Redman Chelsea T, Reddy Pooja, Kneifati-Hayek Jerard Z, Applebaum Jo R, Manzano Wilhelmina, Goffman Dena, Adelman Jason S
Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, N.Y.
Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Columbia University Irving Medical Center, New York, N.Y.
Pediatr Qual Saf. 2020 Oct 23;5(6):e356. doi: 10.1097/pq9.0000000000000356. eCollection 2020 Nov-Dec.
Newborns are at high risk for identification errors due to their inability to speak and indistinguishable features. To reduce this risk, The Joint Commission requires hospitals to use a distinct identification method for newborns. Most hospitals create medical records for newborns at birth using temporary naming conventions, resulting in patients with similar identifiers. Typically, multiple-birth infants are distinguished from their siblings by a single character (1, 2, or A, B), placing them at higher risk for identification errors, which can delay care and compromise patient safety.
We present 2 unrelated cases involving naming errors in sets of infant twins receiving care in a healthcare system using Joint Commission compliant distinct temporary naming convention.
In the 2 cases, system failures contributed to naming errors in 2 sets of infant twins, which resulted in delayed care. In the first case, twins were inadvertently assigned the same temporary name. In the second case, an infant's blood specimen label did not include a single character, which distinguishes a multiple-birth infant from their sibling. Further safeguards are needed to reduce this risk. These cases illustrated the potential for misidentification related to newborn naming conventions during the registration process, especially between siblings of multiple-birth infants.
Further research is needed to determine strategies to prevent newborn identification errors. Potential strategies to reduce this risk and protect newborns include improving the design of newborn identifiers, systems-level interventions such as verification alerts, and improved registration processes.
由于新生儿无法说话且特征难以区分，他们面临着较高的身份识别错误风险。为降低这种风险，联合委员会要求医院对新生儿采用独特的身份识别方法。大多数医院在新生儿出生时使用临时命名惯例创建医疗记录，导致患者标识符相似。通常，多胞胎婴儿通过单个字符（1、2或A、B）与他们的兄弟姐妹区分开来，这使他们面临更高的身份识别错误风险，可能会延误治疗并危及患者安全。
我们介绍了2例不相关的病例，涉及在一个使用符合联合委员会标准的独特临时命名惯例的医疗系统中接受治疗的双胞胎婴儿组中的命名错误。
在这2例病例中，系统故障导致2组双胞胎婴儿出现命名错误，从而导致治疗延误。在第一例中，双胞胎被无意中赋予了相同的临时名字。在第二例中，一名婴儿的血液标本标签没有包含用于区分多胞胎婴儿与其兄弟姐妹的单个字符。需要进一步的保障措施来降低这种风险。这些病例说明了在登记过程中与新生儿命名惯例相关的身份误认可能性，尤其是在多胞胎婴儿的兄弟姐妹之间。
需要进一步研究以确定预防新生儿身份识别错误的策略。降低这种风险并保护新生儿的潜在策略包括改进新生儿标识符的设计、系统层面的干预措施（如验证警报）以及改进登记流程。
