Kushnir Amir, Chulsky Elena, Rubin Robyn, Zohar Daniel, Barak Shay
Department of Neonatology and Neonatal Intensive Care Unit, The Baruch Padeh Medical Center, Poria, Tiberias, Israel; The Bar Ilan Faculty of Medicine in the Galilee, Zafed, Israel.
Department of Neonatology and Neonatal Intensive Care Unit, The Baruch Padeh Medical Center, Poria, Tiberias, Israel; The Bar Ilan Faculty of Medicine in the Galilee, Zafed, Israel.
Int J Med Inform. 2014 Sep;83(9):683-90. doi: 10.1016/j.ijmedinf.2014.06.001. Epub 2014 Jun 12.
During the administrative admittance of extreme premature twin neonates to the Hospital Information System (HIS), at an Israeli government general hospital, a third virtual baby was mistakenly admitted in addition to the twins. The third virtual baby's records were in department occupancy and transactions were performed in the HIS, such as "admittance" to Neonatal Intensive Care Unit (NICU), being appended to a mother as well as clinical orders.
Once noticed, the records of the third virtual baby were merged in the system with the second correct twin (Baby II), whose records were also in the department occupancy list.
An error occurred in the interface whilst merging the records, and patient demography was not updated for clinical orders for Baby II. As a result, all new clinical orders for Baby II carried the non existing third baby's identity.
We emphasize that it is advisable to register all newborns as early on in life whilst still in the delivery room, with a permanent identification number as opposed to a temporary identification number to avoid any mismatching if patients records are to be merged or updated. Furthermore, steps that could help prevent such an event could be additional administrative staff to register newborns. However, we conclude, that it would be most helpful to introduce a Radio Frequency Identification (RFID) system based on a permanent identity number. If any discrepancies in patient information are detected, an alarm will be triggered during transfer of the baby from the delivery room to the designated Department. A RFID receptor is located at the exit of the delivery room. While most literature available regarding Hospital Information Technology (HIT) and patient safety, mainly discusses mismatching of patients during medication and laboratory testing not much literature regarding the process of registering newborns as a source of patient mismatching has been found. The authors feel that there is a need to further investigate this aspect as it is a source that can affect not only accuracy in the Electronic Patient Record (EPR) but furthermore has the impact to change the course of a life and set tone for that person's future.
在以色列一家政府综合医院，极早产双胞胎新生儿录入医院信息系统（HIS）时，除了这对双胞胎外，第三个虚拟婴儿被错误录入。第三个虚拟婴儿的记录显示在科室占用情况中，并且在HIS中进行了诸如“入住”新生儿重症监护病房（NICU）、添加到母亲名下以及下达临床医嘱等操作。
一经发现，第三个虚拟婴儿的记录在系统中与第二个正确的双胞胎婴儿（婴儿II）合并，婴儿II的记录也在科室占用列表中。
合并记录时接口出现错误，婴儿II的临床医嘱患者人口统计学信息未更新。结果，婴儿II的所有新临床医嘱都显示为不存在的第三个婴儿的身份。
我们强调，建议在新生儿出生后尽早在产房内就用永久识别号进行登记，而不是临时识别号，以避免在合并或更新患者记录时出现任何不匹配情况。此外，有助于防止此类事件发生的措施可以是增加登记新生儿的行政人员。然而，我们得出的结论是，引入基于永久身份号码的射频识别（RFID）系统将非常有帮助。如果检测到患者信息有任何差异，在婴儿从产房转运到指定科室时将触发警报。产房出口处设有RFID接收器。虽然现有的大多数关于医院信息技术（HIT）和患者安全的文献主要讨论用药和实验室检测过程中的患者不匹配问题，但关于新生儿登记过程中作为患者不匹配来源的文献却很少。作者认为有必要进一步研究这一方面，因为它不仅会影响电子病历（EPR）的准确性，还会对一个人的生活轨迹产生影响，并为其未来定下基调。
