R E V I E W S & A N A LY S E S Newborns Pose Unique Identification Challenges Susan C. Wallace, MPH, CPHRM INTRODUCTION Patient Safety Analyst Pennsylvania Patient Safety Authority Safe patient care starts with accurately identifying patients, to deliver the correct care.1 Failing to correctly identify patients and match their identity to an intended clinical evaluation or intervention, or for administrative functions, can compromise patient ABSTRACT safety.2 Hospitalized newborns pose unique identification challenges because they often Safe patient care starts with accurate share similar or identical birth dates, similar medical record numbers, and, in the case patient identification. Unique character- of twins and multiple births, common surnames.2 istics of the newborn population pose Newborn misidentification has been reported to result in unintended procedures, such challenges for accurate and consistent as a frenotomy (clipping of the frenulum, which connects the tongue to the floor of patient identification. Hospitalized new- the mouth), performed on the wrong Tennessee newborn after a pediatrician confused borns often share similar birth dates and him with another newborn.3 Other examples of misidentification include two Virginia medical record numbers and, with mul- newborns who were switched at birth in 1995 and discharged to the wrong parents.4 tiple births, even share surnames. Unlike And a Washington, D.C., hospital nurse gave a newborn to the wrong mother, result- older patients, newborns are unable to ing in the newborn receiving formula instead of breast milk.5 actively participate in confirming this information and often lack distinguishing A one-year study from Beth Israel Deaconess Medical Center in Boston found, on physical characteristics. Pennsylvania average, 26% of neonatal intensive care unit (NICU) newborns were at risk for being Patient Safety Authority analysts estimate mistaken for another newborn on any given day because they had similar identifiers.2 that an average of nearly two newborn Health professionals from 54 hospitals in the Vermont Oxford Network reported that misidentification events occur daily in 11% of newborn errors over a more than two-year period involved misidentification.6 Pennsylvania. Safety huddling, distinct The Joint Commission recommends the use of at least two identifiers based on naming systems, clinician awareness, demographic information, such as the patient name, date of birth, or medical record and technology such as bar coding may number.1 Unlike most patients, newborns are unable to actively participate in confirm- help to decrease newborn identifica- ing this information and often lack distinguishing physical characteristics.2 tion errors. (Pa Patient Saf Advis 2016 Because of a scarcity of publications describing the incidence and effects of patient Jun;13[2]:42-50.) identification errors in newborns at a population level, analysts explored newborn identification events reported to the Pennsylvania Patient Safety Authority through its Pennsylvania Patient Safety Reporting System (PA-PSRS). METHODS Analysts queried the PA-PSRS database for reports of events that occurred from January 2014 through December 2015 for patients through 30 days of age using key- words including “identifier,” “ID band,” “patient name,” “label,” “another patient,” “identification,” and “wrong patient.” In this database, events are tagged by reporting health professionals with up to seven event-type categories such as “error related to procedure/treatment/test” or “medication error.” Analysts manually reviewed the resulting set of event report narratives to identify reports describing misidentification events and grouped them into related categories. Event descriptions containing the word “twin” were also identified. The total number of misidentified events for the two years (n = 1,234) was divided by 2 for an average number per year, and then divided by 365 days to determine average newborn misidentification events per day. The total number of events for 2014 (n = 617) was divided by the number of 2014 births reported by the Pennsylvania Department of Health (n = 141,355)* multiplied by 1,000 to determine a rate of misidentification events per every 1,000 live births. * These data were provided by the Division of Health Informatics, Pennsylvania Department of Health. The Department specifically disclaims responsibility for any analysis, interpretations, or conclusions. Data for live births in Pennsylvania