Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems

Jason S. Adelman, Jo R. Applebaum, William N. Southern, Clyde B. Schechter, Judy L. Aschner, Matthew Alan Berger, Andrew D. Racine, Bejoy Chacko, Nina M. Dadlez, Dena Goffman, John Babineau, Robert A. Green, David K. Vawdrey, Wilhelmina Manzano, Daniel Barchi, Craig Albanese, David W. Bates, Hojjat Salmasian

Research output: Contribution to journalArticle

Abstract

Importance: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants. Objectives: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). Design, Setting, and Participants: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included. Main Outcomes and Measures: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes. Results: A total of 10819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P <.001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100000 orders) was similar to that of singleton-birth infants (41.7 per 100000 orders). The excess risk among multiple-birth infants (29.9 per 100000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births. Conclusions and Relevance: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families..

Original languageEnglish (US)
JournalJAMA Pediatrics
DOIs
StateAccepted/In press - Jan 1 2019

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Integrated Delivery of Health Care
Neonatal Intensive Care Units
Multiple Birth Offspring
Parturition
Names
Siblings
Joints

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health

Cite this

Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems. / Adelman, Jason S.; Applebaum, Jo R.; Southern, William N.; Schechter, Clyde B.; Aschner, Judy L.; Berger, Matthew Alan; Racine, Andrew D.; Chacko, Bejoy; Dadlez, Nina M.; Goffman, Dena; Babineau, John; Green, Robert A.; Vawdrey, David K.; Manzano, Wilhelmina; Barchi, Daniel; Albanese, Craig; Bates, David W.; Salmasian, Hojjat.

In: JAMA Pediatrics, 01.01.2019.

Research output: Contribution to journalArticle

Adelman, Jason S. ; Applebaum, Jo R. ; Southern, William N. ; Schechter, Clyde B. ; Aschner, Judy L. ; Berger, Matthew Alan ; Racine, Andrew D. ; Chacko, Bejoy ; Dadlez, Nina M. ; Goffman, Dena ; Babineau, John ; Green, Robert A. ; Vawdrey, David K. ; Manzano, Wilhelmina ; Barchi, Daniel ; Albanese, Craig ; Bates, David W. ; Salmasian, Hojjat. / Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems. In: JAMA Pediatrics. 2019.
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title = "Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems",
abstract = "Importance: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants. Objectives: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). Design, Setting, and Participants: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included. Main Outcomes and Measures: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes. Results: A total of 10819 infants were included: 85.5{\%} were singleton-birth infants and 14.5{\%} were multiple-birth infants (male, 55.8{\%}; female, 44.2{\%}). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100000 orders, respectively; adjusted odds ratio, 1.75; 95{\%} CI, 1.39-2.20; P <.001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100000 orders) was similar to that of singleton-birth infants (41.7 per 100000 orders). The excess risk among multiple-birth infants (29.9 per 100000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births. Conclusions and Relevance: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families..",
author = "Adelman, {Jason S.} and Applebaum, {Jo R.} and Southern, {William N.} and Schechter, {Clyde B.} and Aschner, {Judy L.} and Berger, {Matthew Alan} and Racine, {Andrew D.} and Bejoy Chacko and Dadlez, {Nina M.} and Dena Goffman and John Babineau and Green, {Robert A.} and Vawdrey, {David K.} and Wilhelmina Manzano and Daniel Barchi and Craig Albanese and Bates, {David W.} and Hojjat Salmasian",
year = "2019",
month = "1",
day = "1",
doi = "10.1001/jamapediatrics.2019.2733",
language = "English (US)",
journal = "JAMA Pediatrics",
issn = "2168-6203",
publisher = "American Medical Association",

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TY - JOUR

T1 - Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems

AU - Adelman, Jason S.

AU - Applebaum, Jo R.

AU - Southern, William N.

AU - Schechter, Clyde B.

AU - Aschner, Judy L.

AU - Berger, Matthew Alan

AU - Racine, Andrew D.

AU - Chacko, Bejoy

AU - Dadlez, Nina M.

AU - Goffman, Dena

AU - Babineau, John

AU - Green, Robert A.

AU - Vawdrey, David K.

AU - Manzano, Wilhelmina

AU - Barchi, Daniel

AU - Albanese, Craig

AU - Bates, David W.

AU - Salmasian, Hojjat

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Importance: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants. Objectives: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). Design, Setting, and Participants: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included. Main Outcomes and Measures: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes. Results: A total of 10819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P <.001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100000 orders) was similar to that of singleton-birth infants (41.7 per 100000 orders). The excess risk among multiple-birth infants (29.9 per 100000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births. Conclusions and Relevance: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families..

AB - Importance: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants. Objectives: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). Design, Setting, and Participants: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York-Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included. Main Outcomes and Measures: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes. Results: A total of 10819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P <.001). The rate of extrafamilial RAR events among multiple-birth infants (36.1 per 100000 orders) was similar to that of singleton-birth infants (41.7 per 100000 orders). The excess risk among multiple-birth infants (29.9 per 100000 orders) appears to be owing to intrafamilial RAR events. The risk increased as the number of siblings receiving care in the NICU increased; a wrong-patient order error occurred in 1 in 7 sets of twin births and in 1 in 3 sets of higher-order multiple births. Conclusions and Relevance: This study suggests that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. This excess risk appears to be owing to misidentification between siblings. These results suggest that a distinct naming convention as required by The Joint Commission may provide insufficient protection against identification errors among multiple-birth infants. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families..

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