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Similarities in patient names and medical record numbers increase the risk of misidentification in neonatal intensive care units (NICUs). Infant misidentification accounts for 11% of all medical errors involving NICU patients.


Researchers from Beth Israel Deaconess Medical Center, Boston, Mass., studied how similarities in common patient identifiers contribute to misidentifying NICU patients. They learned that on every day of the 1-year study period, at least one pair of patients was at risk for misidentification. On average, more than half the patients were at risk on any given day.

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The bulk of problems related to similar medical record numbers. Other causes of potential errors stemmed from identical names and similar-sounding last names. The risk of misidentification was substantially higher for NICU patients than for those in other units.


Researchers advise caregivers to be especially vigilant in their processes for identifying NICU patients and to consider using autoidentification technologies, such as bar coding and radiofrequency.




Patient misidentification in the neonatal intensive care unit: Quantification of risk, Pediatrics, JE Gray, et al., January 2006.