Infants Often Mis-identified in Intensive Care

Similarities in patients' names and medical record numbers lead to a high potential for infant mis-identification in neonatal intensive care units (NICUs), according to a recent study.

In the study, published in the January 2006 edition of Pediatrics, researchers studied 12,186 days of patient care for 1,260 newborns at Beth Israel Deaconess Medical Center (Boston, MA, USA) during one calendar year. Each surveyed child spent an average of nine to 10 days in intensive care. A patient day was considered at risk for mis-identification when the index patient shared a surname, similar-sounding surname, or similar medical record number (MRN) with another patient cared for in the NICU on that day. The sequential nature by which MRNs are assigned in many hospitals means that patients who are admitted to the NICU within a relatively short time frame are at highest risk for sharing similar MRNs, a problem exacerbated by multiple births.

The results found that not a single day was free of risk for patient mis-identification. The most common cause of mis-identification risk was similar-appearing MRNs (44% of patient days). Identical surnames were present in 34% of patient days, and similar-sounding names were present in 9.7% of days. Twins and triplets contributed one third of patient days in the NICU.

"NICU clinicians must remain vigilant in their processes to correctly identify NICU patients,” said Dr. James Gray from Beth Israel Deaconess Medical Center and Harvard Medical School (Boston, MA, USA), who led the study. "The use of auto-identification technologies such as bar coding and radiofrequency identification should be explored.”

One of the consequences of misidentification is that the wrong baby could receive medication. Another common error found in neonatal intensive care units was giving breast milk to the wrong infant.