The Joint Commission’s requirements around patient identification is that two patient identifiers are used to correctly associate an individual with the intended service or treatment. These can include the patient’s name, medical record or identification number, telephone number or date of birth. The goal is to ensure accurate identification of a person and matching of that person to the correct service or treatment (Joint Commission, Oct. 2021).
Wristbands are often used as a source of patient information. It is important that these are physically attached to the patient, as opposed to being taped to the bed or bedside table. While wristbands are common, organizations may determine other sources of information to use in various settings including the outpatient one (Joint Commission, Oct. 2021).
Errors Involving Patient Identification
Patient identification can get tricky with individuals who are unable to verify their identity due to the inability to participate in the identification process. This includes our smallest and more vulnerable patient populations- newborns. They present distinct challenges because they look similar to other newborns, usually are not given a first name until several days after birth, and can have similar last names, medical record numbers, and birth dates (ISMP, 2019).
If accurate identification is not established from the start, a cascade of problems can result including expressed breast milk misfeeds, errors involving medications, orders, and documentation, wrong tests/surgeries/procedures, mother-newborn mixups, and even newborns being switched at birth or discharged to the wrong parents (JC, Sept. 2021). A study conducted by the Pennsylvania Patient Safety Advisory in 2016 found that the newborn misidentification events occurred an average of 2 per day, with the largest category of events involving wrong procedures/tests and medication errors (ISMP, 2019). In addition, according to data from the Joint Commission (JC) between 2010-2020, 18 sentinel events related to infant misidentification resulted in circumcision being performed on the wrong patient (JC, Sept. 2021).
Misidentification Case Example
Newborn baby boy given to incorrect mother for breastfeeding. Staff nurse realized the mix-up and went to retrieve newborn from incorrect mother. Event discovered in short period of time. After reviewing event with the incorrect mother, it was confirmed that the baby did indeed latch on to her breast. Infection Prevention notified. Event was disclosed to this baby’s birth mother and father (Wallace, 2016, pp.44-45).
Joint Commission Requirement and National Patient Safety Goal
As of Jan. 1, 2019, the Joint Commission requires that all accredited and critical access hospitals providing labor and delivery services fulfill a distinct newborn identification requirement, including a minimum of two patient identifiers when care, treatment, or services are provided. Several examples are given by the JC (2018):
- Naming convention including mother’s first and last name, along with newborn gender
- Using a standardized practice of banding (ex. 2 body areas where bands are placed, and use of barcoding)
- Additional communication strategies for staff (ex. Process for similar name situations- visual alerts, discussion at safety huddles and shift to shift handoff)
Additional Error Reduction Strategies
- Use of bedside label printers
- The standardized process around specimen collection: printing label, collecting the specimen, and labeling specimen (in this order), all occurring at the location of care
- The standard process around the collection, storage, and dispensing of expressed breast milk. This may include use of barcoding, nurse independent double checks, use of bedside milk warmers, involving parents in the verification process, and use of freezer-appropriate and smudge-proof labels
- Identification bands with barcoding
- Newborn ID bands on 2 sites
- Band design- avoiding handwritten ID bands, use of standardized format including easy to read styles and large font
- Increasing team awareness around patient identification errors
- Real-time communication around similar name alerts including discussion at daily huddles and team meetings
- Use of visual alerts for similar name situations
- Physically placing newborns in different nsy/NICU areas if able (Wallace, 2016)
*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide
The Joint Commission (Oct. 2021). Two Patient Identifiers- Understanding the Requirements. Retrieved from https://www.jointcommission.org/standards/standard-faqs/home-care/national-patient-safety-goals-npsg/000001545/
The Joint Commission (Sept.2021). Quick Safety 17: Temporary Names Put Newborns at Risk. Retrieved from https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety–issue-17-temporary-names-put-newborns-at-risk/temporary-names-put-newborns-at-risk/
The Joint Commission (2018). R3 Report Issue 17: Distinct Newborn Identification Requirement. Retrieved from
Institute for Safe Medication Practices (2019). What’s in a Name? Newborn Naming Conventions and Wrong-Patient Errors. Retrieved from https://www.ismp.org/resources/whats-name-newborn-naming-conventions-and-wrong-patient-errors
Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS