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.

The Department of Health’s list of Never Events 2012/13 includes patient misidentification stating that “death or severe harm as a result of administration of the wrong treatment following inpatient misidentification due to failure to use a standard wristband (or identity band) identification processes” is an event which should never occur.

The 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:

  1. Full name of the patient (minimum first and last names), no abbreviations or pet name.
  2. Date of birth
  3. The unique identifying number (i.e. the hospital identification number, as allocated through PAS/ Real-time).


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.


Identifying the patient (4 steps)

There are FOUR steps to identifying patients. They should be undertaken in the following order of preference (if the first is not possible, undertake the second, etc.):

  1. By asking the patient to tell you their name, date of birth and/or address. Remember to ask an open question that needs more than a ‘yes or ‘no’ answer, i.e. “What is your name?” rather than are you “Mrs Smith?” Check this is compatible with the patient identification wristband; where wearing an identification wristband is contraindicated or not applicable confirm patient’s details against their record.
  2. If the patient is unable to tell you their name, refer to the identification band and, if possible, verify the information by asking family, relatives or another member of the clinical staff who knows the patient or by using the services of an appropriate interpreter.
  3. By asking that the patients relative identify the patient by name, date of birth and/or address.
  4. By the A&E Department identification number.


When identifying patients it is the responsibility of the practitioner to make sure there could be no mix up with another patient. To reduce the risk of error, the clinician should use all patient identifiers and not rely solely on a name. This applies not only to any treatments and procedures to be carried out on the patient but also when requesting any investigations for them or administering prescribed medication.


Policy Details

Download: PDF version
Compiled by: Deputy Chief Nurse / Assistant Chief Nurse
Ratified by: Nursing & Midwifery Leadership Committee
Date Ratified: October 2013
Date Issued: October 2013
Review Date: October 2015
Target Audience: All healthcare staff
Contact name: Deputy Chief Nurse / Assistant Chief Nurse