Are NICUs doing enough to reduce wrong-patient orders among multiple-birth infants?

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Multiple-birth infants often require admission to a neonatal intensive care unit (NICU), but newborns receiving care there are at a significantly higher risk of identification errors than patients in general pediatric units. A recent study in JAMA Pediatrics explored whether risk of wrong-patient orders increased among multiple-birth infants compared with singleton-birth infants in the NICU.

The multicenter, retrospective cohort study examined orders placed for infants in six NICUs at two large, integrated healthcare systems. Throughout the study periods, both study sites used distinct naming conventions that incorporated the mother’s first name and infant’s sex. For multiple-birth infants, a letter or number was added after the infant’s sex depending on the study site.

The primary outcome was wrong-patient electronic orders that were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. A wrong-patient order was defined as an order placed for patient A that was intended for Patient B. The study compared the rate of RAR events between multiple-birth infants and singleton-birth infants receiving care in the NICU and assessed the proportion of RAR events that occurred between multiple-birth infants and siblings (intrafamilial errors) and between multiple-births and non-siblings (extrafamilial errors). Only infants with siblings receiving care in the NICU at the same time were classified as multiple-birth infants; infants who born as a member of a set of multiple births but did not have siblings who received care in the NICU were classified as singleton births for the purpose of the study.

More than 1.5 million orders placed for 10,819 infants were included in the study. Of the infants, 55.8% were male (44.2% female) and 85.5% were singleton-birth infants (14.5% multiple-birth infants). Multiple-birth infants were more likely than singleton-birth infants to be female, white, and have commercial health insurance.

Overall, the rate of RAR events was significantly higher among multiple-birth infants compared to singleton-birth infants (66.0 vs 41.7 RAR events per 100,000 orders, respectively; adjusted OR, 1.75; 95% CI 1.39-2.20; P < .001). Risk of wrong-patient order errors occurring between unrelated infants in the NICU was similar regardless of multiple-birth status. Incidence of extrafamilal RAR events among multiple-birth infants was 36.1 per 100,000 orders compared with 4.17 per 100,000 orders among singletons (OR, 0.95; 95% CI, 0.80-1.20; P = .63).

Infants at study site 1 were more likely to be white and to have commercial health insurance than infants at study site 2 who were more likely to be black or Hispanic and to have Medicaid as their primary health insurance. However, the overall rate of RAR per 100,000 was similar across both sites (46.8 at site 1 vs 45.6 at site 2; P =.89)

The authors noted that the rate of wrong-patient orders increased as the number of siblings receiving care in the NICU increased. Among singleton births, RAR events per 100,000 orders occurred at a rate of 41.7. For twin births, RAR events occurred at a rate of 61.2 per 100,000 orders and high-order multiple births (i.e. triplets and quadruplets) RAR events occurred in 98.2 per 100,000.

The authors believe their findings indicate that multiple birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. They believe this risk is a result of misidentification between siblings. Although both sites had a Joint Commission-compliant distinct naming convention designed to minimize wrong-patient errors, the study results suggest that existing safeguards may be insufficient to reduce risk of wrong-patient order errors among multiple-birth infants. The authors suggest using given names at birth, changing temporary names to given names when they become available, and developing approaches to encourage parents of multiple-birth infants to select names before birth when this practice is acceptable to the families.