Joint Commission: New Newborn ID Requirement to Reduce Error

Megan Brooks

June 29, 2018

In an effort to reduce newborn identification errors, the Joint Commission (JC) has created a new newborn identification requirement for all JC-accredited hospitals and critical access hospitals that provide labor and delivery services.

Because babies do not talk, can sometimes look very similar, and can share a similar naming convention (for example, Baby Boy Smith), the risk of misidentifying newborns is high, the JC said in a statement.

"In addition to well-known misidentification errors in the hospital setting after delivery, such as wrong patient/wrong procedure, misidentification also has resulted in feeding a mother's expressed breast milk to the wrong newborn, posing a risk of passing bodily fluids and potential pathogens to the baby," the JC said.

The goal of the new requirement is to provide "more distinguishable naming methods for this vulnerable population," it said.

The new requirement, which goes into effect January 1, 2019, calls on hospitals to use two distinct methods of identification for newborn patients. The JC provides the following examples of appropriate identification methods:

  • Distinct naming conventions using the mother's first and last names and the newborn's sex (for example, "Smith, Judy Girl" or "Smith, Judy Girl A" and "Smith, Judy Girl B" for multiples)

  • Standardized practices for identification banding (for example, two body-site identification and bar coding)

  • Establishing identification-specific communication tools among staff (for example, visually alerting staff with signage noting newborns with similar names)

The need for improved newborn identification practices in the obstetric unit was brought to the attention of JC leadership by a representative of the American Academy of Pediatrics. Creating the new requirement involved an extensive literature review, a learning visit, and discussions with leaders in the field. During these vetting sessions, the JC determined that a new requirement for newborn identification was needed.

The new requirement was posted for public field review, and more than 500 responses were received.

To help hospitals comply with this new requirement, the JC published in its newsletter R3 Report an in-depth rationale for the requirement, as well as references and evidence that were employed during its development.

The JC has issued additional requirements, published in R3 Report, for JC-accredited hospitals and organizations regarding pain assessment and management standards for ambulatory care, office-based surgery organizations, and critical access hospitals, effective January 1, 2019. These requirements follow the introduction of new and revised pain assessment and management standards for accredited hospitals that became effective on January 1, 2018.

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