Objective

To correctly identify patients prior to medical exposure.

Scope

All x-ray and nuclear medicine exposures.

Responsibility

This procedure is cross departmental, and applies to all staff involved with the identification of patients referred to the clinical radiology department for x-ray or nuclear medicine exposures.  This may include nurses, porters, receptionists, radiographers, radiologists and technical staff.

The operator initiating the exposure, or administering a radioactive medicinal product, is responsible for making the final check on identifying the patient before proceeding.

Practice

1.    Identifying a patient should be an active rather than passive procedure.  In other words the patient should be asked to give their full name, date of birth, and address. If they are wearing a wrist band this should also be read.  These details should be checked against the request card, or other available documentation.

2.    If the patient is unable to respond to the above questions because they are too ill, too young, have language or hearing difficulties etc, the required details should be ascertained from the patient’s wrist-band.  If this is not possible, the patient must be accompanied by a nurse, escort or relative who is able to verify the patient’s identity.  The method by which the patient is identified should be noted on the request form.

3.    If the patient has foreign language problems please contact the link workers between 09.00hrs and 17.00 hrs, outside hours please consult with the referrer for clarification.

4.    The referrer must ensure that sufficient details are included on the request form to enable the patient to be unambiguously identified by the practitioner, operator, and other relevant members of staff.

5.    The identification procedure described in 1. and 2. above must be undertaken whenever a patient is initially identified, or collected by a member of staff, or transferred from the responsibility of one department or member of staff to another.

6.    Particular care needs to be taken in correctly identifying patients with the same or similar names.  If, at any stage, a member of staff becomes aware that patients with similar names are in the department, or on the same ward, they must attach a warning label to the request cards and/or notes of the patients concerned.

7.    The operator responsible for initiating the radiation exposure, or administering radioactive material, must make a final check on the patient’s identity to confirm that the correct patient is about to be irradiated.

NOTE

Special considerations will need to be made if drugs are administered during the procedure and / or if consent if required. 

Update v1 njo 19/10/00