to main content Two Patient Identifiers - Distinct Newborn Identification Requirement | Critical Access Hospital | National Patient Safety Goals NPSG | The Joint Commission
Two Patient Identifiers - Distinct Newborn Identification Requirement

The new requirement regarding use of distinct methods of identification for newborn patients includes three bullet points that include use of a distinct naming system, standardized practices and communication tools. Are organizations expected to strictly comply with the examples provided in the 'note' included in the requirement?

Any examples are for illustrative purposes only.

The intent of the new requirement at NPSG.01.01.01 EP 3 is that organizations implement practices to prevent misidentification of newborns.   The goal is to have a reliable process in place to ensure accurate identification of the newborn for whom the service or treatment is intended and to match the service or treatment to that neonate.

The information provided in the 'Note' provides examples on how an organization can meet the intent of the requirement. The naming convention listed in the 'note' at NPSG.01.01.01 EP 3 is not prescriptive. The organization may use any naming convention that works for them as long as it meets the intent of the requirement.

The naming convention selected is only to be utilized during the initial admission following delivery. This would not apply to a pediatric, neonatal intensive care, and/or special care unit settings if the newborn has been re-admitted following discharge from delivery and given an official name.

Regarding standardized practices for banding, while the practice of applying identification (ID) bands to two limbs is common, organizations may elect to use other devices and/or technologies designed to support accurate patient identification. Whatever device(s) is selected, organizations should give consideration to any risks of them separating from the infant.

The use of communications tools, such as visual prompts/alerts, are intended to alert all staff providing care that there may be infants with similar names, twins, etc., that may contribute to ID ambiguity. During survey, staff should be able to speak to how they handle a situation in which there is a baby with a name alert.
Click here to review the R-3 report for this new requirement.
Manual: Critical Access Hospital
Chapter: National Patient Safety Goals NPSG
First published date: November 16, 2018 This Standards FAQ was first published on this date.
This page was last updated on October 27, 2021
Was this response helpful?

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form

Get Extra Help with Books and E-books

Browse our gallery of books and e-books to find trusted prep and readiness resources, practical checklists and toolkits, and resources on specialized health care topics.

Stay Informed with Online Education

Online education is the most convenient and cost-effective way to educate your staff and minimize expenses without the need to leave your organization.

Reach Your Safety Goals with eProducts

Assessing and sustaining compliance with accreditation standards or CMS CoPs can be a challenge, but it doesn’t have to be. Rely on our proven software solutions developed by our team of industry experts.

Can't Find What You're Looking For?

If you do not find an answer to your question, please contact the Standards Interpretation Group (SIG).

Note: To provide adequate support to those organizations that are either accredited/certified or seeking accreditation/certification, we will only answer those questions submitted by those organizations seeking accreditation/certification or currently accredited/certified by the Joint Commission. The Joint Commission no longer answers questions submitted by students or vendors. Thank you for your understanding.