Name
Western Governors University
D221 Organizational Systems and Healthcare Transformation
Prof. Name
Date
Accurate identification of patients is a foundational element in delivering safe and effective healthcare, particularly for inpatient newborns. This population is uniquely vulnerable to identification errors due to factors such as shared birthdates, similar medical record numbers, and identical last names, especially among multiples (Redman et al., 2020). Misidentification in newborns can lead to severe adverse events including performing incorrect laboratory tests, administering the wrong medications, undergoing unnecessary procedures, or receiving breast milk intended for another infant. Unlike adults, newborns cannot communicate or verify their identity, and their physical features often lack distinguishing characteristics, which heightens the risk of these critical errors.
In 2022, approximately 3.66 million live births were recorded in the United States (Hamilton, Martin, & Osterman, 2023). Research highlights that newborns are especially susceptible to misidentification-related errors in clinical settings. For instance, around 10% of medical errors and 25% of serious medication errors in Neonatal Intensive Care Units (NICUs) involve misidentification. Moreover, infants born as multiples face nearly double the risk of wrong-patient order errors compared to singletons (Adelman et al., 2019).
A notable study at Beth Israel Deaconess Medical Center found that 26% of NICU newborns were daily at risk for misidentification due to overlapping identifiers. The Vermont Oxford Network further reported that 11% of newborn errors over a two-year span were linked to identification mistakes. Analysis of 1,234 newborn identification incidents documented by the Pennsylvania Patient Safety Authority from 2014 to 2015 categorized errors as follows:
| Error Type | Percentage of Events |
|---|---|
| Procedural errors | 74.3% |
| General misidentification | 9.6% |
| Medication errors | 8.9% |
| Breast milk administration errors | 7.2% |
These figures underscore the significant threat misidentification poses to newborn safety and overall quality of care (Wallace, 2016).
The 2023 National Patient Safety Goals (NPSGs) from The Joint Commission prioritize accurate patient identification. Goal 1 (NPSG.01.01.01) mandates the use of at least two patient identifiers throughout care processes, which is particularly crucial for newborns. Recommended strategies include standardized naming conventions, banding protocols, and communication tools aimed at minimizing errors (The Joint Commission, 2023).
Additionally, Goal 3 emphasizes medication safety, which is directly impacted by patient identification accuracy. Though applicable to all patient populations, medication errors related to misidentification highlight the necessity of robust identification protocols for newborns (The Joint Commission, 2023).
Misidentification events have serious consequences for newborns and their families. Examples include infants undergoing wrong diagnostic imaging due to mixed records, receiving inaccurate ID bands with wrong birthdates, being breastfed by other mothers, or getting breast milk intended for others (Wallace, 2016). Such incidents cause direct harm to infants and erode parental trust, which can have long-lasting effects on the family’s confidence in healthcare services.
For healthcare organizations, these errors decrease patient satisfaction scores, damage institutional reputation, and may discourage families from seeking future care. Nurses and staff involved often experience increased stress, reduced job satisfaction, and diminished morale, which can further compromise patient safety.
Patients and families expect reliable, safe healthcare. For parents of newborns, trust in caregivers is critical. Identification mistakes undermine this trust, influencing future care choices and patient satisfaction negatively. From an organizational perspective, such errors compromise clinical outcomes and institutional credibility, challenging the commitment to quality and safety.
Implementing unique identification methods for newborns—such as distinct naming conventions on ID bands—has proven effective. Research by Adelman et al. (2019) showed a 36% reduction in wrong-patient orders when using distinctive naming protocols compared to nondistinct methods. The Joint Commission also endorses these practices as part of its patient safety goals.
A specialized newborn identification system enhances accuracy and safety by reducing errors like incorrect lab tests, medication mistakes, and mismatches between infants and parents. High-reliability organizations (HROs) emphasize consistent quality and proactive harm prevention, making precise identification a fundamental component to achieving these aims.
| Barrier | Description |
|---|---|
| Similar names among multiples | Newborns with shared last names and birthdates may have confusingly similar ID bands. |
| Staff inattentiveness or rushed verification | Staff distractions or workload pressures may lead to skipped or improper ID checks. |
| Barrier | Intervention |
|---|---|
| Similar names among multiples | Implement visual alerts or notifications to flag infants with similar identifiers; involve parents in verification. |
| Staff inattentiveness or rushed verification | Provide staff education on the critical importance of accurate ID checks; require double nurse verification; educate parents to alert staff if ID bands are lost. |
Shared decision-making promotes collaboration among nurses, physicians, administrators, and parents, ensuring that the solution is practical and widely accepted. Involving frontline staff brings awareness of operational challenges, while parental engagement fosters partnership in safeguarding infant identity. This cooperative approach improves safety, quality, and cost-efficiency.
Effectiveness can be assessed by monitoring incident reports for misidentification before and after implementation, categorized by procedural, medication, and breast milk administration errors. Additionally, staff surveys can provide feedback on process acceptance and identify areas for improvement.
NICU and postpartum units typically use a total patient care model, where nurses deliver comprehensive newborn care. The proposed change would cause minimal disruption, requiring short parent education sessions and a second nurse to verify ID band accuracy. This protocol can be integrated smoothly into admission and routine care practices.
Adelman, J. S., Applebaum, J. R., Southern, W. N., et al. (2019). Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems. JAMA Pediatrics, 173(10), 979–985. https://doi.org/10.1001/jamapediatrics.2019.2733
Hamilton, B. E., Martin, J. A., & Osterman, M. J. K. (2023). Vital statistics rapid release. Births: Provisional data for 2022 (Report No. 28). National Vital Statistics System, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. https://dx.doi.org/10.15620/cdc:127052
Redman, C. T., Reddy, P., Kneifati-Hayek, J. Z., Applebaum, J. R., Manzano, W., Goffman, D., & Adelman, J. S. (2020). Incident reports of naming errors among two sets of infant twins. Pediatric Quality & Safety, 5(6), e356. https://doi.org/10.1097/pq9.0000000000000356
The Joint Commission. (2023). National patient safety goals. Hospital: 2023 national patient safety goals.
Wallace, S. C. (2016). Newborns pose unique identification challenges. PA Patient Safety Advisory, 13(2), 42-49.
