It’s not a huge number, but it is startling nonetheless: Nearly two newborns are misidentified daily across Pennsylvania, according to a report issued last month by the state’s patient safety authority.

Imagine being one of those parents. Your heart stops for a minute, doesn’t it, and your mind goes crazy playing out dozens of scenarios. “Unique characteristics of the newborn population pose challenges for accurate and consistent patient identification,” Ellen S. Deutsch, M.D., medical director for the authority, said in a press release. “Hospitalized newborns often share similar birth dates and medical record numbers and, with multiple births, even share surnames.”

Those comments echo what Albert Oriol, CIO at Rady Children’s Hospital & Health Center in San Diego, and a CHIME board member, told Modern Healthcare earlier this year. “In many cases, when the baby is born, the birth hospital doesn't even have a name yet,” Oriol said. “It may be 'baby girl A' or 'baby girl B.' By the time the parents come up with a name, that baby is already in our” neonatal intensive-care unit.

The majority of misidentification events in Pennsylvania involved such procedural errors as mislabeled blood specimens and unlabeled urine samples. General misidentification, including no ID band or mismatched ID bands on the mother and newborn, was the next largest category of errors.

What happened? Here are some examples listed in the report:

  • There were two baby girls with the same last name in the unit. An x-ray was ordered on the wrong patient but was performed on the correct patient.
  • Patient was fed breast milk that was from another patient with the same last name.
  • Patient had the wrong identification band. It contained the right name but another patient’s birth date. The staff had used the ID band for several days.
  • Antibiotic order faxed to pharmacy. When entering the order, pharmacist noted this patient’s weight was significantly different from the weight on the order (2.185kg vs. 0.83kg). The pharmacist found that the sticker on the antibiotic order was incorrect. There are currently two patients with the same last name.

Thankfully, none of these events resulted in harm to the baby. Still, until we can accurately and safely identify every patient, including newborns, the risk for harm exists.

Thank you for joining us in the important journey to improve care delivery and patient safety.

We’d also like to thank you for your patience as we finalize the Final Innovation Round Use Cases. We hope to have them posted shortly.