wrist for identification.• The ID bracelets will be compared each time the infant is

returned to mother/father or significant other

Unresponsive Patients• Ask the caregiver or guardian to verbalize the patient's full

name• Where the health care provider "knows" the patient, one

of the identifiers can be direct facial recognition (e.g. ICU), Home Healthcare Patient)

• Patient Identification process is the responsibility of ALL Healthcare providers:

Nurse

Physician

Pharmacist

Nutritionist

Radiologist

Physiotherapist

Right or Wrong?• To correctly identify my patient, I should ask him “Are

you Mr. Mohammed Qahtani”? • I should identify my patient each time Iam giving him

a medication?

• In the event of death, I should remove the band from the patient’s body during transfer to the morgue?

• The Identification Armband shall be applied to the patients in the IVF clinic?

Select one of the best answers?1- The staff member having initial contact with the patient

shall affix the patient’s Identification Armband. This is applied for the following areas:a) Adult Day Care Unit, Pediatric Day Care Unit,

Cardiac Catheterization Laboratoryb) Hematology/Oncology units c) Endoscopyd) Haemodialysise) All of the abovef) A and C only

Select one of the best answers?2- One of the TWO identifiers can be direct facial

recognition with the following type of patients:a) Home Health Care Patients

b) ICU

c) Business Center patients

d) All of the above

e) a and b only