Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems

Abstract

IMPORTANCE Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants.OBJECTIVES To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission.

<p>Drug Use and Type of Adverse Drug Events–Identified by a Trigger Tool in Different Units in a Swedish Pediatric Hospital</p>

“…We did not exclude twins or triplets (similar looks and similar names), known to be at higher risk of ADE than singletons. 25 In addition, the type of medication error causing the ADE was not analyzed. Finally, in this study, we have done the assumption that ADE were equal or indistinguishable, which may not always be the case.…”

Study on preventing adverse events in neonates (SEPREVEN)

“…[ 9 ] Supplementary risk factors in the ELGAN subgroup are clinical fragility due to low weight, overall immaturity and inability to compensate for clinical alterations as well as complex care (catheters, tubes, artificial ventilation) and types of medications needed. [ 9 , 14 – 21 ] In addition, neonatal-specific AEs described include identification errors among multiple-birth infants, [ 22 ] breast milk errors, [ 21 ] skin lesions due to immaturity [ 9 , 15 ] and nasal injuries from non-invasive ventilation. [ 23 ] Finally, hospital-acquired infections (HAIs), especially central-line-associated bloodstream infections (CLABSIs) are a leading cause of mortality and neurological morbidity in premature neonates [ 23 – 25 ] which can be reduced by adherence to appropriate infection control measures.…”

A National Survey on the Use of Temporary Naming Conventions for Newborns: 5-Year Follow-up

“…6,8 However, this approach has been shown to be less effective for reducing errors among multiple-birth infants than among singleton births. 7…”

“…4,5 This vulnerable population is at significantly higher risk for identification errors compared with other inpatient pediatric populations, and the risk is further increased among multiple-birth infants compared with singleton-birth infants. 6,7 Use of a distinct naming convention incorporating the mother's first name and the newborn's gender, such as Anitasboy/Anitasgirl, was associated with a significant reduction in the risk of wrong-patient order errors when compared with temporary, nondistinct naming conventions, such as Babyboy/ Babygirl. 6,8 However, this approach has been shown to be less effective for reducing errors among multiple-birth infants than among singleton births.…”