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
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
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
wrong breast milk
wrong patient (restricted to patients less than 1 year of
patient identification issues (restricted to patients less
than 1 year of age)
mislabeled specimens (restricted to patients less than 1 year
labeling issues (restricted to patients less than 1 year of
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
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.