ATTACHMENT 6- JAMES H. QUILLEN PATIENT IDENTIFICATION POLICY.pdf

JAMES H. QUILLEN VETERANS AFFAIRS MEDICAL CENTER

(JOHNSON CITY)

MOUNTAIN HOME, TENNESSSEE 37684

November 12, 2010

PATIENT IDENTIFICATION POLICY

MEDICAL CENTER MEMORANDUM

NO…………………………….00-11-02

1. PURPOSE: This memorandum is published to promote patient safety by establishing procedures for a uniform standard to positively identify all patients prior to receiving any care, treatment, or services.

2. SCOPE: The contents of this memorandum apply to all staff that are involved in providing care, treatment, or services to patients and staff.

3. POLICY: Any patient accessing care or services at this medical center will be definitively identified utilizing a uniform method that employs two patient identifiers at the point the patient enters the system. The patient’s identity must be confirmed using a source of information+ other than the patient, such as a Veteran’s Identification Card (VIC), driver’s license, or other official identification (ID). Once positively identified, a wristband is placed on the patient and becomes the source of ID for all inpatient activities. The VIC is the preferred source of ID for all outpatient activities. The patient and/or accompanying responsible person(s) must be actively involved in the identification process and will be asked to state the patient's name and social security number as a second method of verification.

Patient ID shall be reconfirmed using the patient's armband and the patient's statement of name and last 4 of their SSN, provided the patient is able, whenever blood samples or specimen collections are obtained, diagnostic procedures are performed, medications or treatments are dispensed or administered, when diet trays or snacks are delivered, blood products infused, and prior to any invasive or other procedure.

a. When active patient involvement is not possible or the patient's reliability is in question, the medical center will designate the caregiver responsible for identity verification.

These include:

(1) Relatives (parent, spouse, adult sibling, adult child).

(2) Legal guardian.

(3) Domestic partner.

MEDICAL CENTER MEMORANDUM

NO………………….…………00-11-02

(4) Staff who can positively identify the patient due to the fact that they have had a long-term relationship with the patient.

(5) Staff from a transferring facility.

(6) Official picture ID card (e.g., driver’s license).

(7) Legally documented power of attorney.

b. No procedure shall be conducted if a patient’s identity cannot be verified except in situations of life-threatening emergency requiring immediate treatment to stabilize the patient.

c. A patient that remains incapacitated/unresponsive and for whom no alternative source of ID documentation is available to confirm ID, will be assigned a preassembled packet in the Emergency Department (ED). The packets are marked in alphabetical order A through Z. Example: An unresponsive male would start with packet A and a male name associated with the letter A, such as Allen would be assigned. The same would apply for the unresponsive female, assigning a female name to the packet.

Packets would progress in order of the alphabet. The patient's record will be in paper until such time the patient is identified and can be placed into the automated system.

4. ACTION/RESPONSIBILITIES:

a. When identifying a patient, two pieces of information must be used to ID the patient; neither may include the patient’s room number. Patient identifiers must include any two of the following: patient’s statement of name, SSN, date of birth, driver’s license, VA VIC or bar code medication administration (BCMA) bar-coded wrist band.

b. The identification process is always active and involves the patient as an active participant:

(1) The staff/healthcare provider shall ask patients to state their first and last names.

Staff shall not verbalize a patient’s name and then ask the patient to confirm it. The patient may be hearing impaired or respond to what they thought they heard.

(2) The staff/healthcare provider shall ask the patient to provide the last four digits of their SSN or complete date of birth.

(3) The staff/healthcare provider shall verify the ID provided against the medical record and/or other presenting documents (e.g., request/prescription for procedure) to confirm that the information/identifiers match.

c. If the patient had a VIC and the picture is confirmed to be that of the presenting patient, the card satisfies the two-identifier requirement in that the card has a photograph of the patient, the SSN bar-coded on the card and a magnetic strip that contains encoded demographic patient identifying data.

The identification wristband is:

(1) An Endure ID wristband which is computer generated,, containing the patient’s full name, full SSN, and date of birth.

(2) The Endure ID wristband shall be placed on patients undergoing blood transfusions, outpatient chemotherapy, Ambulatory Surgery patients and patients receiving care in the Emergency Department, which includes Urgent Care.

