Newborns pose distinct challenges when it comes to patient identification, which results in an average of two infant misidentification events every day in Pennsylvania, according to recent analysis published by the Pennsylvania Patient Safety Authority.
"Hospitalized newborns often share similar birth dates and medical record numbers and, with multiple births, even share surnames," said Ellen S. Deutsch, MD, medical director of the PPSA. These characteristics make proper patient identification more difficult.
While analysts noted that specific information on newborn identification errors is limited, they were able to detect 1,234 newborn identification events that occurred in the state between January 2014 and December 2015. The events reported were largely procedure errors involving lapses like mislabeled specimens and mismatched or missing identification bands. While the vast majority of errors were determined to not have harmed the patients, five serious events were detected, including instances in which the wrong breast milk was given to the patient and a circumcision was performed without consent.
Based on the circumstances surrounding the incidents, analysts made error reduction recommendations to improve newborn identification. Advice includes:
• Checking for two patient identifiers before entering information into a medical record.
• Using bedside label printers to generate labels at the point of care.
• For identification bands, use auto identification technologies like bar coding and radiofrequency.
• For breast milk, use individual warmers at the bedside to reduce opportunities for misidentification.
Dr. Deutsch said, "The information can be a start to ongoing discussions that purposefully address newborn identification errors in healthcare facilities."
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