Using Two Patient Identifiers in the Pharmacy for Safety: How to Prevent Medication Errors

Every year, thousands of patients in the U.S. receive the wrong medication-not because of a mistake in the prescription, but because the pharmacy mixed up who the patient was. It sounds impossible, but it happens more often than you think. The fix? Simple, proven, and required by law: using two patient identifiers before handing out any prescription.

Why Two Identifiers? The Real Risk

Imagine this: two patients walk into the same pharmacy on the same day. One is Mary Johnson, 68, taking warfarin for atrial fibrillation. The other is Mark Johnson, 69, taking aspirin for heart disease. Same last name. Similar age. Same pharmacy. If the pharmacist only checks the name, the risk of giving Mary Mark’s pills-or worse, giving Mark a blood thinner he doesn’t need-is real.

This isn’t hypothetical. According to The Joint Commission, patient misidentification causes nearly 20% of all serious medication errors in hospitals and pharmacies. And it’s not just about names. Patients with common names, similar birthdays, or those who’ve moved and changed their records can easily get lost in the system. One study found that up to 10% of dangerous drug interactions go undetected simply because systems can’t link a patient’s full history across different providers.

The solution isn’t fancy tech-it’s discipline. Use two pieces of information that belong only to that person. Not just the name. Not just the date of birth. Both.

What Counts as a Valid Identifier?

Not everything you think is a patient identifier actually counts. The Joint Commission’s National Patient Safety Goal (NPSG.01.01.01) is clear: only certain data qualify.

• Accepted identifiers: Full legal name, assigned medical record number, date of birth, phone number, or a unique patient ID assigned by the healthcare system.
• Not accepted: Room number, bed number, location, or any information that could be shared by multiple patients.

Why exclude room number? Because patients move. A patient in Room 304 today might be in Room 306 tomorrow. If you rely on that, you’re not verifying identity-you’re verifying location. And that’s not safe.

In community pharmacies, staff often say, “I know her by face.” But what if she’s a relative? What if she’s confused? What if it’s a new patient you’ve never seen before? Relying on memory or recognition is a gamble you can’t afford.

Manual vs. Tech: What Actually Works?

You might think, “I just ask for name and DOB. That’s enough.” But manual checks have a flaw: humans get tired. They get busy. They skip steps.

A 2023 survey of 1,200 pharmacists found that 63% admitted to occasionally cutting corners during peak hours. In community settings, 42% said they rarely document the verification-meaning there’s no record if something goes wrong.

Technology changes the game. Barcode scanning, when used correctly, cuts medication errors by 75%. Here’s how it works:

1. Pharmacist scans the patient’s wristband (with barcode containing name and MRN).
2. System cross-references the medication label with the patient’s profile.
3. If there’s a mismatch-wrong drug, wrong dose, wrong person-the system flags it immediately.

Biometric systems, like palm-vein scanners, are even more accurate. One study showed a 94% match rate with biometrics versus just 17% without a unified patient database. That’s not just convenience-it’s life-saving.

But here’s the catch: tech only helps if it’s used properly. A 2020 review in BMJ Quality & Safety found no clear benefit to having two staff members double-check a medication unless the process was standardized and tracked. Without technology, human double-checks often become performative-something you do to check a box, not to catch errors.

The Hidden Danger: Duplicate Records

One of the biggest silent killers in patient safety is duplicate medical records. A patient gets treated at three different clinics. Each one creates a separate record. No one links them. The result? A patient with diabetes gets prescribed a new drug that interacts with a medication they’re already taking-because the second doctor never saw the first record.

A case from Altera Health in 2024 showed a woman admitted for severe fatigue. Doctors couldn’t find her history. She was given a new set of tests, new meds-and almost received a drug she was allergic to. Only after days did they find her original record under her middle name.

This is where Enterprise Master Patient Index (EMPI) systems come in. They act like a central filing cabinet that pulls together all a patient’s records, no matter where they’ve been treated. Hospitals without EMPI systems have 8-12% duplicate records. That’s not a glitch-it’s a systemic failure.

And it’s expensive. Each large hospital loses an estimated $40 million a year just cleaning up these errors.

What Happens When You Don’t Follow the Rules?

This isn’t just best practice-it’s mandatory. The Joint Commission makes compliance with two-identifier verification a condition for hospital accreditation. In 2023, non-compliance was the third most common violation in hospital surveys, accounting for 28% of all patient safety goal failures.

Lose accreditation, and you lose Medicare and Medicaid payments. That’s not a fine. That’s financial suicide for a pharmacy or hospital.

The 21st Century Cures Act and CMS rules now tie patient identification directly to interoperability. If your system can’t reliably identify patients, you can’t share data with other providers. That means fragmented care, delayed treatment, and higher risk.

How to Implement This Right

You don’t need a billion-dollar system to get this right. Start small, but start now.

• Train staff daily: Make it part of every shift. Role-play scenarios. Don’t just hand out a policy document.
• Use tech when you can: Even a simple barcode scanner on the counter can cut errors in half.
• Document everything: The Joint Commission found that 37% of non-compliant pharmacies didn’t record the verification. If it’s not written down, it didn’t happen.
• Use timeouts for high-risk meds: Before giving insulin, heparin, or chemotherapy, pause. Say the name. Say the DOB. Scan the wristband. Confirm the drug. Then give it.

In community pharmacies, where time is tight, create a visual checklist above the counter. A simple sign: “Name + DOB + Scan.” No exceptions.

What’s Next? The Future of Patient ID

The U.S. is moving toward a voluntary national patient identifier. A pilot program launched in January 2025 in five regional health exchanges is testing a system that assigns each person a unique, encrypted ID-like a Social Security number for health records, but safer and private.

If it works, it could eliminate duplicate records entirely. It could make it impossible to give a drug to the wrong person-not because someone remembered the right name, but because the system just knew.

But until then, the answer is simple: use two identifiers. Every time. No shortcuts. No exceptions.

Patients don’t need fancy gadgets. They need you to slow down, confirm, and care enough to get it right.

Frequently Asked Questions