IPSG#1- Patient Identification Committee

King Abdulaziz Medical City-Riyadh

National Guard Health Affairs
 Goal # 1
Identify patients correctly
JCIA Requirement:
Use at least two ways (MRN and patients full name) to identify a patient
when giving medications, blood, or blood products, taking blood samples,
and other specimens for clinical testing; or providing any other treatments
or procedures. The patient’s room number can’t be used to identify the
patient.
NGHA Relevant Policies
APP: QMHA-00-06-10 :PATIENT IDENTIFICATION
It is the policy of NGHA to ensure that all patients are properly
identified prior to any care, treatment/service provided using
“Two Unique Identifiers”
Medical record number and the Patients’ full name
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 QuadraMed 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 Laboratory
b) Hematology/Oncology units
c) Endoscopy
d) Haemodialysis
e) All of the above
f) 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