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Positive patient identification policy

1 Policy summary

The purpose of this policy is to ensure that all patients can be correctly identified, to reduce and where possible, eliminate the risks and consequences of misidentification.

The National Learning Report: Positive Patient Identification acknowledges that positive patient identification is seen as a routine task, but is common, complex and critical for patient safety. The risk of patient misidentification is underestimated, and patient misidentification can result in significant harm to patients.

A report by the National Health Executive and Melissa state that patient verification is a foundational element of effective healthcare delivery. By ensuring accurate identification, practices can enhance patient safety, streamline processes, and reduce fraud.

The trust provides care to a multi-diverse client group which may require different methods of patient identification (ID). It is imperative that positive patient identification, at the earliest opportunity, is achieved using core patient identifiers (for example, asking for the patient’s name, date of birth and address). The trust considers photographic ID to be a useful enhancement to positive identification, however, permits the use of wristbands as an alternative across inpatient settings where clinically indicated.

The policy provides clear guidance on the procedure for positive patient identification, including colleague responsibility for storage, use and disposal of identification methods.

2 Introduction

Positive patient identification means correctly identifying a patient to ensure they receive the right care, whether this is diagnostic testing, routine treatment, or emergency intervention.

Patient misidentification occurs when a patient is mistaken for someone else. This can lead to a patient either missing necessary care or receiving care intended for another person, both of which pose significant risks to safety and quality.

Patient identification is required at every point of contact between a patient and healthcare colleagues. This involves an initial identification on registration or admission and ongoing verification throughout care.

Key identifiers include:

In inpatient settings, wristbands are generally recommended by the National Patient Safety Agency (NPSA). However, wristbands may not be appropriate in mental health units, where their use is excluded by local agreement (Department of Health, Never Event List 2012 and 2013).

Photographs are encouraged in inpatient areas as an additional safeguard. Wristbands may still be used where clinically appropriate and with patient choice.

3 Purpose

This policy sets out a clear process to ensure:

  • accurate identification of patients at registration or admission
  • ongoing verification of patient identity during care
  • reduction, and where possible elimination, of risks related to misidentification

4 Scope

This policy applies to all care teams and services across the trust.

Forensic services: Amber Lodge colleagues should also refer to the admission of a patient to forensic services procedure.

For roles, responsibilities and accountabilities, see appendix A.

5 Procedure

5.1 General principles

  • Patient identity must be confirmed at the earliest opportunity; at referral, admission, registration, and at each care interaction.
  • Identification is especially important when patients are unable to reliably confirm their own details (for example, unconscious, confused, communication difficulties, lacking capacity).
  • In inpatient areas: the person in charge of each shift is responsible for ensuring a reliable identification method is in place.
  • In community services: the team manager is responsible for compliance.
  • No single identification method is 100% reliable. Colleagues must balance patient safety with respect for privacy, dignity, and equality.

5.2 Confirming patient identity at registration

Core patient identifiers:

  • full name
  • date of birth
  • address
  • NHS number (or temporary number if NHS number unavailable)
    Identity must be confirmed at the earliest opportunity, for example:

    • referral, registration or admission
    • first meeting or telephone call
    • before any care is delivered

5.3 Confirming patient identity at point of care

At every care interaction, identity must be checked using core identifiers, supplemented in inpatient areas by photographic identification (ID) or wristbands (if clinically indicated).

Verification is required whenever a colleague:

  • administers treatment, medication or an intervention
  • collects specimens or samples
  • performs examinations or investigations
  • undertakes assessments or provides results
  • gives a diagnosis or management plan
  • arranges appointments or transport
  • confirms or verifies death

5.4 Confirming identify of children and young people

  • Identity may be confirmed with the support of parents or carers.
  • For very young children, parents or carers provide confirmation.
  • For school-based services, details (name, address, date of birth (DOB), contact number) must be cross-checked with the electronic patient record (EPR) or vaccination consent forms.
  • For medication at home, checks should be against the electronic patient record and confirmed at the home address.

