Patient Safety Tip of the Week

July 19, 2016    Infants and Wrong Site Surgery



A mother was dumbfounded when nurses brought her newborn back from what she thought was a routine physical examination and instead was listening to instructions about aftercare for her newborn’s frenulectomy (CBS News 2016). The newborn had no reason to have a frenulectomy. Apparently a pediatrician had mistaken this newborn for another newborn who was to have the frenulectomy.


No details about the events leading to that misidentification error are available. The newborn, of course, could not communicate to staff that he did not need a frenulectomy. Was there an appropriate consent in the chart? Certainly, the hospital should have had in place Universal Protocol or its equivalent to ensure correct patient and procedure. The reports don’t mention where the procedure was done. Sometimes minor procedures don’t require an operating room and are simply done in a procedure room. However, even bedside procedures should have an appropriate timeout to ensure correct patient, correct procedure, and correct laterality (see our June 6, 2011 Patient Safety Tip of the Week “Timeouts Outside the OR”).


We’ve done multiple columns on misidentification errors in newborns and infants. See our Patient Safety Tips of the Week for November 17, 2009 “Switched Babies”,

September 4, 2012 “More Infant Abductions”, December 11, 2012 “Breastfeeding Mixup Again”, April 8, 2014 “FMEA to Avoid Breastmilk Mixups” and our August 2015 What's New in the Patient Safety World column “Newborn Name Confusion”.


So just how frequent are newborn misidentification errors? The Pennsylvania Patient Safety Authority recently published an advisory on patient identification issues in newborns (Wallace 2016). They found 1234 such misidentification errors in newborns over a 2 year period, an average of almost 2 misidentification errors in Pennsylvania hospitals and birthing centers per day. That may even be an underestimate since many misidentification errors impact 2 patients (for example, one patient gets a medication intended for someone else and the other patient does not get his/her intended medication) and the reports to the PPSA may have each only included 1 patient.


The good news from the PPSA report, though, is that very few of the misidentification errors actually reached the patient and caused harm. Of the 1234 reports, harm occurred in only 5 cases and was serious in only one. The majority of errors were intercepted by interventions like double checks, barcoding, ID tags, etc.


In our Patient Safety Tips of the Week November 17, 2009 “Switched Babies” and December 11, 2012 “Breastfeeding Mixup Again” we noted that one of the risk factors for these mixups are similar sounding names. Similar names are always an issue when it comes to wrong patient events but neonates may be even more at risk. In our May 20, 2008 Patient Safety Tip of the Week “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?” we noted you would be surprised to see how often patients with the same or very similar names may be hospitalized at the same time. Shojania (2003) described a near-miss related to patients having the same last name and noted that a survey on his medical service over a 3-month period showed patients with the same last names on 28% of the days. The problem is even more significant on neonatal units, where multiple births often lead to many patients with the same last name being hospitalized at the same time and medical record numbers being similar except for one digit. Gray et al (2006) found multiple patients with the same last names on 34% of all NICU days during a full calendar year, and similar sounding names on 9.7% of days. When similar-appearing medical records numbers were also included, not a single day occurred where there was no risk for patient misidentification. Both these studies were on relatively small services so one can anticipate that the risks of similar names is much higher when the entire hospitalized patient population is in the database.


So it is common for newborns to have similar last names, similar dates of birth, and even similar medical record numbers (since most hospitals assign medical record numbers sequentially). The inability of the newborn to participate in the identification verification process is another obvious contributing factor. And, though we’re trying to not sound politically incorrect, newborns look alike! Keep in mind that a mother who just delivered may have seen her newborn for only a short time and her cognition might be clouded by medications received during or after the labor and delivery. So even a mom might have difficulty identifying her own newborn.


Our June 26, 2012 Patient Safety Tip of the Week Using Patient Photos to Reduce CPOE Errors”) highlighted an intervention developed by Children’s Hospital of Colorado (Hyman 2012) in which a patient verification prompt accompanied by photos of the patient reduced the frequency of wrong patient order entry errors. That may be helpful for older children and adults but, frankly, is not of much benefit in neonates.


In our August 2015 What's New in the Patient Safety World column “Newborn Name Confusion” we noted researchers have applied the retract-and-reorder or RAR tool to assess the impact of a change in naming conventions for newborns (Adelman 2015). Hospitals need to create a name for each newborn promptly on delivery because the families often have not yet decided on a name for their baby. Most hospitals have used the nonspecific convention “Baby Boy” Jones or “Baby Girl” Jones. A suggested alternative uses a more specific naming convention. It uses the first name of the mother. For example, it might be “Wendysgirl Jones”. Montefiore Medical Center switched to this new naming convention in its 2 NICU’s in July 2013 and the RAR tool was used to measure the impact on wrong patient errors. Wrong patient error rates measured in the one year after implementation of the new more specific naming protocol were 36% fewer than in the year prior to implementation. For reasons not immediately clear, error rates were reduced even more for orders placed by housestaff (52% reduction) and orders placed on male patients (61% reduction).


