[Skip to Content]
[Skip to Content Landing]
Views 814
Citations 0
Original Investigation
August 26, 2019

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

Author Affiliations
  • 1Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York
  • 2Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York
  • 3New York–Presbyterian Hospital, New York
  • 4Division of Hospital Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York
  • 5Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York
  • 6Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
  • 7Hackensack Meridian Health School of Medicine, Seton Hall University, Nutley, New Jersey
  • 8Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, Bronx, New York
  • 9Montefiore Health System, Bronx, New York
  • 10Department of Pediatrics, Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts
  • 11Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, New York
  • 12Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
  • 13Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Pediatr. Published online August 26, 2019. doi:10.1001/jamapediatrics.2019.2733
Key Points

Question  Is the risk of wrong-patient orders increased among multiple-birth infants compared with singleton-birth infants in the neonatal intensive care unit?

Findings  In this cohort study of 1 536 160 orders placed for 10 819 infants in 6 neonatal intensive care units at 2 health care systems, the risk of wrong-patient orders was significantly higher among multiple-birth infants compared with singleton-birth infants. The excess risk among multiple-birth infants may have been owing to identification errors that occurred between siblings, with the greatest risk among sets of higher-order multiple-birth infants.

Meaning  Requirements for newborn identification may provide insufficient protection against wrong-patient errors among multiple-birth infants in neonatal intensive care units.

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 Participants  A 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. Data were collected from 4 NICUs at New York–Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included.

Main Outcomes and Measures  Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes.

Results  A total of 10 819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100 000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P < .001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100 000 orders) was similar to that of singleton-birth infants (41.7 per 100 000 orders). The excess risk among multiple-birth infants (29.9 per 100 000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births.

Conclusions and Relevance  This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.

×