Patient misidentification in emergent situations can reduce the appropriateness of care delivery and safety. This report analyzes an incident where the healthcare team misidentified a patient (who had a do-not-resuscitate order) and withheld cardiopulmonary resuscitation (CPR) from the wrong patient. The lack of access to health information technology at the bedside, and reference to the patient’s wristband, were factors contributing to the patient’s death.