Administration General Policy Version 6
The purpose of this policy is to describe the process of verifying the identification of a patient prior to any encounter.
It is the responsibility of the staff on Inpatient units, Emergency Departments, and Radiology (further referred to as "In-house") to properly identify all patients prior to placing any identification (ID) band on patients. It is also the responsibility of all staff to verify this identifying information corresponds with planned encounter at the time of each encounter.
It is also the responsibility of staff in Outpatient areas not using ID bands to properly identify all patients prior to interacting with the patient.
It is the requirement of Akron Children's Hospital Enterprise as specified to follow the guidelines as dictated in this policy.
Applies to: All Akron Children's Hospital Enterprise.
The exact method of patient identification will depend on the circumstances, setting, and ability of the patient to communicate. Every staff member interacting in any clinical manner with the patient will follow the guidelines listed below. Every In-house patient (see above definition) must wear an identification band at all times. Identification bands will contain at least two patient identifiers (name, birthdate, and/or medical record number) which are used to verify the identification of the patient prior to any clinical interaction. Verification of patient identification is to ensure that the appropriate patient receives the ordered care and/or treatment and appropriate documentation is connected to the correct patient. Care and treatment requiring identification verification prior to completion includes, but is not limited to, taking a history, drawing blood, administering a procedure, performing a radiographic exam, administering medication, etc.
Identification of the Patient and Application of ID Band
1. The patient who presents for treatment/service will be identified by two identifiers; name and birth date or other unique identifier (Social Security number) by the responsible adult accompanying the patient or the patient will identify self in the same manner. If there is missing or conflicting information about the patient identification, contact immediate supervisor for assistance in resolving issue. See Registration Policy.
2. If a patient cannot be immediately identified because there is no responsible adult accompanying or the patient is not able to take an active role (age and condition appropriate) in verbal communication establishing a preliminary identification of the patient, a temporary ID will be established using the procedures from "Unknown Patient Name Assignment" policy. This will result in their last name being "unknown". The identity will be used for registration and ID band will be made with this temporary ID.
3. Once an In-house registration is completed and an ID band is made, it will be placed on the patient by a staff member that can confirm the identification of the patient. At this time the staff member that can confirm the patient's identity matches the ID band by asking the patient/responsible adult for Patient name and birthdate. This step is not possible in the case of unidentified patients.
4. Specific ID Bands:
a. Patients will have a white snap style pediatric or adult size ID band applied appropriately sized to the patient.
b. Unit specific ID bands will be applied in the following areas:
1. Emergency Department - neon orange
2. Neonatal Units - soft velcro band
3. Inpatient Behavioral Health Unit (8100) - white slip and stick style band.
c. Alternate ID bands need to be applied for allergies: All allergies, including latex use red ID bands.
d. Alternate ID bands for patients who have been identified as a high risk for falling: Increased risk of falling use a bright yellow ID bands.
e. Alternate ID band for blood product administration, in use at Beeghly campus: Green.
Patient Identification at the Time of a Clinical Encounter
1. ID band in place(Must be presented to draw any specimen for Blood Bank)
a. Preliminary ID - When approaching the patient/family, staff will allow patient/family to take an active role (age and condition appropriate) in verbal communication establishing a preliminary identification of the patient. Staff may ask for the first and last name and birth date of the patient. This information is verified against the request about to be fulfilled.
b. Final ID - Prior to taking any action, the patient's ID band must be checked for the proper two identifiers - Medical Record Number and Name with the request that is about to be fulfilled.
i. Two staff members must validate the two patient identifiers against the Blood Bank Requisition at the time a patient's transfusion specimen is being drawn.
2. No ID band in place
a. If no ID band is present on the patient, the staff member is to find a nurse or physician who can identify the patient and follow the procedure for identifying the patient prior to placing an ID band on the patient. Once the patient is identified with an ID band, the above procedure can be followed for completing any interactions with the patient.
Outpatient/Clinic Areas/Outpatient Surgery
1. Two identifiers must be used to identify each patient.
a. Preliminary ID - In a public setting use the first name only to call the patient. If two patients/families respond, quietly approach one family and request the entire name.
b. Final ID - Once in a private setting follow the procedure listed:
Identification - Allow the patient/family to take an active role (age and condition appropriate) in verbal communication establishing the identity of the patient.
Ask them to state the first and last name and birth date of the patient. Verify both of these identifiers against the request you are about to fulfill.
c. Two staff members must validate the two patient identifiers against the Blood Bank requisition at the time a patients transfusion specimen is being drawn.
1. All those treating the patient should continue to follow the procedures above using two unique identifiers created by the temporary identification.
2. Once the patient is fully identified, a corrected registration will be created with appropriate information according to the "Unknown Patient Name Assignment" policy. The account number and medical record number will remain the same until after discharge at which time changes will be made if applicable. Ancillary areas will update information as provided.
Joint Commission Hospital Manual NPSG 01.01.01 2013 Regulations and interpretive Guidelines for Hospitals Rev. 12/22/2011
(8 a.m.-4:30 p.m.)
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