for 2015 were unavailable. Page 42 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority Analysts conducted a review of the lit- Table 1. Newborn Misidentification Events Reported to the Pennsylvania Patient Safety erature, as well as an Internet search, to Authority, by Event Type,* January 2014 through December 2015 (N = 1,234) identify strategies to reduce identification EVENT TYPE NO. (%) OF EVENTS errors and patient harm in healthcare facil- Error related to procedure, treatment, or test 987 (80.0) ities. Interviews with laboratory, NICU, and obstetric personnel in Pennsylvania Medication error 102 (8.3) hospitals were also conducted to identify Complication of procedure, treatment, or test 28 (2.3) best practices and resources developed for Transfusion 25 (2.0) identification practices to reduce misiden- tification events. Skin integrity 1 (0.1) Equipment, supplies, or device 1 (0.1) RESULTS Other 90 (7.3) Analysts identified 1,234 misidentifica- * Event types are defined by Pennsylvania Patient Safety Reporting System taxonomy and are assigned tion events occurring between January to events by healthcare facilities at the time of report submission. Total percentage listed is greater than 2014 and December 2015. The identified 100% due to rounding. events were submitted in seven event type categories with 80% (n = 987) reported Table 2. Newborn Misidentification Events Reported to the Pennsylvania Patient Safety in “error related to procedure/treatment/ Authority, by Event Harm,* January 2014 through December 2015 (N = 1,234) test,” followed by 8.3% (n = 102) reported HARM SCORE NO. (%) OF EVENTS in “medication error” (Table 1). Incident: Unsafe conditions (harm score A) 93 (7.5) All reported events occurred in a hospital or birthing center. Five event reports were Incident: No harm (harm scores B1 through D) 1,136 (92.1) reported as Serious Events, with assigned Serious Event: Temporary harm (harm scores E 4 (0.3) harm scores of E or G; these were events through F) in which breast milk was given to the Serious Event: Significant harm (harm scores G 1(0.1) wrong patient and a circumcision was through I) performed without consent. No harm or * Event harms are defined by Pennsylvania Patient Safety Reporting System taxonomy and are assigned unsafe conditions were reported with the to events by healthcare facilities at the time of report submission. remainder of the events, with the majority 40.3% (n = 497) assigned a harm score of C and 37.4% (n = 462) assigned a harm identification band on patient and mis- Analysts estimated that 1.7 or nearly score of B2* (Table 2). matched identification bands on mother 2 newborn misidentification events occur Analysts grouped events into four cat- and newborn; documentation practices, daily in Pennsylvania, impacting 4.6 new- egories, based on event report narrative such as another patient’s consent in the borns per every 1,000 births or 1 newborn descriptions (see Figure). medical record; and transferring issues for every 217 live births. such as the wrong newborn taken to the The majority of the misidentification parents. Medication events (n = 110, Newborn Misidentification events (n = 917, 74.3%) involved proce- 8.9%) included administering the wrong dure errors, including mislabeled blood Events drug to the patient; breast milk adminis- Procedure errors. Examples of events specimens, unlabeled urine samples, tration mishaps (n = 89, 7.2%) included wrong patient respiratory reports, and reported to the Authority involving providing the wrong breast milk to the diagnostic misidentification events are as wrong patient radiographs. The next newborn. largest category was general misidentifica- follows:† tion events (n = 118, 9.6%), including no Events in the procedure errors group- Another nurse picked up the printed ing were separated into diagnostic areas cord blood labels for this delivery and impacted by the misidentification: labora- * The Pennsylvania Patient Safety Authority tory, radiology, surgical, and respiratory. Harm Score Taxonomy is available online at The word “twin” was documented in http://patientsafetyauthority.org/ 3.3% (n = 41 of 1,234) of the events. † The details of the PA-PSRS event narratives ADVISORIES/AdvisoryLibrary/2015/ in this article have been modified to preserve mar;12(1)/PublishingImages/taxonomy.pdf. confidentiality. Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 43 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure. Misidentification Error Types, January 2014 through December 2015, as reported to the Pennsylvania Patient Safety Authority (n = 1,234)* Diagnostic Breast milk areas impacted administration mishaps 89, 7.2% Radiology 14, 1.5% Medication Surgical events Procedure errors Laboratory 5, 0.5% 110, 8.9% 917, 74.3% 895, 97.6% Respiratory 3, 0.3% General misidentification MS16429 118, 9.6% *Total percentage listed is less than 100% due to rounding. used them for the specimens from a another patient’s birth date. The staff noted this patient’s weight was sig- previous delivery without verifying had used the ID band for several days. nificantly different from the weight the name on the label. The primary Phlebotomist was in the NICU to on the order (2.185kg vs. 0.83kg). nurse for this delivery called the lab draw blood from a baby. When she The pharmacist found that the sticker to reproduce cord blood labels, believ- looked at the baby’s name band on on the antibiotic order was incorrect. ing the printer did not print them. the wrist it said a different name. She There are currently two patients with Both specimens were sent with the notified the nursing staff that it was the same last name. same label. the incorrect baby. The resident in the Lasix [furosemide] ordered on wrong There were two baby girls with the room stated it was the right baby. She baby in NICU. Error caught and same last name in the unit. An x-ray then told them the name on the band corrected before administration. was ordered on the wrong patient but was not the name on her requisition. Breast milk administration mishaps. was performed on the correct patient. The nurse checked and confirmed the Examples of events reported to the General misidentification events. baby in fact had the incorrect band on. Authority involving breast milk misidenti- Examples of events reported to the It was removed, and the phlebotomist fication events, are as follows: Authority involving general misidentifica- states the nurses were trying to figure out if another baby had the incorrect Newborn baby boy given to incor- tion events, are as follows: rect mother for breast feeding. Staff band and how to correct the mistake. Patient did not have an identification nurse realized the mix-up and went Medication events. Examples of events band. It was taped to the bassinet to retrieve newborn from incorrect and mother reports staff scanned the reported to the Authority involving medi- mother. Event discovered in short taped ID band. cation misidentification events, are as period of time. After reviewing event follows: with the incorrect mother, it was con- Patient had the wrong identification band. It contained the right name but Antibiotic order faxed to pharmacy. firmed that the baby did indeed latch When entering the order, pharmacist on to her breast. Infection Prevention Page 44 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority notified. Event was disclosed to this baby’s birth mother and father. UNIQUE HEALTH IDENTIFIERS Patient was fed breast milk that was When the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was from another patient with the same proposed by the US Department of Health and Human Services, it called for the last name. creation of a unique health identifier (UHI); each person would be issued a unique medical identification number. Use of a UHI was never enacted because of fears of DISCUSSION privacy and security breaches.1 Hospitalized newborns create unique Health providers seek ways to link patients across a burgeoning number of electronic identification challenges, especially the patient information management systems, but these systems may not coordinate their high-risk NICU population that has patient identification processes.2 Advocates of a UHI point to other countries, such as Australia and England and Wales, which have started their own UHI programs, prolonged lengths of stay. Analysis of including guidelines for identification of newborns.3,4 PA-PSRS reveals that an average of nearly two newborn misidentification events are In the absence of consensus, information management advocates, such as the Col- reported daily in Pennsylvania, including lege of Healthcare Information Management Executives of Ann Arbor, MI, have called errors related to procedures, general mis- for the creation of patient identifier systems outside of federal government control.5 identification events, medication events, Privacy advocates, such as the Patient Privacy Rights organization, support using a patient identifier on an