(3) If the patient’s medical condition prohibits the application of the ID wristband to the patient’s wrist (first choice) then the ID wristband will be placed on an ankle as an alternative choice for application.

(4) Patients entering through the Admitting Office will have their ID verified by the admitting clerk using the two-identifier process before placement of the ID wristband.

(5) Patients entering the system through Ambulatory Surgery will have their identification verified by the Ambulatory Surgery staff using the uniform two-identifier process before placement of an ID wristband.

(6) Patients entering through the ED will have their ID verified using the two-identifier process immediately upon entry to the ED at check-in or triage. After the admitting clerk or registered nurse verifies ID, the ID wristband will be placed on the patient. The ED armband will have a blue stripe on the wristband.

(7) Before a patient is admitted, the transferring ED nurse verifies that the ID wristband is in place. The inpatient admitting nurse or Admissions clerk will again verify the patient’s ID using the two-identifier process. Once the patient arrives to the inpatient unit, the nurse will complete the nursing assessment and update any special color alerts. They will then remove the ED ID wristband and replace it with a white inpatient ID bracelet that has a bar code with the updated Endure ID information.

(8) Color coded alert indicators that may be added to the ID wristband include:

(a) Green for latex allergy

(b) Red for all other allergies

(c) Yellow for “High Fall Risk” (HFR)

(d) Purple for “Do Not Attempt Resuscitation” (DNAR)

(e) Pink for restricted extremity

(f) Flesh color for skin precautions

(g) Black for isolation/colonization

(9) For medication administration while a patient is in the ED prior to release or admission to the hospital, confirmation of the patient’s identity will be confirmed by comparison of the order to administer medication to the patient’s ED ID wristband.

(10) For medication administration in non-ED areas after the patient is admitted to the hospital, the bar code on the patient’s wristband and the bar code on the medication to be administered are scanned electronically matching the patient’s identity to the medication being administered. This ensures validation that the correct drug is matched to the correct patient.

(11) Defective, illegible, or missing ID bands shall be replaced IMMEDIATELY after re-validating the patient’s identity using the two-identifier process.

(12) In the event of an emergency, nursing staff will ensure that an ID band is placed on the patient as soon as possible.

(13) Special color-coded wristbands shall be placed on outpatients as indicated per interdisciplinary assessment.

(a) Light Purple wristbands will be placed on patients with “Do Not Attempt Resuscitation” (DNAR) orders.

(b) Red wristbands will be placed on patients with known allergies.

(c) Yellow wristbands will be placed on patients identified to be “High Fall Risk” (HFR) patients.

d. In the event that a unit has one or more patients with the same or similar last name, the Endure ID wristband will be used to place an orange box around the patient’s name. In addition, signage will be placed at any location where there is a possibility of mistaken identity.

e. All other areas that do not use the ID wristband (clinics, Community Based Outpatient Clinics, outpatient radiology, outpatient laboratory, pharmacy, and others).

Patients receiving care in these areas will have their identification verified with the two-identifier process by the healthcare personnel providing the care.

f. In the home care setting the two patient identifiers are required at the first encounter. Thereafter, in continuing one-on-one care where the healthcare provider "knows" the individual, one of the identifiers can be direct facial recognition. In the home, the correct address is also confirmed and can be used as an acceptable identifier.

g. Blood Administration. In addition to verifying patient identity using the two-identifier process, the blood administration protocol is followed as indicated in the Medical Center Memorandum “Blood Transfusion Procedures and Policy.”

h. Blood administration in the Operating Room (OR). Patients receiving blood in the OR will have their identity verified by scanning the bar coded wristband and the item being transfused.

i. Identification errors identified by personnel will be immediately reported to the appropriate Physician, Nurse Manager or Supervisor, and Quality Management & Improvement or Patient Safety Manager. Tracking and trending of adverse events will be done by the Office of Patient Safety.

5. REFERENCES: The Joint Commission Patient Safety Goals Medical Center Memorandum “Bar Code Medication Administration Policy” Medical Center Memorandum “Blood Transfusion Procedures and Policy”

6. RESCISSION: MCM 00-09-05 Patient Identification Policy

7. RESCISSION DATE: November 12, 2013

8. FOLLOW-UP RESPONSIBILITY: Patient Safety Manager (00PS)

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Charlene S. Ehret, FACHE Medical Center Director