General Principles

Secure patient identification plays a key part in all aspects of safe healthcare. Patient misidentification is increasingly being recognised as a widespread problem within healthcare organisations.

SHOT reports have identified that ‘patient identification band missing, defaced or hidden’ is a significant contributory factor to wrong blood incidents.

All patients receiving a blood transfusion must wear a patient identification band, or risk assessed equivalent (BCSH Guideline for the Administration of Blood Components 2009)

Positive patient identification (asking the patient to state their name and date of birth and matching this information against the patients identification band and any other associated paperwork) is essential at every stage of the transfusion process, e.g.

• Clinically assessing the patient – are you assessing the right patient with the right blood results
• Blood sampling – are you taking the right blood sample from the right patient and labelling the sample with the right patient details. Labelling the sample with another patients details is a ‘wrong blood in tube’ incident, which could result is an ABO incompatible transfusion
• Collection of the blood component – is the right unit of blood being collected for the right patient
• Blood administration – is the right patient receiving the right blood

Further information:

• The use of Information Technology (IT) or electronic systems to enhance patient identification [link to electronic patient ID page]
• Paediatric specific patient identification considerations [link to paediatric ID page]
• Sample labelling [link to section – patient safety and laboratory practice]
• Patient Safety [link to patient safety section]

 

National guidance / recommendations

British Committee for Standards in Haematology (BCSH 2009) Guidelines for the Administration of Blood Components

• Detailed patient identification recommendations, including wristband requirements and positive patient identification throughout the blood administration process

Department of Health (2012) ‘Never Events’

• ABO incompatible transfusion (which are primarily caused by patient misidentification) is a Department of Health ‘never event’

National Patient Safety Agency (NPSA 2005) Safer Practice Notice ‘Wristbands for hospital inpatients improves safety’

• Recommendations for the use of wristbands

National Patient Safety Agency (NPSA 2006) Safer Practice Notice ‘Right patient, right blood’

• Discusses use of electronic identification systems and other alternative methods of patient identification e.g. photo ID

National Patient Safety Agency (NPSA 2007) Safer Practice Notice ‘Standardising wristbands improves patient safety’

• Defines the NPSA wristband design requirements – content and format

National Patient Safety Agency (NPSA 2007) Safer Practice Notice ‘Risk to patient safety of not using the NHS Number as the national identifier for all patients’

• Recommends use of the NHS number

National Patient Safety Agency (NPSA 2008) Patient identification errors from failure to use or check ID numbers correctly

• ​www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=29225

Note: On Friday 1 June 2012 the key functions and expertise for patient safety developed by the National Patient Safety Agency (NPSA) transferred to ‘NHS England’