Although ensuring the correct patient receives the appropriate treatment may seem a straightforward task, patient misidentification has resulted in highly publicized errors. The Joint Commission has required standardized processes for avoiding patient misidentification as one of the National Patient Safety Goals. This qualitative study of nurses and residents identified barriers to following appropriate identification practices and characterizes workarounds that providers use to circumvent these perceived barriers. A near miss caused by a patient identification error is discussed in detail in this AHRQ WebM&M commentary.