INTERNATIONAL PATIENT SAFETY GOAL (IPSG): Identify Patients Correctly

CHAPTER ONE: 

INTERNATIONAL PATIENT SAFETY GOAL (IPSG):  

IPSG  

Identify Patients Correctly

Two approved identifiers (inpatient & OPD) Use third identifier if patients with same name, look-alike, sound-alike + name alert flagging.   

DEFINITIONS

• Active Patient Identification — the process of identifying a competent adult patient by asking his/ her to tell the staff his/ her full name while staff ensures it matches the information on his/ her ID band and medical record file, as appropriate.
• “Patient identifiers” are those names, numbers, etc., whose purpose is to uniquely identify one particular patient and distinguish him/her from all other eligible medical recipients.
• Electronic ID Band — Patient ID Band is being printed electronically using thermal printers. It is a new system implemented in the hospital as part of initial phase of implementation for the integration of hospital information through electronic system.
• Vulnerable Patients — patients who are unable to communicate due to temporary communication impairments (such as those who are unconscious, heavily medicated, on ventilators, or are in intensive care or recovery) or cannot communicate because of language barriers and an interpreter is not readily available, age (such as infants), cognitive impairments (such as dementia or behavioral disorders), or medical condition (such as coma).

Patient Identification is required in the following (but not limited to):

• Upon admission/ first contact — patient identification shall commence upon the first contact with administrative staff members like reception for check-up/ follow-up (for outpatient) and ADT (admission, discharge & transfer) staff during opening file for admission (for inpatients). This step is crucial because all subsequent identification episodes will be based on the information captured in the first contact.
  • Before providing treatments (such as administering medications, blood, or blood products, serving restricted diet trays; or providing radiation therapy).
  • Performing procedures (such as insertion of an intravenous line or hemodialysis).
  • Before any diagnostic procedures (such as taking blood and other specimens for clinical testing, or performing a cardiac catheterization or diagnostic radiology procedure).
  • During transfer, discharge and confirmation of death
• For labor cases, upon admission aside from taking the female patient’s I.D., it is a must to take copy of the male companion (father/husband/brother) I.D. must be kept in the patient’s file.
• For emergency cases, if the patient’s ID is not available, copy of the ID from patient’s next of kin must be kept in the patient file.

There are two (2) approved identifiers per setting for:

1. INPATIENT setting:
   1. Patient full name (three names for Arabic patients)
   2. Patient Medical Record number
2. OUTPATIENT setting:
   1. Patient full name (three names for Arabic patients)
   2. National ID and/ or Iqama number

• Additional identifier for inpatient must be used in rare cases when two (2) patient identifiers are the same for more than one person, ID and of the patient must be used as third identifier.
• Room number, bed number and sex (except for newborns) are never used as patient identifiers.
• In cases when patients are having the same name and look or sound very much alike, a NAME ALERT process must be carried out to decrease the risk of error.
• ID Band (Electronic or Manual)
  All admitted patients will have an ID band Outpatients do not wear ID bands except for outpatient setting in which patients are receiving treatments/ medications and procedures like:

   

  • Patients in Emergency Room (ER).
  • Patients having procedures with procedural moderate sedation / analgesia.
  • Patients on haemodialysis
  • Patients in Assisted Reproduction Unit
  • Patients in Nuclear Medicine
  • Patients in Radiology & Imaging Department where prolonged stay is anticipated [e.g. Intravenous Pyelogram (IVP), MRI with contrast, CT-Scan with contrast, Fine
  • Needle Aspiration (FNA)]
  • Newborn Circumcision
• Application of ID Band will be as follows:
  • Patient wrist or the easiest accessible limb
  • In case when patient is undergoing surgery and the existing ID band needs to be removed then OR staff will generate temporary ID band and attach to the next available limb.
• Exemptions in ID Band application:
  • If application of ID band as a “bracelet” is impossible (i.e. if patient is limbless, or is extremely agitated and harms him or herself by trying to remove the bracelet, if the patient has burned extremities, or is an extremely premature newborn, etc.).
  • Visibly attach ID band to the patient’s bed / crib
  • This application is to be noted in the patient’s Nurses Progress Notes.
• If the ID band is fading, missing, or contains information that is incorrect, the test, treatment, medication, procedure, etc. will not be performed until the information is corrected and the patient is accurately identified.
• Vulnerable Patients:
  • Vulnerable patients with ID band – verification of patient identification must be done by having the Registered Nurse check the patient’s name and medical record number on the ID band against the information from the medical record file.
  • Vulnerable patients without ID band – verification of patient identification must be done by confirming patient ID against the medical record and contact next of kin to confirm patient identification.
• For unknown and unresponsive patients (such as Trauma Patient in ER) identification is made by ER Staff, assigned a temporary name and an ER number or medical record number until the patient true identity is established.
• Labeling of medical record with correct patient identification. Check addressograph labels to ensure the patient information is correct before using them on medical records, test requests, prescriptions, etc.
• Label specimens using electronically printed sticker labels and apply it in the room or in the immediate vicinity of the patient and never in another location. Check carefully that the ID information matches the patient and the clinician’s order. Always finish labeling one patient’s specimen before collecting/ labeling another set of specimens.
• Discharge of Patient, the Registered Nurse will be the one removing the ID band before patient is released from the unit.
• In the event of patient death, the ID band shall remain on the patient.

A new ID Band shall be generated and re-applied to the following situation:

• when ID band is fading
• when ID band is missing
• when ID band is having incorrect information
• when ID band was removed for clinical procedures like cannulation

• If the ID Band is fading, missing, or contains information that is incorrect, the test, treatment, medication, procedure, etc. will not be performed until the information is corrected and the patient is accurately identified.
• For inpatients, a new Electronic ID band shall be requested from the ADT Office by the Registered Nurse with patient’s medical record.
• Two (2) Registered Nurses shall be involved in changing patient ID band after patient verification.
• Documentation of change of ID band shall be reflected in the Nurses Progress Notes.

• For unknown and unresponsive patients (such as Trauma Patient in ER) identification is made by ER Staff, assigned a temporary name and an ER number or medical record number until the patient true identity is established.
• Labeling of medical record with correct patient identification. Check addressograph labels to ensure the patient information is correct before using them on medical records, test requests, prescriptions, etc.
• Label specimens using electronically printed sticker labels and apply it in the room or in the immediate vicinity of the patient and never in another location. Check carefully that the ID information matches the patient and the clinician’s order. Always finish labeling one patient’s specimen before collecting/ labeling another set of specimens.
• Discharge of Patient, the Registered Nurse will be the one removing the ID band before patient is released from the unit.
• In the event of patient death, the ID band shall remain on the patient.

NAME ALERT

To decrease the risk of error when patients have same name and look or sound very much alike:

1. Patient should not routinely be placed in the same room.

Exception: Husband, wife, mothers, sisters, father / son, mother /daughter — requesting the same room may the accommodated.

1. At the time of admission, prepared “Name Alert” label, shall be placed on the patients:
   1. Chart front
   2. Unit dose ( MAR )
   3. Nursing notes
   4. Inform all personnel or duty and at change on shifts of name similarity.a