Executive Summary

Positive patient identification is a process which when followed will promote good patient identification practice and reduce the risk of misidentification from occurring. This process should be an integral part of patient care. Checking the patient’s identity should not only take place at the beginning of a care episode but continue at each patient intervention throughout the patient’s entire episode of care to maintain the patient’s safety.

In addition, as per the Patient Safety Alert NHS/PSA/RE/2018/008, each Trust must have a mechanism to temporary identify unknown patients who attend Emergency departments and where care and treatment is delivered for patients unable or unwilling to give their identity. This includes people who are unconscious or who have a critical illness, people with a mental health condition or delirium, and people affected by drink or drugs. Several unidentified patients may arrive together after an accident, or in mass casualty situations.

Giving a unique identity to each unknown patient ensures safe and prompt diagnostic testing and treatment.

The National Patient Safety Agency (NPSA) recommend that where possible, the patient’s NHS number is used as standard. However, an individual hospital number can be used locally for individual identification. Within Ashford and St Peter's Hospitals NHS Foundation Trust, the hospital number is used as standard but the NHS number must be used on all correspondence leaving the trust relating to individual patients (see Trust Information Governance Policy).

All identification procedures will use a minimum of three mandatory descriptors:

  • Full name of the patient (minimum first and last names), no abbreviations or pet name.
  • Date of birth.
  • The unique identifying number (i.e. the hospital identification number).

The patient/parent/carer/partner should verify patient identification details entered into the patient health records by being asked (where possible) to repeat the information back.


Policy Details

Download: PDF version
Compiled by: Andrea Lewis, Deputy Chief Nurse
Ratified by: Nursing, Midwifery & Allied Health Professional Board
Date Ratified: October 2019
Date Issued: October 2019
Review Date: September 2021
Target Audience: All healthcare staff
Contact name: Andrea Lewis, Deputy Chief Nurse


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