encrypted card held by patients, who would be in control of and breast milk administration mishaps. their own health information.6 Other systems use facial recognition authentication, Healthcare workers perform patient iden- palm vein recognition, and fingerprint scanning.7 tification several times a day for almost Notes every instance of care. A medical error 1. US Department of Health and Human Services. Unique health identifier for individuals: a of identification can result if any step in white paper [online]. [cited 2016 May 10]. https://aspe.hhs.gov/legacy-page/white-paper- this process is not properly performed.7 unique-health-identifier-individuals-152126 Similarities in the newborn population 2. Gliklich RE, Drey NA, Leavy MB. Registries for evaluating patient outcomes: a user’s guide. including surnames, medical record 3rd ed. Agency for Healthcare Research and Quality 2014 Apr. numbers, and birth dates contribute 3. National Patient Safety Agency. NHS number to be used as the unique patient identifier by significantly to misidentification risk. all NHS organisations in England and Wales [online]. [cited 2016 May 10]. http://www. Gray and co-authors found the most com- npsa.nhs.uk/corporate/news/nhsnumber/ mon cause was similar-appearing medical 4. Australian Commission on Safety and Quality in Healthcare. Patient identification [online]. record numbers, followed by identical or [cited 2016 May 10]. http://www.safetyandquality.gov.au/our-work/patient-identification/ similar-sounding names.2 5. College of Healthcare Information Management Executives. Leading healthcare IT associa- tion announces $1 million initiative to protect patients from life-threatening medical errors Voluntary anonymous reporting in the [online]. 2016 Jan 19. [cited 2016 May 10]. https://chimecentral.org/leading-hit-association- Vermont Oxford Network uncovered a announces-1m-initiative/ broad range of medical errors affecting 6. McQuaid J. Patient mix-ups happen more often than you think. Why the easy fix isn’t easy neonates at high risk of health problems at all [online]. Statnews.com 2016 Jan 28. [cited 2016 May 10]. http://www.statnews. and their families. Patient misidenti- com/2016/01/28/patient-mixups-universal-identification/ fication was the root cause of 11% of 7. Cuberos D. In your face: the future of federated patient identification [online]. Right Patient diagnosis, treatment, prevention, and 2015 Oct 7. [cited 2016 Apr 8]. http://www.rightpatient.com/blog/the- future-of-federated- other events.6 patient-identification-your-face/ Strategies to prevent misidentification error for newborns include changing from a nondistinct naming convention (e.g., for patient identification for medication Contributory Factors Babyboy) to a distinct naming convention administration, breast milk administra- Misidentifications can occur in diagnostic, that uses the mother’s name and new- tion, and blood collection.10,11 Another therapeutic, or supportive areas of care born’s gender (e.g., Wendysboy); 8 using area of discussion includes implementing because in some cases newborns lack communication tools such as huddling national identification numbers as unique facial or other distinguishing physical and color coding for like-sounding names; 9 health identifiers (see “Unique Health features (i.e., some newborns may look standardizing practices for identification Identifiers”). similar). PA-PSRS event analysis, Authority banding; and using bar-code technology Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 45 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S interviews, and a literature review isolated Patient identification band concerns. (e.g., twins, triplets), this can increase the following contributory factors that can Healthcare workers help to reduce mis- the presence of similar patient identi- lead to misidentification errors. identification errors with placement of fiers, including birthdates. A 2015 study patient identification bands, usually on published in Pediatrics demonstrated that Documentation practices. Henneman both the newborn’s ankle and wrist.10 and co-authors concluded that medi- replacing a non-distinct naming conven- Bands can include the patient’s name, tion (e.g., Babyboy) with a distinct naming cal providers infrequently verify patient date of birth, medical record number, identification with two identifiers dur- convention that uses the mother’s first visit number, admission date, and physi- name (e.g., Wendysboy) can reduce mis- ing