5.5 Photographs (inpatient only)

5.5.1 Taking a photograph

  • Use a clear, light, non-glossy background.
  • Ensure good lighting on the face; avoid shadows.
  • Head and shoulders shot (passport style).
  • Patients should keep glasses and cultural headwear unless they obscure key features.
  • Indicate coloured contact lenses in the electronic patient record.

5.5.2 Updating photographs

Photographs should be renewed every 3 months or sooner if:

  • appearance significantly changes
  • print quality is impaired
  • requested by the patient

5.5.3 Storage and security

  • Upload to electronic patient record using the trust’s patient identification guide (staff access only).
  • One printed copy may be attached to paper medication charts.
  • Immediately delete digital files from devices after upload.
  • Replace and securely destroy old photographs when updated.

5.5.4 Consent and capacity

  • Consent must always be sought and explained clearly in line with the trust consent to care and treatment policy.
  • Patients with capacity to consent to having their photo taken who refuse a photo may be offered a wristband.
  • Alternative methods must be agreed, documented, and regularly revisited.
  • If capacity is lacking, follow Mental Capacity Act (MCA) processes and make a best interest decision.

5.5.5 Use and disposal

  • Photographs may only be used for identification unless legally required or in the patient’s best interests.
  • On discharge, photographs must be removed as the demographic photo and securely destroyed (or returned to the patient if printed).

5.6 Wristbands (inpatient only)

5.6.1 Standardisation

  • White wristbands with black text only.
  • Include only:
    • full name
    • date of birth
    • address
    • NHS number (or temporary number)
  • Allergies must not be listed on the wristband.

5.6.2 Fitting and maintenance

  • Must be comfortable, secure, and fit all patient sizes.
  • Check at least weekly for legibility and fit.
  • Replace if damaged, illegible, or missing.
  • Wristbands may be placed on the ankle if necessary.

5.6.3 Risks and limitations

  • Wristbands can fall off, be swapped, or cause discomfort or skin irritation.
  • Colleagues must not rely on wristbands alone but always confirm with additional identifiers.

6 Training implications

All areas must have clear induction guidelines for temporary colleagues who may be required to take patient photographs, including area specific training for colleagues on the use of the relevant digital equipment used to take photographs.

All colleagues need to be aware of the key points that the policy covers. Colleagues can be made aware through:

  • one to one meetings or supervision
  • continuous professional development sessions
  • practice development days
  • group supervision
  • intranet
  • staff app
  • team meetings
  • local induction
  • lessons learned from complaints and incident

7 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

7.1.1 How this will be met

No issues have been identified in relation to this policy.

7.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure for that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

7.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the mental capacity Act (2005).

9 References

10 Appendices

10.1 Appendix A responsibilities, accountabilities and duties

10.1.1 Board of directors

It is the responsibility of the board of directors to have policies in place that meet any legislation, national and local requirements and promote best practice.

10.1.2 Care group directors

Care group directors are responsible for the implementation of the policy within their respective care group.

10.1.3 Clinical leads, modern matron’s and deputy care group directors service managers

Clinical leads, modern matron’s and services are responsible for:

  • ensuring colleagues are aware of this policy and monitoring compliance
  • performing regular patient identification audits as per appendix B

10.1.4 Clinical colleagues

Clinical colleagues are responsible for:

  • adhering to this policy
  • taking a photograph or applying a wristband on admission
  • obtaining, recording or checking the patients’ details or identity
  • checking the patients’ identity prior to administration of medicines or treatments or care interventions
  • reporting any incidents involving patient misidentification via the trust incident reporting system
  • replacing photographs and wristbands where required

10.2 Appendix B monitoring arrangements

10.2.1 Compliance with this policy

  • How: incident reports.
  • Who by: patient feedback.
  • Reported to: care group.
  • Frequency: monthly.

Document control

  • Version: 6.
  • Unique reference number: 341.
  • Approved by: clinical policies review and approvals group.
  • Date approved: 7 January 2026.
  • Document author: head of information quality.
  • Title of accountable director: chief nurse.
  • Date issued: 4 February 2026.
  • Review date: 28 February 2029.

Page last reviewed: February 04, 2026
Next review due: February 04, 2027

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