Purpose: The purpose of this study is to understand the general nurses's experiences of missing patient identification. Methods: Participants were 12 nurses who experienced missing patient identification in general wards in hospitals. Data were collected with focus group interviews and individual in-depth interviews and data were analyzed using qualitative content analysis. Results: As the results of this study, 128 statements, 4 themes and 13 sub-themes were derived. The four themes derived were ‘Situations that we had not to check patient identification properly’, ‘Fear and pressure from the result of missing patient identification’, ‘Feeling guilty to the results of missing patient identification’and ‘Efforts to reassuring patient identification’. Conclusion: In order to prevent the failure of patient identification, we need specialized programs to cultivate patient safety culture not only for nurses, also patients and caregivers, and all departments of hospital. We also need institutional efforts and effective hospital investment and supports for accomplishing the goal.