computerized provider order entry.12 cian.19 Bands may also include technology Carroll and colleagues found frequent identification errors by 36%.8 such as barcodes that can be scanned NICU documentation discrepancies in prior to medication administration.19 Hospitals may also provide medical written resident progress notes, including Howanitz and colleagues found patient record numbers in sequence.2 The Joint errors in documentation of medications, identification band errors in up to 7.4% Commission’s Sentinel Event database vascular lines, and patient weight. Notes of all patients over a two-year period. reported 10 cases of wrong-person surger- omitted information and documented Missing wristbands accounted for 71.6% ies since 2010 in which circumcisions inaccurate information.13 In another of the errors, with the remainder involv- were performed on the wrong newborn NICU study, a serious error was caused by ing incorrect, conflicting, or incomplete because of similar identifiers.21 “OB Safety a documentation mistake, resulting in the information.20 Elizabeth Quigley, MSN, Rounds” are conducted every four hours wrong newborn receiving an antibiotic.14 Nurse Manager Intensive Care Nursery, in the Birth Center at Magee-Womens Computerized order entry helps decrease The University of Pennsylvania Health Hospital of the University of Pittsburgh written documentation errors, said System, said that “barcoding is used on Medical Center to promote situational Vivian Haughton, MSN, Clinical Nurse patient identification bands placed on the awareness of current issues that have the Specialist, Women and Babies Hospital, newborn’s wrist and ankle. Nurses then potential to impact safety, quality, and Lancaster General Health. “The providers scan the barcode when administering care delivery, such as identifying similar- must enter orders, even remotely,” she medication or breast milk.”9 sounding names, said Vivian Petticord, said. “Nurses do not have to interpret DNP, Perinatal Safety Nurse at the hos- handwriting.”15 Registration issues. To generate orders pital. The around-the-clock rounds are and labels for specimens, newborns need multidisciplinary and include medical and Labeling errors. Breast milk and other to be registered in the electronic health specimens such as blood and urine nursing representation from anesthesia, record, according to Booth.18 “Confusion obstetrics, and neonatology, she said. A require a patient-specific label. Previous around registration becomes an issue work by the Authority analyzed events per- “Stop” symbol is placed on the centralized soon after birth,” Booth said. “Most patient board and on the patient’s room if taining to mismanagement of expressed patients who come into the hospital are breast milk and provided information there are similar-sounding names.23 registered.” She explained further: “When and resources about best practices.16 you have a new baby come into the world, Misidentified specimens create a serious Limitations you had one patient, now you have two. risk to safety, leading to misdiagnosis and This report may have limitations. Getting that baby registered and treated inappropriate treatment.17 Labeling errors Events may not have been reported as an individual is important for correct for blood or other specimens can occur as an outcome of a misidentification identification.”18 when the labels are not readily available because it may not have been recognized at the point of care. The wrong label may Similar identifiers. Hospitals commonly at the time the event was submitted. be used in the rush to provide a label for a provide temporary names to newborns Misidentification events may involve two specimen. For example, a cord blood spec- soon after they are born, such as Babygirl newborns, (i.e., the wrong newborn gets imen might mistakenly have the mother’s Jackson or Babyboy Jones.21 A 2013 survey medication, while the correct newborn label applied, said Barbara Booth, of 335 NICUs showed these non-distinct misses a dose) but may have been identi- BS, Laboratory Service Improvement names are used by more than 80% of fied in only one event report. Because of Coordinator, Geisinger Wyoming Valley hospitals.22 Although this provides a quick the way PA-PSRS is structured, analysts Medical Center.18 Mismanagement of way to assign a name for registration and were unable to determine the causal and breast milk can occur with the placement patient identification bands, it also results associated factors