Study Warns of Potential for Patient Mixups in NICUs

Authors cite bar coding and radio frequency identification systems as possible solutions

THURSDAY, Jan. 5 (HealthDay News) -- Infants in neonatal intensive care units (NICUs) can be easily misidentified due to common problems, such as similar medical record numbers, identical surnames and similar sounding names, according to a study published in the January issue of Pediatrics. These problems occur with such frequency, it can increase the risk for medical errors, the authors say.

During the year-long study, James E. Gray, M.D., of the Center for Patient Safety in Neonatal Intensive Care, University of Vermont in Burlington, and colleagues analyzed the electronic medical records of 1,260 patients in a NICU with an average daily census of 33.4. They determined that the patients received 12,186 days of patient care.

The researchers found that not a single day was free of risk for patient misidentification. On any given day, the mean number of at-risk patients was 17, representing more than 50% of the average daily census. The investigators identified the most common causes of misidentification risk as similar-appearing medical record numbers (44% of patient days), identical surnames (34% of patient days) and similar-sounding names (9.7% of patient days).

"The use of point-of-care bar coding systems is a frequently cited technology for reducing patient identification errors. Similarly, radio frequency identification systems, which do not require line-of-sight access to patient identification bands, may prove valuable", the authors write. "Clinicians must ensure that such technologies are tested adequately in the unique environment of the NICU and that they are implemented in a manner that avoids disruption of workflow."

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