ARTICLE

Patient Misidentification in the Neonatal Intensive

Care Unit: Quantification of Risk
James E. Gray, MDa,b, Gautham Suresh, MDa,c, Robert Ursprung, MDa,d, William H. Edwards, MDa,e, Julianne Nickerson, MSWa,
Pat H. Shiono, PhDa, Paul Plsek, MSa, Donald A. Goldmann, MDa,b,f, Jeffrey Horbar, MDa,g

aCenter for Patient Safety in Neonatal Intensive Care, University of Vermont, Burlington, Vermont; bBeth Israel Deaconess Medical Center, Children’s Hospital, Harvard
Medical School, Boston, Massachusetts; cMedical University of South Carolina, Charleston, South Carolina; dPediatrix Medical Group, Cook Children’s Medical Center, Fort
Worth, Texas; eDartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; fInstitute for Healthcare Improvement, Cambridge, Massachusetts; gUniversity of
Vermont College of Medicine, Burlington, Vermont

Financial Disclosure: Dr Horbar is Chief Executive and Scientific Officer for the Vermont Oxford Network.

ABSTRACT
OBJECTIVE. To quantify the potential for misidentification among NICU patients re-
sulting from similarities in patient names or hospital medical record numbers
www.pediatrics.org/cgi/doi/10.1542/
(MRNs). peds.2005-0291

METHODS. A listing of all patients who received care in 1 NICU during 1 calendar year doi:10.1542/peds.2005-0291

was obtained from the unit’s electronic medical record system. A patient day was Key Words
patient safety, errors, misidentification,
considered at risk for misidentification when the index patient shared a surname, neonatal intensive care
similar-sounding surname, or similar MRN with another patient who was cared Abbreviations
for in the NICU on that day. JCAHO—Joint Commission on
Accreditation of Healthcare
Organizations
RESULTS. During the 1-year study period, 12 186 days of patient care were provided MRN—medical record number
to 1260 patients. The unit’s average daily census was 33.4; the maximum census EBM— expressed breast milk
was 48. Not a single day was free of risk for patient misidentification. The mean Accepted for publication Jul 5, 2005

number of patients who were at risk on any given day was 17 (range: 5–35), Address correspondence to James E. Gray,
MD, Beth Israel Deaconess, Neonatology, 330
representing just over 50% of the average daily census. During the entire calendar Brookline Ave, Boston, MA 02215. E-mail:
year, the risk ranged from 20.6% to a high of 72.9% of the average daily census. jgray@bidmc.harvard.edu