for the newborn identi- of the wrong label. in similar identifiers. If two newborns fication errors that were described. from different families have the same last name or if there are multiple births Page 46 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority RISK REDUCTION STRATEGIES —— Ask parents to participate in the place newborn information into elec- The following strategies may be useful double-check process.16,26 tronic health records.18 to healthcare facilities seeking to reduce —— Use individual warmers at the misidentification events for diagnostics, bedside to reduce opportunities for Similar Identifiers general identification, medication man- misidentification.16,26 —— Assign distinct first names at birth agement, and breast milk administration. —— Use a freezer-safe and smudge-proof by incorporating the mother’s first Some of these strategies may be consid- label to ensure legibility of patient name into the newborn’s first name, ered for more than one event category. identifiers.16,26 (e.g., Wendysgirl Jackson versus Babygirl Jackson).8 Documentation Practices Patient Identification Band —— Meet in a huddle daily or more —— Make important information legible Concerns often to acknowledge and discuss and prominent on identification —— Use auto identification tech- newborns who have similar-sounding bands, the electronic health record nologies, such as bar coding and names.23 screen, and the specimen label.12 radiofrequency.2 —— Place newborns with similar-sound- —— Check for two patient identifiers —— Ensure patient identification bands ing names in a different pod, or before entering information into a are properly placed before treat- across the nursery or NICU.15,23 medical record.12 ment administration or diagnostic —— Use an identifying symbol such as —— Use provider order entry systems testing.17 a star, “Stop” sign, color-coding, that physicians can use in the health- —— Apply newborn identification bands or plain language such as “similar care facility or remotely.15 to two body sites, such as the wrist name” to visually alert workers to and ankle.9 similar-sounding names.15,23 —— Provide awareness to healthcare professionals of the potential for —— Replace identification bands if the CONCLUSION identification errors, such as pull- information on them is not complete ing or entering orders in the wrong and legible.25 Unique characteristics of the newborn medical record.12 —— Educate parents on the importance population pose challenges for accurate of maintaining patient identification and consistent patient identification. Labeling Errors bands on their newborn at all times.6 These can include similarities in patient —— Use identification verification tech- identifiers such as similar names, medi- nologies, such as bar coding and Band Design19 cal record numbers, and birth dates.2 radiofrequency.7 Misidentification has contributed to —— Simplify unnecessary informa- wrong patient procedures, issues in breast —— Use bedside label printers to gener- tion not used for positive patient milk mismanagement, wrong medica- ate labels at the point of care.24 identification. tions, and newborns switched at birth and —— Collect specimens after a label is —— Locate the patient identifiers in an given to the wrong parents. Unlike other printed and at the point of care.18 easy-to-find place. populations, newborns cannot participate —— Use blood tube extenders or a “tube- —— Use large font sizes and readable text in the identification process and may have within-a-tube” system when using styles. similar physical characteristics.2 Authority microtainers, if small labels are not —— Standardize information layout and analysts estimated that an average of available.17,18 presentation. nearly two newborn misidentification —— Educate staff about labeling pro- —— Avoid using all capitalized letters. events occur daily in Pennsylvania, which tocols and verify understanding equates to one misidentification error for of the correct procedure through Registration Issues every 217 live births. Safety huddling,15,23 demonstration.25 —— Pre-register newborns with informa- distinct naming systems,8 clinician aware- tion that is known and then activate ness, and technology such as bar coding11 Breast Milk the registration with the additional may help to decrease newborn identifica- —— If auto identification technologies information after birth.18 tion errors. are not available, use nursing double —— Meet with registration departments checks.16,26 to streamline procedures needed to Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 47 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S NOTES 1. The Joint Commission. National 10. Phillips SC, Saysana M, Worley S, et al. 21. The Joint Commission, Division of Patient Safety Goals effective January Reduction in pediatric identification Health Care Improvement. Temporary 1, 2016 [online]. 