Patient Identification Errors Tip Sheet

Accurate patient identification is a foundational safety practice. When identification fails, the result can be wrong patient, wrong procedure, wrong medication, wrong test, or wrong documentation. This tip sheet offers a fast, actionable overview to help teams prevent identification errors across clinical and operational workflows.

Who it’s for:

  • Nurses, physicians and frontline care teams
  • Registration, admitting, and scheduling staff
  • Lab, radiology, imaging and procedural areas
  • Pharmacy teams and medication safety leaders
  • Risk, quality and patient safety teams

What it can be used for:

  • Reinforcing two-identifier practices at every point of care
  • Reducing wrong-patient orders, labels, specimens, and documentation
  • Strengthening safety at transitions (admit, transfer, discharge)
  • Supporting audits, rounding, and compliance monitoring

What’s Inside:

  • Situation: Common scenarios where ID errors occur (similar names, high volume, interruptions)
  • Background: System factors that increase risk (workarounds, EHR issues, label printing, registration gaps)
  • Assessment: Where to look for vulnerabilities across intake, bedside care, diagnostics, and procedures
  • Recommendations: Practical steps to standardize identification, reduce workarounds, and confirm identity
     

Access the Tip Sheet

Patient identification errors continue to burden health care across the care continuum. Read the research-based recommendations to advance accurate patient identification.