The most common causes of misidentification risk were similar-appearing MRNs PEDIATRICS (ISSN 0031 4005). Copyright © 2006
by the American Academy of Pediatrics
(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 misidentifica-
tion. 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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T HE COMPLEX NATURE of NICU care and the vulnera-
bility of the patient population served places NICU
patients at extremely high risk for errors and adverse
calendar day (1) shared a last name, (2) shared a similar-
sounding last name (names were considered similar
when they had identical Soundexx or Metaphone
events related to these errors. A particularly common codes,3), or (3) shared a similar MRN. MRNs were con-
class of errors results from patient misidentification. sidered similar when they differed by only a single digit
Suresh et al1 reported that errors related to patient mis- substitution (see Table 1 for examples). Categorization of
identification represented 11% of all errors submitted to risk was performed by a custom-designed computer pro-
the Vermont Oxford Network’s voluntary error-report- gram written in Visual Basic.NET (Microsoft Co, Red-
ing system. Accurate patient identification is a necessary mond, WA). The study was approved by the Beth Israel
component of providing both safe and effective diagnos- Deaconess Committee on Clinical Investigation.
tic and therapeutic services. As such, improving the ac-
curacy of patient identification has been first among the
Joint Commission on Accreditation of Healthcare Orga- RESULTS
nizations (JCAHO) national patient safety goals in 2003, During the study period, 12 186 days of patient care
2004, and again in 2005. The purpose of the present were provided to 1260 patients. The NICUs average daily
project was to quantify the role that similarity in stan- census was 33.4 (range: 21– 48). Twins and triplets con-
dard medical identifiers might play in misidentification tributed 4063 patient days (33.3% of total).
among NICU patients. There was not a single calendar day without at least 1
pair of patients at risk for misidentification. In fact, the
METHODS minimum number of patients at risk on any day was 5;
The Beth Israel Deaconess Medical Center (Boston, MA) the maximum was 38. On average, 50.9% of patients
maintains a 40-bed level III NICU that serves a predom- were at risk on any given calendar day. As seen in Fig 1,
inantly inborn population. Patients are identified using the daily risk ranged from 20.7% to 72.9%.
standard identification bands from the Hollister Corpo- The reasons for categorizing a patient day at risk for
ration (Libertyville, IL). In accordance with the JCAHO’s misidentification are seen in Table 2. The most common
national patient safety goal 1A, 2 patient identifiers are cause for a patient to be at risk for misidentification was
to be used whenever administering medications or blood the presence of similar MRNs (44.1% of patient days)
products, taking blood samples and other specimens for followed by identical names (34% of patient days) and
clinical testing, or providing any other treatments or similar-sounding last names (9.7% of patient days). Of
procedures.2 The labels for these bands are created using note, 33.3% of patient days were at risk for misidentifi-
an Addressograph card and contain a patient’s last name, cation because patients shared both similar MRNs and
gender (infant boy or infant girl), birth order (in the case similar-sounding/identical last name.
of multiple gestations), date of birth, and medical record The presence of twins, triplets, and higher order mul-
number (MRN). Maternal last name is used throughout tiple births dramatically affects the presence of similar
a newborn’s hospital stay as the infant’s last name. patient identifiers because they share last names and
MRNs contain 8 digits and are assigned sequentially. may have consecutive MRNs. We therefore repeated the
Check digits are not present in the MRN used at the analyses while excluding infants whose multiple-gesta-
study NICU. A check digit guards against errors caused tion sibling(s) was(were) present on the same day. Here
by the incorrect transcription of an MRN. It is an addi- again, virtually all calendar days had at least 1 pair of
tional 1-digit integer appended to the end of an MRN to patients at risk. Only 6 of 365 days had no singleton
provide confirmation that the number is valid. The ad- patients at risk. On average, 26% of patients were at risk
ditional check digit is determined by applying a simple for misidentification on any given day. The daily risk
mathematical formula to the other digits of the number. ranged from 0% to 56% (Fig 2). Similarity in MRNs
All patients who were cared for in the Beth Israel remained the most common cause of misidentification
Deaconess Medical Center’s NICU between January 1, risk, although it was much lower among singletons than
2003, and December 31, 2003, were identified from the the entire population (see Table 2).
census logs contained in the unit’s clinical data archive
(Carevue, Philips Medical Systems, Andover, MA). De-
mographic information, including patient last name, TABLE 1 Examples of Misidentification Risk
MRN, maternal identifiers, and dates of service, were
Risk Example
downloaded to a database table in which separate
Similar last names McDonald, Baby Boy MacDonald, Baby Boy
records were created for each patient day of care pro- Similar MRNs
vided. Each patient day then was categorized as to Single-digit substitution Smith, Baby Girl Jones, Baby Boy
whether it was at risk for misidentification. A patient day MRN 1234568 MRN 1234567
was considered at risk when the index patient and an- Single-digit pair transposition Smith, Baby Girl Shen, Baby Girl
other patient who was cared for in the NICU on the same MRN 1234568 MRN 1243568

e44 GRAY, et al
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FIGURE 1
Potential for misidentification as a result of similarities in
MRNs and last names.