Switch to the more specific neonatal naming convention was simple and effective and done without significant financial or labor cost and done with technology already present in most NICU’s. Though the Montefiore study was not blinded and was potentially subject to the Hawthorne effect, the more specific naming convention is very promising. Validation at other NICU’s would be the next logical step before adopting this convention in a more widespread fashion.


The authors note that they only studied the impact on order entry. They point out that mixing up names is also a potentially serious for reading imaging studies or pathology specimens, giving blood products, and may also be a factor in breastmilk mixups. So the potential for this new naming convention to avert wrong patient errors is substantial.


In the PPSA advisory (Wallace 2016) misidentification errors were most commonly related to procedures, treatment, or tests (80%). Another 8.3% were medication errors. Some errors were related to identification bands missing (eg. might be taped on the bassinet rather than infant) but others were related to having the wrong identification band. Sometimes the errors were related to labeling errors on blood or urine specimens or on breastmilk. The PPSA advisory on misidentification errors in newborns noted breastfeeding the wrong infant or breast milk administration mishaps were also common. We’ve addressed those in our Patient Safety Tips of the Week November 17, 2009 “Switched Babies” and December 11, 2012 “Breastfeeding Mixup Again” and April 8, 2014 “FMEA to Avoid Breastmilk Mixups”. We refer you to those columns for details. If your organization does obstetrics and cares for newborns or young infants, we highly recommend you do your own FMEA (failure mode and effects analysis) to assess your risk for breastmilk mixups. We suspect you will be very surprised at the potential vulnerabilities you identify.


The PPSA advisory offers recommendations for risk reduction strategies to reduce labeling errors, registration issues, documentation practices, and issues related to identification bands and band design. In addition to the baby naming convention we noted above, the PPSA advisory also suggests daily huddles to acknowledge and discuss newborns with similar names, and try not to place newborns with similar names in the same location where possible. They also suggest using some visual flag (like a star, or “stop” sign, or color-coding) to visually alert workers that a newborn with a similar name may be present in the unit. (How many of you even do a daily printout, by unit, of patients so you can flag instances where patients have similar names?) Use of technologies that assist correct identification (barcoding, radiofrequency ID, etc.) should be used and might also reduce labeling errors. One important point is having bedside label printers to generate labels for specimens at the point of care (so phlebotomists and others don’t arrive at the bedside with a slew of pre-printed labels from which they might select the wrong one).


In several of our columns, most recently in our January 19, 2016 Patient Safety Tip of the Week “Patient Identification in the Spotlight” we’ve discussed many of the reasons that CPOE (computerized physician order entry) may lead to wrong patient errors. That column also includes some of the tools that have been adapted to CPOE to reduce the risk of those errors.



Another issue related to infant identification is infant abductions from hospitals. Think you are not at risk for infant abductions at your facility? Watch this man attempt to abduct an infant in a shopping bag (Urbanski 2015). See our Patient Safety Tips of the Week for December 20, 2011 “Infant Abduction” and September 4, 2012 “More Infant Abductions” for details about how infant abductions occur and ways to identify your vulnerabilities to these. In those we’ve described some of the characteristic scenarios by which infant abductions occur. Another infant abduction in Canada two years ago also illustrates a rather typical scenario seen (Schwartz 2014). And the excellent NCMEC resources for healthcare professionals includes descriptions of typical abductors and scenarios.


Also timely is this month’s ECRI Institute’s PSO Monthly Brief, which has an article on faulty infant security systems. It has descriptions of several scenarios in which infant alarms will not work properly and other vulnerabilities. It has good recommendations on what you should be doing to ensure your system is functioning properly, including daily testing and regular drills. We've discussed infant abduction drills in several of our prior columns and even recommend you consider doing one coincident with a fire alarm drill to make sure your system does not become disabled during such events. Note that the monthly brief is one of several free newsletters provided by ECRI Institute. You are missing out if you don’t subscribe to any of these very valuable free resources. You can subscribe at:


Doing drills is important. But you need to do them the right way. In our December 20, 2011 Patient Safety Tip of the Week “Infant Abduction” we noted that the hospital at which an abduction occurred had done 4 such “Code Pink” drills in the two prior years and that in each of those drills the “abductor” had been able to exit the facility. So when you do drills you need to be sure your observer/evaluators know what to look for. Then you need to be sure you follow up on items that need correction. The NCMEC resources for healthcare professionals includes a good drill critique form with a list of items to evaluate during drills and provides a good bibliography to other resources about doing drills. One item you would evaluate is whether during the “Code Pink” appropriate people were stopped and interrogated or prevented from exiting. Even though NCMEC has developed a profile of a typical abductor, we would caution against “profiling” during a Code Pink and recommend every person be considered a potential abductor. Also, given our comments about doors during fire alerts you might even consider doing a “Code Pink” drill immediately following a fire alert drill.