2015 [cited 2015 Mar band errors: a quality collaborative. Pediat- names put newborns at risk. Quick- 1]. http://www.jointcommission.org/ rics 2012 Jun;129(6):1587-93. Safety 2015 Oct;17;1-2 [cited 2016 Mar assets/1/6/2016_NPSG_HAP.pdf 11. Steele C, Bixby C. Centralized breastmilk 9]. http://www.jointcommission.org/ 2. Gray JE, Suresh G, Ursprung R, et al. handling and bar code scanning improve assets/1/23/Quick_Safety_Issue_17_ Patient misidentification in the neonatal safety and reduce breastmilk administra- Oct_2015_10_20_15.pdf intensive care unit: quantification of risk. tion errors. Breastfeed Med 2014 Nov 22. Adelman JS, Schechter C, Aschner J, et al. Pediatrics 2006 Jan;117(1):437. 9(9):426-9. The “babyboy/babygirl” problem: evaluat- 3. Chuck E. Tennessee mom says hos- 12. Henneman PL, Fisher DL, Henneman ing the risk of non-distinct, temporary pital performed procedure on wrong EA, et al. Providers do not verify patient first names for newborns and measuring baby [online]. NBC News 2016 identity during computer order entry. the effect of changing the paradigm to Feb 11 [cited 2016 May 9]. http:// Acad Emerg Med 2008 Jul;15(7):641-8. reduce wrong patient orders. Presented www.nbcnews.com/news/us-news/ at: Vermont Oxford Network Conference; 13. Carroll AE, Tarczy-Hornoch P, O’Reilly E, tennessee-mom-says-hospital-performed- Nov 2014; Chicago, IL [online]. 2014 et al. The effect of point-of-care personal procedure-wrong-baby-n515886 Nov [cited 2016 May 4]. www.vtoxford. digital assistant use on resident docu- org/meetings/AMQC/Handouts2014/ 4. Kemp J. Virginia teen talks about being mentation discrepancies. Pediatrics 2004 LearningFair/Montefiore_BabyBoyBaby- switched at birth, a mistake that changed Mar;113(3 Pt 1):450-4. GirlIntheNICU.pdf security in hospitals nationwide. New 14. Simpson JH, Lynch R, Grant J, et al. York Daily News. 2013 Nov 14. [cited 23. Petticord, Vivian (Perinatal Safety Nurse, Reducing medication errors in the neona- 2016 Mar 2]. http://www.nydailynews. Magee-Womens Hospital of the University tal intensive care unit. Arch Dis Child Fetal com/news/national/virginia-teen-talks- of Pittsburgh Medical Center). Conversa- Neonatal Ed 2004 Nov;89(6):F480-2. switched-birth-mistake-changed-security- tion with Pennsylvania Patient Safety 15. Haughton, Vivian (Clinical Nurse Spe- Authority. 2016 Feb 18. hospitals-nationwide-article-1.1516610 cialist, Women & Babies Hospital, Penn 5. Tanabe K. Babies are still switched at 24. Reducing errors in blood specimen label- Medicine, Lancaster General Health). birth? Yes, it happened to me, briefly. The ing: a multihospital initiative. Pa Patient Conversation with: Pennsylvania Patient Washington Post 2016 Apr 7 [cited 2016 Saf Advis [online] 2011 Jun [cited 2016 Safety Authority. 2016 Mar 8. Apr 13]. https://www.washingtonpost. Mar 2]. http://patientsafetyauthority.org/ 16. Mismanagement of expressed breast milk. ADVISORIES/AdvisoryLibrary/2011/ com/news/parenting/wp/2016/04/07/ PA PSRS Patient Saf Advis [online] 2007 jun8(2)/Pages/47.aspx babies-are-still-switched-at-birth-yes-it- Jun [cited 2016 Mar 2]. http://patient- happened-to-me-briefly/ 25. Patient misidentification in the NHS safetyauthority.org/ADVISORIES/ 6. Suresh G, Jorbar J, Plsek P, et al. Volun- is recognised as a significant risk to all AdvisoryLibrary/2007/jun4(2)/Pages/ tary anonymous reporting of medical groups of patient’s, however certain 46.aspx. errors for neonatal intensive care. Pediat- groups of patients are more vulnerable, 17. Dunn EJ, Moga PJ. Patient misidentifica- this include neonates. J Neonatal Nurs rics 2004 Jun 6;113(6):160918. tion in laboratory medicine. Arch Pathol 2008 Oct.14(5):170-1 7. Gray JE, Goldman DA. Medication errors Lab Med 2010 Feb 134:244-55. in the neonatal intensive care unit: special 26. NSW Health. Maternity-breast milk: 18. Booth, Barbara (Laboratory Service safe management [online]. 2010 Mar 23 patients, unique issues. Arch Dis Child Improvement Coordinator, Geisinger [cited 2016 Mar 4]. http://www0.health. Fetal Neonatal Ed 2004 Nov;89:472-3. Wyoming Valley Medical Center). Con- nsw.gov.au/policies/pd/2010/pdf/ 8. Adelman J, Aschner J, Schechter C, et al. versation with: Pennsylvania Patient PD2010_019.pdf Use of temporary names for newborns Safety Authority. 