Infants in the ICU too easily misidentified

The odds are high for misidentification of infants in hospital neonatal intensive care units (NICUs), largely due to similarities in patients’ names and medical record numbers, doctors warn in a report in the journal Pediatrics.

“A recent review by our group demonstrated that medical errors related to patient misidentification accounted for 11 percent of all reported NICU errors,” Dr. James E. Gray told Reuters Health. Similarly, a recent report from England found that 25 percent of serious medication errors in a NICU were caused by patient misidentification, he added.

Gray, from Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, and colleagues investigated the role that similarity in standard medical identifiers might play in misidentifying NICU patients in their institution.

Throughout the 1-year study period, “there was not a single calendar day without at least one pair of patients at risk for misidentification,” the investigators report. On average, just over half the patients were at risk on any given day.

Similar medical record numbers accounted for most of the potential errors, followed by identical names, and similar-sounding last names.

Even when infants whose multiple-gestation siblings were present on the same day were excluded from the analysis, just over a quarter of patients were at risk for misidentification on any given day, the report indicates, and only six of 365 days had no singleton patient at risk.

“NICU clinicians must remain vigilant in their processes to correctly identify NICU patients,” Gray said, adding that his team is exploring the value of radiofrequency identification technologies in the NICU.

SOURCE: Pediatrics January, 2006.

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