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To the Editor The Editorial by Freed, “When New Standards to Improve Safety Do Not Actually Improve Safety,”1 makes an important point: all organizations must be careful when implementing changes to improve safety and assess whether the changes were made successfully, achieved the desired improvement, and did not have unintended consequences. Unfortunately, the Editorial had several important inaccuracies about the Joint Commission’s standard on newborn identification and the study by Adelman et al.2
First, the new Joint Commission standard requiring efforts to prevent newborn misidentification3 was developed to address the well-documented problem of misidentification for all newborns and to prevent the resulting harms (eg, wrong-patient circumcision)4; the standard was not focused only on newborns in the neonatal intensive care unit or on the more vexing problem of misidentification of children of multiple births. The standard states simply “use distinct methods of identification for newborn patients.”3 In addition, the standard did not prescribe any specific intervention to mitigate newborn misidentification. The standard states, “Examples of methods to prevent misidentification may include the following:…” One of the examples was “distinct naming systems.”3
In contrast to what Freed claimed, the study by Adelman et al2 did not demonstrate that the distinct naming convention failed to reduce the wrong patient error rate in multiple-birth newborns. The study2 did not evaluate the outcomes of the change in Joint Commission policy; it simply assessed differences in order-entry errors between singleton- and multiple-birth children after the intervention had been implemented and found that the error rate was higher for multiple-birth newborns. The error rate for multiple-birth newborns might have been reduced from its baseline by the same or even a greater proportion than for singletons while still remaining higher than the rate for singletons. Adelman et al correctly concluded “These results suggest that a distinct naming convention … may provide insufficient protection against identification errors among multiple-birth infants.”2
If previous studies are correct,5 it is likely that the newborn naming convention that was implemented at the hospitals in the Adelman et al study2 decreased wrong-patient order entries for singleton-birth infants but failed to close the gap in the error rate for children of multiple births. We agree that more research is necessary to identify optimal ways to protect the children of multiple births, but we should applaud the progress being made to protect singleton-birth children.
Corresponding Author: David W. Baker, MD, MPH, Healthcare Quality Evaluation, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181 (firstname.lastname@example.org).
Published Online: March 23, 2020. doi:10.1001/jamapediatrics.2020.0062
Conflict of Interest Disclosures: None reported.
Baker DW, Chassin MR. Inaccuracies Regarding the Joint Commission Newborn Identification Standard. JAMA Pediatr. Published online March 23, 2020. doi:10.1001/jamapediatrics.2020.0062
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