So see our Patient Safety Tips of the Week for December 20, 2011 “Infant Abduction” and September 4, 2012 “More Infant Abductions” and the NCMEC resources for healthcare professionals to see what you should be doing to protect against infant abductions from your facilities. But we also highly recommend those facilities taking care of newborns and children do a FMEA (failure mode and effects analysis) to assess their potential vulnerabilities to infant abductions. Doing a FMEA gets you to always consider “what if…?” scenarios to help you identify areas of vulnerability.

The whole point of a FMEA is to identify areas where unexpected circumstances might occur that could breach your safe processes.


Newborns can’t fend for themselves very well from a medical standpoint. We can’t afford to also expose them to a host of threats from a variety of other sources.



Some of our prior columns related to identification issues in newborns:

November 17, 2009    Switched Babies”,

December 20, 2011     Infant Abduction

September 4, 2012      More Infant Abductions”.

December 11, 2012     Breastfeeding Mixup Again”.

April 8, 2014               FMEA to Avoid Breastmilk Mixups

August 2015               Newborn Name Confusion

January 19, 2016         Patient Identification in the Spotlight



Some of our prior columns related to wrong-site surgery:

  September 23, 2008 Checklists and Wrong Site Surgery

  June 5, 2007              Patient Safety in Ambulatory Surgery

  July 2007                   Pennsylvania PSA: Preventing Wrong-Site Surgery

  March 11, 2008         Lessons from Ophthalmology

  July 1, 2008               WHO’s New Surgical Safety Checklist

  January 20, 2009       The WHO Surgical Safety Checklist Delivers the Outcomes  

  September 14, 2010 Wrong-Site Craniotomy: Lessons Learned

  November 25, 2008 Wrong-Site Neurosurgery

  January 19, 2010       Timeouts and Safe Surgery

  June 8, 2010              Surgical Safety Checklist for Cataract Surgery

  December 6, 2010     More Tips to Prevent Wrong-Site Surgery

  June 6, 2011              Timeouts Outside the OR

  August 2011             New Wrong-Site Surgery Resources

  December 2011         Novel Technique to Prevent Wrong Level Spine Surgery

  October 30, 2012      Surgical Scheduling Errors

  January 2013             How Frequent are Surgical Never Events?

  January 1, 2013         Don’t Throw Away Those View Boxes Yet

  August 27, 2013       Lessons on Wrong-Site Surgery

  September 10, 2013 Informed Consent and Wrong-Site Surgery

  July 2014                   Wrong-Sided Thoracenteses

  May 17, 2016            Patient Safety Issues in Cataract Surgery







CBS News. Mix-up leads to surgical procedure on wrong baby. CBS News February 5, 2016



Wallace SC. Newborns Pose Unique Identification Challenges. Pa Patient Saf Advis 2016; 13(2): 42-49;13(2)/Pages/42.aspx



Shojania KG. AHRQ Web M&M Case and Commentary. Patient Mix-Up. February 2003



Gray JE, Suresh G, Ursprung R, et al. Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 2006; 117: e43-e47



Hyman D, Laire M, Redmond D, Kaplan DW. The Use of Patient Pictures and Verification Screens to Reduce Computerized Provider Order Entry Errors. Pediatrics 2012; 130: 1-9 Published online June 4, 2012 (10.1542/peds.2011-2984)



Adelman J, Aschner J, Schechter C, et al. Use of Temporary Names for Newborns and Associated Risks. Pediatrics 2015; Published online July 13, 2015



Urbanski D. When You Realize Who’s Inside the Bag He’s Trying to Sneak Out of a Hospital, You Will Be One Step Ahead of the Staffers. The Blaze 2015; March 12, 2015



Schwartz D. Baby Victoria abduction: What hospitals can do to boost security. Educating nurses, moms most important safety measure, expert says after Trois-Rivières incident. CBC News 2014; Posted: May 28, 2014



NCMEC (National Center for Missing & Exploited Children). For health care professionals: Guidelines on prevention of and response to infant abductions. 10th edition. 2014



ECRI Institute PSO. Babies and Buzzers: Faulty Infant Security Systems. ECRI Institute's PSO Monthly Brief 2016; July 2016







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