2016 Mar 1. and associated risks. Pediatrics 2015 19. Probst CA, Wolf L, Bollini M, et al. Aug;136(2):327-33. Human factors engineering approaches 9. Quigley, Elizabeth (Nurse Manager, Neo- to patient identification armband design. natal Intensive Care Unit, Pennsylvania Appl Ergon 2016 Jan;52:1-7. Hospital of the University of Pennsylvania 20. Howanitz PJ, Renner SW, Walsh MK. Health System). Conversation with: Pennsyl- Continuous wristband monitoring over 2 vania Patient Safety Authority. 2016 Feb 12. years decreases identification errors. Arch Pathol Lab Med 2002;126:809-15. Page 48 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS —— Identify common reasons why new- The following questions about this article may be useful for internal education and born misidentification occurs. assessment. You may use the following examples or develop your own questions. —— Recall newborn misidentification 1. All of the following are common reasons why newborns are misidentified except: events most likely to occur as identi- a. Similar birth dates fied in events reported through the b. Same medical record number as mother c. Identical surname for multiple births Pennsylvania Patient Safety Reporting d. Similar weight and length System (PA-PSRS). 2. Which one of the following is the most common type of event associated with —— Recall the predominant contributory newborn misidentification, as reported in Pennsylvania? factors for newborn misidentifica- a. Managing breast milk tion identified in events reported b. Administering medications through PA-PSRS. c. Performing radiology procedures —— Assess strategies to decrease newborn d. Carrying out laboratory orders misidentification. 3. Which one of the following is identified as a contributory factor in newborn misidentification? a. Labels not readily available at the point of care b. Patient identification labels placed on both the wrist and ankle of the newborn c. Scanning barcodes before administering breast milk d. Using two identifiers during computerized provider-order entry 4. Adelman et al. suggest a distinct naming system using a combination of the moth- er’s and newborn’s names such as . a. BabyboyWendy Jackson b. Babygirl and Wendy Jackson c. Wendysboy Jackson d. Wendysbabyboy Jackson 5. Which one of the following breast milk administration practices could contribute to newborn misidentification? a. Including parents in the identification process b. Warming breast milk in the preparation area c. Using a nursing double-check process d. Placing smudge-proof labels to ensure legibility Question 6 refers to the following scenario: A 31-week-old newborn was transferred to the Neonatal Intensive Care Unit for monitoring and evaluation. The nurse found a signed surgical consent for a biliary atresia in the patient’s chart, but the patient was not scheduled for this procedure. She contacted the resident who obtained the consent and was told to disregard it. The nurse discovered there was another patient in the unit with a similar last name. 6. In the above scenario, which one of the following statements is most likely true? a. Information on the patient’s identification bands was incorrect. b. The resident did not check two forms of identification in the patient’s chart. c. The parents consented to the wrong procedure. d. The resident used the wrong consent form. Question 7 refers to the following scenario: A newborn is found in a mother’s room without any patient identification bands. One identifica- tion band is found taped to the newborn’s bassinet and the other has been placed on the counter. 7. Which one of the following interventions is most effective in preventing newborn misidentification? a. Make sure the identification band taped to the bed is correct. b. Place one of the identification bands on the newborn. c. Find out why the identification bands were removed and take corrective action. d. Remove the identification bands from the patient’s room. Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 49 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 2—June 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://www.patientsafetyauthority.org. An Independent Agency of the Commonwealth of Pennsylvania ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 50 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.