TJC Requirement for Distinct Newborn Identification - Effective January 1, 2019

PUBLISHED: Jun 27, 2018
Relevant to: Critical Access Hospitals, Hospitals

The Joint Commission (TJC) is requiring a new element of performance (EP) effective January 1, 2019 applicable for all TJC-accredited hospitals and critical access hospitals providing labor and delivery services.

EP 3 will be added to National Patient Safety Goal NPSG.01.01.01 and is intended to “…improve the quality and safety of care for newborns during their hospital stay following delivery.” EP 3 requires a distinct naming system for accurate newborn patient identification.

TJC gives the following examples:

  • Mother's first and last names, newborn gender (Smith, Judy Baby Girl)
  • Standardized practice for identification banding (use of barcoding, using two-body site identification)
  • Establishing communication tools for staff (checking for two patient identifiers prior to medical record entries; visually alerting staff with signage noting newborns with similar names)

Included with today’s notice are example policies reflective of this new requirement.

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