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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.
Last updated on March 15, 2021
Manual: Hospital and Hospital Clinics
Chapter: National Patient Safety Goals NPSG

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