Requirements around Patient Identification

Updated 8/6/2026

The Joint Commission (TJC) requires that two patient identifiers be used to associate an individual with care, service, or treatment. Patient identifiers include patient name, medical record or identification number, telephone number, and date of birth (The Joint Commission, 2025). Wristbands often provide the patient information. They should be attached to the patient, not taped to the bed or bedside table. TJC also specifies that neither location nor room number is to be used as a patient identifier.

Errors Involving Patient Identification

Patient identification can be challenging when an individual cannot participate in the identification process — such as our littlest and most vulnerable patient populations, newborns.  They present distinct challenges: They look alike, they’re often not given a first name until several days after birth, and they can have similar last names, medical record numbers, and birth dates (ISMP, 2019).

Multiple birth infants, in particular, pose increased risk due to the same last name and birth date, virtually identical first name, and often consecutive medical record numbers. Studies have shown that the risk of wrong patient orders are nearly doubled in multiple birth infants in the NICU, in comparison to regular pediatric units (Redman et al., 2020).   

If accurate identification is not established from the start, a cascade of problems can result. Problems include expressed breast milk misfeeds; medication, order, and documentation errors; wrong tests, surgeries, or procedures; mother-newborn mix-ups; and even newborns being switched at birth or discharged to the wrong parents (The Joint Commission, 2021).

A study conducted by the Pennsylvania Patient Safety Advisory in 2016 found that newborn misidentification events occurred, on average, twice per day in Pennsylvania, with wrong procedures or tests and medication errors occurring most frequently (ISMP, 2019). In addition, according to TJC data from 2010 to 2020, 18 sentinel events related to infant misidentification resulted in circumcision being performed on the wrong patient (The Joint Commission, 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 Performance Goal

As of Jan. 1, 2019, The Joint Commission states that all accredited and critical access hospitals that provide Labor and Delivery services must fulfill a distinct newborn identification requirement. They must use a minimum of two patient identifiers when care, treatment, or services are provided.

Current National Performance Goals as per The Joint Commission (2026), and specified in the elements of performance around distinct methods of identification for newborn patients, state that hospitals may include the following methods: 

 • Distinct naming systems that include using the mother’s first and last names and the newborn’s gender (for example: “Smith, Judy Girl” or “Smith, Judy Girl A” and “Smith, Judy Girl B" for multiples)

 • Standardized practices for identification banding (for example, using two body sites and/or bar coding for identification)

 • Communication tools used among staff (for example, visually alerting staff with signage noting newborns with similar names) (The Joint Commission, 2025, p. 1)

Additional Error Reduction Strategies

• Use of bedside label printers

• Standardizing the process around specimen collection: printing label, collecting specimen, and

  labeling specimen (in that order), all occurring at the location of care

• Standardizing the process for collecting, storing, and dispensing expressed breast milk: using bar

  coding, nurse-independent double-checks, bedside milk warmers, and/or freezer-appropriate and

  smudge-proof labels, as well as involving parents in the verification process

• Using identification bands with barcoding

• Placing newborn ID bands on two sites

• Using a standardized band with easy-to-read, large font type

• Avoiding handwritten ID bands and letters in all capitals

• Increasing team awareness around patient identification errors

• Communicating in real-time about similar names, as well as discussing at daily huddles and team meetings

• Using visual alerts for similar name situations

• Placing newborns with similar names in separate nursery/NICU areas if possible

  (Pennsylvania Patient Safety Authority, n.d.)

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References

Institute for Safe Medication Practices. (2019, April 25). What's in a name? Newborn naming conventions and wrong-patient errors. https://www.ismp.org/resources/whats-name-newborn-naming-conventions-and-wrong-patient-errors 

Pennsylvania Patient Safety Authority (2016). Newborns pose unique identification challenges. Pa Patient Saf Advis, 13(2), 42-49. Retrieved from http://patientsafety.pa.gov/ADVISORIES/Pages/201606_42.aspx

Redman, C. T., Reddy, P., Kneifati-Hayek, J. Z., Applebaum, J. R., Manzano, W., Goffman, D., & Adelman, J. S. (2020). Incident reports of naming errors among two sets of infant twins. Pediatric Quality & Safety, 5(6), Article e356. https://doi.org/10.1097/pq9.0000000000000356 

The Joint Commission. (2025). National performance goals effective January 2026 for the hospital program. https://digitalassets.jointcommission.org/api/public/content/9ca80055182b4274842a5780a94f2c82 

The Joint Commission. (2021, September). Temporary names put newborns at risk (Quick Safety Issue 17). https://digitalassets.jointcommission.org/api/public/content/bba9048c71aa44b7aa39d35a274335fb 

The Joint Commission (2018). R3 Report Issue 17: Distinct Newborn Identification Requirement.  Retrieved from https://digitalassets.jointcommission.org/api/public/content/fedc3542068f49648b539b96d18d2930?v=159de9f3

About the Author:

Jeanette Zocco, MSN RNC-OB, C-EFM, C-ONQS , is a perinatal safety expert and healthcare entrepreneur. As the founder of Obneonatalstudyguide.com, she leverages her clinical background to provide evidence-based education and quality improvement tools that bridge the gap between best practice and bedside integration. Discover her latest resources for maternal-child professionals at obneonatalstudyguide.com. 

Copyright by Jeanette Zocco MSN RNC-OB, C-EFM, C-ONQS