TABLE 2 Factors That Contribute to Misidentification Risk wrong patient breast milk administration errors. In de-
% of Days at Risk scribing their experience in Toronto, Dougherty and col-
leagues5,6 noted 12 breast milk errors in 18 months in
All Singletons
Patients Only their 48-bed NICU. In addition, these authors present
Similar-sounding last name 9.7 9.1 results from a survey of 15 Canadian NICUs. Two thirds
Same last name 34.0 1.1 of the surveyed units reported experiencing similar
Similar MRN 44.1 17.6 events.
At least 1 of the above 50.9 26.3 The occurrence of breast milk feeding errors is not
surprising given the frequency with which EBM feeds
are given. In the study NICU, ⬎40 000 EBM feeds will be
administered each year. In many ways, the processes
DISCUSSION
needed for the administration of EBM parallel those
We have demonstrated that NICU patients frequently
used with blood transfusion. Despite the safeguards re-
share similar identifiers with others who receive care in
quired during the transfusion process, 1 out of 16 000 to
the unit concurrently. We believe that the potential
20 000 transfusions are complicated by a patient’s re-
confusion created by these similarities is a significant
ceiving blood intended for another.7 Applying these
contributor to misidentification risk within the NICU.
same rates to the often less rigorous processes of EBM
The importance of misidentification errors in the
NICU has been demonstrated by several authors. Simp- administration suggests that at least several events per
son et al4 recently reported that 25% of the serious year can be expected in a large, busy unit. The frequency
medication errors that were seen during a 6-month of EBM feeds along with the already high demands
study period in a British NICU were caused by patient placed on NICU clinicians dictates that interventions that
misidentification. Similarly, Suresh et al1 reported that are designed to decrease this rate be extremely time
11% of errors that were submitted to the Vermont Ox- efficient.
ford Network’s NICQ.org voluntary error-reporting sys- Misidentification errors are not only restricted to di-
tem involved patient misidentification. The data from agnostics and therapeutics but also may affect docu-
NICQ.org demonstrates that misidentification errors are mentation. Carrol et al8 found frequent discrepancies in
not limited to medication errors. These errors affected resident progress notes that were written using an elec-
both diagnostics and therapeutics (25% of reports). tronic medical record system. These discrepancies in-
A particularly common misidentification error in the cluded errors in documentation of medications (27.7%
NICU involves feeding a mother’s expressed breast milk of notes), vascular lines (33.9%), and patient weight
(EBM) to the wrong infant. One quarter of misidentifi- (13.3%). In 1 type of documentation error, the wrong
cation errors that were reported to the Vermont Oxford information may be written in the correct patient’s
Network involved EBM.1 Contributing factors to these chart. In another type, the correct information may be
events included incorrectly labeled specimens, difficult- written in the wrong patient’s chart. The authors do not
to-read handwritten specimen labels, errors in verifica- provide sufficient information to distinguish between
tion of patient/aliquot identification, and systematic these possibilities. Computer systems, such as that in the
problems with the way EBM aliquots are stored. Other study by Carroll et al,8 require clinicians to select patients
investigators have also documented the occurrence of by either recognizing or searching by patient identifiers

PEDIATRICS Volume 117, Number 1, January 2006 e45

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FIGURE 2
Potential for misidentification (multiples excluded).

