Published online January 4, 2006
PEDIATRICS Vol. 117 No. 1 January 2006, pp. e43-e47 (doi:10.1542/peds.2005-0291)

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ARTICLE

Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk

James E. Gray, MD^a,b, Gautham Suresh, MD^a,c, Robert Ursprung, MD^a,d, William H. Edwards, MD^a,e, Julianne Nickerson, MSW, Pat H. Shiono, PhD^a, Paul Plsek, MS^a, Donald A. Goldmann, MD^a,b,f and Jeffrey Horbar, MD^a,g

^a Center for Patient Safety in Neonatal Intensive Care, University of Vermont, Burlington, Vermont
^b Beth Israel Deaconess Medical Center, Children's Hospital, Harvard Medical School, Boston, Massachusetts
^c Medical University of South Carolina, Charleston, South Carolina
^d Pediatrix Medical Group, Cook Children's Medical Center, Fort Worth, Texas
^e Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
^f Institute for Healthcare Improvement, Cambridge, Massachusetts
^g University of Vermont College of Medicine, Burlington, Vermont

OBJECTIVE. To quantify the potential for misidentification among NICU patients resulting from similarities in patient names or hospital medical record numbers (MRNs).

METHODS. A listing of all patients who received care in 1 NICU during 1 calendar year was obtained from the unit's electronic medical record system. A patient day was considered at risk for misidentification when the index patient shared a surname, similar-sounding surname, or similar MRN with another patient who was cared for in the NICU on that day.

RESULTS. During the 1-year study period, 12186 days of patient care were provided to 1260 patients. The unit's average daily census was 33.4; the maximum census was 48. Not a single day was free of risk for patient misidentification. The mean number of patients who were at risk on any given day was 17 (range: 5–35), representing just over 50% of the average daily census. During the entire calendar year, the risk ranged from 20.6% to a high of 72.9% of the average daily census. The most common causes of misidentification risk were similar-appearing MRNs (44% of patient days). Identical surnames were present in 34% of patient days, and similar-sounding names were present in 9.7% of days. Twins and triplets contributed one third of patient days in the NICU. After these multiple births were excluded from analysis, 26.3% of patient days remained at risk for misidentification. Among singletons, the contribution to misidentification risk of similar-sounding surnames was relatively unchanged (9.1% of patient days), whereas that of similar MRNs and identical surnames decreased (17.6% and 1.0%, respectively).

CONCLUSIONS. NICU patients are frequently at risk for misidentification errors as a result of similarities in standard identifiers. This risk persists even after exclusion of multiple births and is substantially higher than has been reported in other hospitalized populations.

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Key Words: patient safety • errors • misidentification • neonatal intensive care

Abbreviations: JCAHO—Joint Commission on Accreditation of Healthcare Organizations • MRN—medical record number • EBM—expressed breast milk

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Accepted Jul 5, 2005.

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