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.
Related Resources
Toolkits/Methodology
ASHRM has identified the following resources on patient safety to assist you in identifying useful information and helpful contacts.