such as name or MRN. When these identifiers are similar bands are placed around arms or legs. In addition, the
or identical, errors in selection may be more likely. Al- need to rotate intravenous lines frequently between lim-
though the errors reported by Carroll et al8 involved ited sites often requires identification bands to be re-
documentation, similar errors in identification also could moved.
occur with computerized provider order entry systems. Even when identification bands are present and con-
As noted by Chassin and Becher,9 many factors may tain the correct identifying information, these identifiers
contribute to misidentification errors. These may include may not be recognizably unique to busy NICU clinicians.
issues related to workflow, materials used in the identi- The sequential nature by which MRNs are assigned in
fication process, or the approach taken by staff to con- many hospitals means that patients who are admitted to
firm the identity of individual patients. The NICU envi- the NICU within a relatively short time frame are at
ronment and patient population also present additional highest risk for sharing similar MRNs, a problem exac-
unique challenges. Unlike many pediatric or adult erbated by multiple births.
wards, NICU patients are not able to participate actively Shojania11 found that 28% of calendar days on the
in the identification process. In addition, many of the University of California, San Francisco adult medical
commonly used methods to identify individuals in ev- service were at risk for misidentification as a result of the
eryday life, such as physical appearance (size, age, hair sharing of identical last names; this situation was found
color, and gender), are often not immediately apparent in 100% of days during our year-long survey. Indeed,
or distinguishable within the NICU population. As such, when considering misidentification risk as a result of
NICU clinicians must rely on standardized patient wrist similar MRNs or last names, no fewer than 5 patients
bands for identification purposes. were at risk on any given calendar day in this NICU.
Unfortunately, reports from general hospital and Certainly, the presence of multiples within the NICU
NICU populations demonstrate that errors in wristband obviously contributes dramatically to the risk attribut-
content or use are frequent. A study of 217 volunteer able to identical names. That this particular misidentifi-
hospitals by Howanitz et al10 found wristband errors in cation risk pertains mainly to one’s own siblings pro-
up to 7.4% of inpatients. Most (71.6%) errors involved vides little comfort as these patients often do not share
missing wristbands. Incorrect, conflicting, or incomplete the same diagnostic and therapeutic needs. Confusion
information was found in the remainder. Missing wrist- between patients, even related ones, can have disastrous
bands can be especially common in the NICU. Recent effects.
reviews of experience within the 34 NICUs of the Ver-
mont Oxford NICQ 2002 Quality Improvement collabo- CONCLUSIONS
rative found that standard identification bands are not We have demonstrated that the information that is used
present on 20% to 80% of NICU patients (K Leahy, RN, routinely in NICU patient identification is frequently
Vermont-Oxford Network, personal communication, similar and often not recognizably unique. We believe
May 30, 2003). Instead, identification bands are often that these findings demonstrate a need to reconsider the
affixed to a patient’s bedside or chart. In part, this prac- methods that are used for NICU patient identification.
tice is related to concerns regarding the fragility of a The use of point-of-care bar coding systems is a fre-
premature infant’s skin that can lead to skin lacerations quently cited technology for reducing patient identifica-
and erosions when standard plastic-coated identification tion errors.6 Similarly, radio frequency identification sys-

e46 GRAY, et al
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tems, which do not require line-of-sight access to patient 4. Simpson JH, Lynch R, Grant J, Alroomi L. Reducing medica-
identification bands, may prove valuable. Despite the tion errors within the neonatal intensive care unit. Arch Dis
Child Fetal Neonatal Ed. 2004;89:F480 –F482
potential benefits of these auto-identification technolo-
5. Dougherty D, Giles V. From breast to baby: quality assurance
gies, clinicians must ensure that such technologies are for breast milk management. Neonatal Netw. 2000;19:21–25
tested adequately in the unique environment of the 6. Barry C, Lennox K. Is the right breast milk being fed to infants?
NICU and that they are implemented in a manner that Can J Infect Control. 1998;Spring:16 –20
avoids disruption of workflow. 7. Wald H, Shojania KG. Prevention of misidentifications. In:
Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds.
Making Health Care Safer: A Critical Analysis of Patient Safety
ACKNOWLEDGMENT
Practices. Rockville, MD: Agency for Healthcare Research and
This study was supported in part by Agency for Health- Quality; 2001. AHRQ Publication 01-E058
care Research and Quality grant AHRQ P20 HS 11583. 8. Carroll AE, Tarczy-Hornocj P, O’Reilly E, Christakis DA. Resi-
dent documentation discrepancies in a neonatal intensive care
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Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of
Risk
James E. Gray, Gautham Suresh, Robert Ursprung, William H. Edwards, Julianne
Nickerson, Pat H. Shiono, Paul Plsek, Donald A. Goldmann and Jeffrey Horbar
Pediatrics 2006;117;e43
DOI: 10.1542/peds.2005-0291

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Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of
Risk
James E. Gray, Gautham Suresh, Robert Ursprung, William H. Edwards, Julianne
Nickerson, Pat H. Shiono, Paul Plsek, Donald A. Goldmann and Jeffrey Horbar
Pediatrics 2006;117;e43
DOI: 10.1542/peds.2005-0291

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/117/1/e43

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