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Patient Identification Errors in Infants and Neonates

Incidents involving misidentification resulting in infants undergoing unnecessary surgical procedures appear in the news with surprising frequency. As recently as 2016, an infant in Tennessee underwent an unnecessary frenulectomy. A few years before that the wrong newborn was circumcised in a NICU in Miami when his mother left briefly to shower and grab a change of clothes. Wrong patient surgeries are rare. In a review of nearly 10,000 paid malpractice claim reports filed between 1990 and 2010, only 27 (0.03%) were due to a wrong-patient surgery. However, a 2015 report from the Joint Commission revealed a total of ten sentinel events since 2010 that occurred due to the misidentification of newborns and all ten of those reports involved a circumcision performed on the wrong infant.

Cases of newborns receiving the wrong mother’s breastmilk are also reported. In 2016, an article published in the American Journal of Case Reports detailed an incident in which a premature infant in a NICU received breastmilk designated for another patient. There have also been cases in the news media from cities across the US including New York, Chicago, Minneapolis, Houston , and the San Francisco Bay Area of newborns receiving the wrong breastmilk. In these cases the wrong infant is brought to the wrong mother, often in the wee hours of the morning, and breastfed in a dimly lit hospital room before anyone recognizes the mix up. While the risk of harm is low, there is always a small chance of infectious disease transmission. In addition, wrong breast milk cases should raise a red flag that the risk of serious harm related to patient misidentification exists and thus the lessons learned from these events should not go unheeded.

In order to determine the scope and nature of patient misidentification in this patient population, we examined the CHPSO databases for cases involving patient identification in infants and neonates. A query utilizing the key words listed below yielded a total of 853 cases from 82 facilities in multiple states.

  • wrong baby
  • wrong infant
  • incorrect baby
  • incorrect infant
  • wrong neonate
  • incorrect neonate
  • wrong breastmilk
  • wrong breast milk
  • wrong milk
  • wrong patient (restricted to patients less than 1 year of age)
  • patient identification issues (restricted to patients less than 1 year of age)
  • mislabeled specimens (restricted to patients less than 1 year of age)
  • labeling issues (restricted to patients less than 1 year of age)

A total of 59 cases were removed as not applicable. Of the remaining 792 cases, the majority involved specimen collection issues and lab errors. Among these errors were lab draws on the wrong patient, lab draws on the correct patient that were mislabeled, mislabeled cord blood, and point of care testing performed on the wrong patient or resulted to the wrong record. In one of these cases the correct labs for the newborn were drawn, then the baby’s mother (who was not a patient at the time) had labs drawn that were intended for the baby’s grandmother (who was a patient in the facility at the time). The tubes containing the mother’s blood were labeled with the grandmother’s patient identifiers.

Safety reports involving the wrong patient or wrong encounter were the next largest category in the data set. These cases included testing or treatment performed on the wrong patient, orders placed on the wrong patient and medications dispensed or administered to the wrong patient. A common issue among the medication related cases involved pulling medications under mom’s profile instead of baby, or vice versa.

Admitting and/or registration errors were evident in 8 of the cases and, not surprisingly, the cases with errors in this category also had other issues. For example, one case involved two mothers with the same last name. In this case Mom A gave birth to a set of twins, while Mom B gave birth to a singleton neonate. The twins were admitted under Mom B which resulted in: patients admitted to the wrong locations; documentation in the wrong records; orders in the wrong charts; medications dispensed to the wrong patients, and delays in lab work and treatments.

Mix ups between siblings, often twins, occurred in 36 cases. One involved Baby Twin-A receiving a blood transfusion that was meant for Baby Twin-B. The transfusion was stopped partway through when the error was discovered.

Breastmilk related errors and mix ups were evident in 93 of the cases and there were four cases that involved newborns having been taken to the wrong mother. Like the cases discussed from the news media and the literature these cases caused significant distress for the mothers/families. In at least one of these cases the mix up resulted in a mother breastfeeding the wrong infant.

Two of the 792 cases reviewed involved circumcision. In one, both of the infants were scheduled for a circumcision: checking the consent and the patient’s armband before the case confirmed that a circumcision was to be done, but the physician that did the case was scheduled to do a circumcision for a different patient. However, in the second of the two wrong infant circumcision cases, it is unclear from the report whether the mother wanted to have her son circumcised.

Appropriate identification is important in all patients. However, the analysis of these data show that there are issues that are unique to babies. Facilities would be well served to examine vulnerabilities in their patient identification practices that are specific to infants and newborns. For example, an article published by the American Academy of Pediatrics echoes the recommendation from the Joint Commission to adopt strategies to avoid non-distinct naming conventions. In addition, many organizations have developed strategies to minimize the risk of misidentification errors related to breastmilk administration. See the following references for more information.

References and Resources

Adelman, J. S., Aschner, J. L., Schechter, C. B., Angert, R. M., Weiss, J. M., Rai, A., … & Dadlez, N. M. (2017). Evaluating serial strategies for preventing wrong-patient orders in the NICU. Pediatrics, 139(5), e20162863.

CHOC Children’s Breast Milk Management FEMA and QI project.

Mehtsun, W. T., Ibrahim, A. M., Diener-West, M., Pronovost, P. J., & Makary, M. A. (2013). Surgical never events in the United States. Surgery, 153(4), 465-472.

Oza-Frank, R., Kachoria, R., Dail, J., Green, J., Walls, K., & McClead, R. E. (2017). A quality improvement project to decrease human milk errors in the NICU. Pediatrics, e20154451.

Paull, D. E., Mazzia, L. M., Neily, J., Mills, P. D., Turner, J. R., Gunnar, W., & Hemphill, R. (2015). Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the Veterans Health Administration. The American Journal of Surgery, 210(1), 6-13.

Sauer, C. W., & Marc-Aurele, K. L. (2016). Parent Misidentification Leading to the Breastfeeding of the Wrong Baby in a Neonatal Intensive Care Unit. The American journal of case reports, 17, 574.

Steele, C., & Bixby, C. (2014). Centralized breastmilk handling and bar code scanning improve safety and reduce breastmilk administration errors. Breastfeeding Medicine, 9(9), 426-429.